The Johns Hopkins Medical Journal 32 (1921)

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The Johns Hopkins Medical Journal - Volume 32 (1921)

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The Johns Hopkins Medical Journal 32 (1921)

The Johns Hopkins Hospital Bulletin

BULLETIN OF THE JOHNS HOPKINS HOSPITAL

(THE PUBLICATION OF THE MEDICAL SCHOOL AND HOSPITAL)

Vol. XXXII— No. 359


BALTIMORE, JANUARY, 1921


CONTENTS

  • George Miller Steinberg, 1838-1015. By Howard A. Kelly
  • Hydrocephalus in Chondrodystrophy. (Illustrated.) By Walter E. Dandy
  • The Mechanism of the Carrier State, With Special Reference to Carriers of FriedUlnder's Bacillus. By Arthur L. Bloomfield
  • Tuberculosis of the Kidney in Women. By Leo Brady
  • Portal Thrombosis. By L. T. Webster
  • The Relation of Histamin to Leukocytosis. By John R. Paul
  • The Influence of the Anterior Lobe of the Hypophysis Upon the Development of the Albino Rat. (Illustrated.) By Warren R. Sisson and Edwin N. Broyles ... 22
  • Syphilitic Rupture of a Papillary Muscle of the Heart. (Illustrated.) By Edward D. Spalding and William C. Von Glahn . 30
  • Notes and News 31
  • Notes on New Books 32


GEORGE MILLER STERNBERG, 1838-1915

By HowAKiJ A. KJELLv


George M.' Sternberg, Surgeon General of the United States Army, reorganizer of the TJ. S. Army Medical Corps and eminent bacteriologist, was bom June 8, 1838, at Hartwick Seminary, Otsego County, New York. He was the eldest son of the Eeverend Levi Sternberg a descendant of an old Lutheran family of the Palatinate, wHcli had settled in Schoharie and the Mohawk Valley — one Lambert Sternberg (we are told) having been the first to sow wheat in Schoharie County in 1713. His mother, Margaret Levering, whose maiden name was Miller, was an excellent linguist. When he was ten years old Geoi-ge went to live with his grandmother at Hartwick, where two years later his father became principal of the Theological Seminary.

At thirteen he took a situation in a book store, which he held for about a year, spending most of his spare time in reading fiction. At sixteen the res angusta domi of the clergyman's family drove George to teaching school at $10 a month and board, some twelve miles from home. Later he secured a school at $20 where he taught for two years, his salary tfeing gradually increased to $100 a quarter. With money saved

' George Miller Sternlierg. A Biography. By his wife, Martha L. Sternberg. Chicago, American Medical Association, 1920.


he retui'ned to his studies at Hartwick, where he at the same time taught mathematics, chemistry and natural philosophy. Having made up his mind to take up medicine he began his preparatory studies under Dr. Hiram Lathrop of Cooperstown, N. Y. He attended his first course of lectures in 1859-60 in Buffalo, N. Y. and later on went to the College of Physicians and Surgeons in New York City, graduating in the spring of 1860. He at once settled in Elizabeth City, N. J., and practised there until the Civil War broke out.

In May, 1861, he entered the Federal Army as Assistant Surgeon and was sent to the Army of the Potomac under General George Sykes. At Bull Bun he was captured but escaped later and after sundiy vicissitudes made his way to Waslungt,on. He was with Sykes until August, 1863, when he suifered from an attack of typhoid fever. After his recovery, for a short time he held the position of executive of the U. S. General Hospital at Portsmouth Grove, R. I., a hospital of 3200 beds.

In November, 1863, he joined General Banks and served as Assistant to the Medical Director of the Department of the Gulf and with the Board of Health until Januaiy, 1864. He then became Assistant Medical Director at Columbus and


later was put in-charge of a large general hospital in Cleveland, Ohio, whence he was transferred to Jefferson Barracks in •Inly, 1865. During the war he was hrevetted Captain and later Major.

In October, 1865, he married Miss Louise Russell of Coopersto^vn, N. Y.

From Jefferson barracks, in April, 1866, he was ordered to Iort Harker. Here cholera broke out in a colored regiment ; it spread to the civil population and Mrs. Sternberg died of the disease July 15, 1867. The sanitary conditions in and around were deplorable, as was noted by Sternberg's report.^ His habits of close observation are already apparent in this (arly memorandum : In it he says : " There have been an unusual number of flies and mosquitoes. Houses have been infested with a large fly which differs from the common house 1ly."

After being on leave from Augaist to December, 1867, he was ordered to Fort Riley as Post Surgeon and on court martial duty. He saw some Indian campaign service under Major M. H. Kidd in 1868.

In September, 1868, he was assigned as chief medical officer to Col. A. Tulley's expedition against hostile Indians about the Arkansas River, with bases near Fort Dodge. Fort Hayes, Kansas, and Camp Supply, I. T.

In December, 1868, he joined Major General Sheridan, in the field depot and headquarters, on the North Canadian River at the junction of Beaver Creek, I. T., dealing with hostile Cheyennes and other tribes. Here he collected crania and fossils, some of which were sent to Joseph Leidy of Philadelphia, and others to the Army Medical iluseum.

After being relieved from Sheridan's command March 2, 1869, he was sent for a short while to Fort Hayes, Kansas, but in the same year returned to Fort Riley. Here he had the advantages of a good post with a fine hospital and a thriving town. Junction City, two miles away, where he could obtain photographic materials. Here he married Martha L. Pattison, daughter of Thomas Thurston Nelson Pattison of Scotch-Irish ancestry, a pioneer in Indiana from the Eastern Shore of JIaryland, and of Huguenot descent on the side of her mother, Elizabeth Grant Mauzy. At Fort Riley Sternberg indulged his penchant for invention and devised and perfected an anerometer, which, however, the patent office decided had been anticipated Ijy a German. He also invented a practical heat regulator by which an even temperature could be maintained in the wards. Some years later he received $5000 for this device, which in principle is still in use.

In June, 1870, Dr. and Mrs. Sternberg arrived at Governors Island, where in September an epidemic of yellow iever broke out. During this trj-ing period he rendered faithful service and began his epochal studies of this disease.

After a short service at Fort Hamilton and Fort Warren in July, 1872, he was sent to New Orleans where yellow fever was then prevalent.


'Surgj-Gen. Office Circular No. 1, pp. 29-30.


In September, 1873, he was assigned for duty to Fort BarI'ancas, nine miles from Pensacola, where he stayed for three years. Here, as everywhere they went. Dr. and Mrs. Sternberg were deeply interested in the botany of their immediate surroundings, and spent much of their spare time studying and collecting plants.

In the summer of 1873 yellow fever broke out at Barrancas and as the only effectual (and in view of present knowledge the most sensible) remedy then knoM'n was to move from the infected area to fresh ground, the troops were at once transferred to a camp near old Fort Pickens across the bay, where they remained until the autumn frost. Again in the summer of 1874 another invasion claimed numerous victims. These epidemics were made the subject of a thorough, intensive study and the conclusion reached that the infection was brought by ship. As a result of these studies Sternberg became our leading authority on yellow fever.

In his spare time" he made a study of various shell heaps and mounds in this region and a fine collection of pottery was excavated and sent to a state museum. On this Sternberg made a report before the American Association for the Advancement of Science at Salem, Massachusetts, in 1879.

Another epidemic of yellow fever occurred in June, 1875. Ijrought by the steamship Yon Moltke from Havana, in spite of a strict quarantine. At last, Sternberg himself was stricken, but recovered after a severe illness. This was followed by a rest of six months in Europe (1875-76), and promotion to the rank of major, to which he had been entitled since F^bruarj', 1869.

In May, 1876, he reported at Headquarters, Portland, Oregon, where he utilized the opportunity to become proficient in French.

A side trip to Fort Colville and the Snake River secured some fine fossils, forwarded to Professor Edward D. Cope of Philadelphia.

In 1877 he went through the Lapwai Campaign; he was present at the battle in the Clearwater, and underwent many hardships.

From 1878 to 1885 he was busy experimenting with commercial disinfectants, having only an improvised equipment at his disposal, and pursuing studies in bacteriology, laying sotmd foundations for the future in these fields in this country.

In 1879 he reported again at Washington, and was detailed for duty witli the Havana Yellow Fever Commission of the Xatioual Board of Health. He was now able to spend time in intensive microscopic work, with high power lenses, and in making micro-photographs.

In Cuba he -became intimate with Carlos Finlay, who was fully conduced that yellow fever was propagated by the stegomyia mosquito. Sternberg's official instructions were to study sanitary conditions, to increase knowledge in ]>athology, and to investigate endemicity, with some hesitating suggestions as to any elucidation of the fundamental problem of the true nature of the disease. It being generally thought that the organism must be in the blood, Sternberg devoted his time to making micro-photographs and analyzing the records


of all patients. He made as many as 105 from 41 clear cases, rigging up a heliostat to illuminate a dark room.

In 1880 he returned to Georgetown, D. C. Later in 1880 he went to New Orleans to investigate the micro-organisms of the air in their possible connection with malarial fever. A year before this, Klebs with Tommasi-Crudeli had announced the discovery of a bacillus as the causative factor in malaria ; this Sternberg proved to be incorrect.

In 1880 while working on the malaria problem in New Orleans he discovered, by inoculating a rabbit with his own sputum, the micrococcus, which he named Micrococcus pasteuri, iind which was subsequently demonstrated by Sternberg and others to be the infectious agent in croupous pneumonia. Mrs. Sternberg in her biography is in error in identifying this microorganism, with the Friedlander bacillus. Sternberg was anticipated in publication by Pasteur.

In August, 1881, he was assigned to Fort Mason; here at his own expense he established a laboratory for biological research, and demonstrated the tubercle bacillus discovered liy Koch in 1883. His original scientific work was done after the L-ompletion of his round of post duties each day.

On November 27, 1883, he wrote Surgeon General Eobert Murray summarizing his post work, and begging for better siirroundings and facilities for scientific investigation. As a result in April, 1884, he was transferred to the Department of tlie East, where he was appointed Attending Surgeon and Examiner of Eecniits at Baltimore, and found laboratory facilities in Newell Martin's laboratory of The Johns Hopkins University. Culture bouillon and media were made for him by ]\Irs. Sternberg, who maintained throughout an active and intelligent interest in all his studies.

In 1885 he went as Delegate for the United States to the International Sanitary Conference in Eome, where he was made honorary member of the Eoyal Academy of Medicine.

Returning in March, 1885, he demonstrated, at The Johns Hopkins University, the living motile plasniodium of malaria discovered in 1880 by Laveran.

In 1886 Dr. with Mrs. Sternberg went to Berlin, where they met Koch ; on their return he received the Bausch and Lomb prize for his work on the practical value of disinfectants, begun in Walla Walla in 1878 and completed in the laboratory of The Johns Hopkins University, the culmination of a series of studies undertaken as chairman of a committee of the American Public Health Association.

In May, 1887, he and Mrs. Sternberg went to South America to investigate certain alleged discoveries relating to yellow fever, that of Dr. Ereire of Eio de Janeiro, and that of Dr. Carmona de Valle, of Mexico City. The claims of l)oth these workers were sho\ra by Sternberg to have no scientific data tu justify them.

On his return from this mission he again located in Baltimore and resumed work with William H. Welch and Wm. T. Councilman in the pathological laboratory of The Johns IIo]!kins Hospital.

In April, 1888, he asked to be sent to Havana to continue his yellow fever studies. In the course of these he was al)le


to prove conclusively that Gibier's organism was not the cause of yellow fever.

The summer of 1889 saw liim once more at work in Havana; this time his wide bacteriologic knowledge enabled him to show that Carlos Finlay's organism, Micrococcus tetragenus febris flavae was merely a common non-pathogenic tetrad tropic skin coccus, which often accidentally contaminated cultures. About this time he originated the alkaline treatment of yellow fever.

In 1890 he published his researches on the " Etiology and Prevention of Yellow Fever."

In October, 1890, he was again assigned to San Francisco, where he pursued his scientific studies, worked on his Manual of Bacteriology and lectured on preventive medicine and sanitary conditions.

In February, 1892, he returned to New York as Surgeon and Examiner of Eecruits ; it was at this time that j\Irs. Sternberg isolated a new protozoon in Brooklyn which was named after Dr. Hoagland.

In September, 1892, during the Hamburg cholera epidemic. Dr. Sternberg was called as an authority into active and most successful cooperation in the quarantine service. His " Disinfection at Quarantine Stations, Especially against Cholera," ' and other papers written at this time were full of practical interest.

On May 30, 1893, he was made Surgeon General of the United States Army. This high position of responsibility increased his powers for service, and one act taken promptly and with far-reaching consequences was to put Walter Eeed in the pathological laboratory of The Johns Hopkins Hospital for advanced study, preparing the way for his great work. At General Sternberg's recommendation the Army Medical School in Washington, D. C, was established June 24, 1893, designed to instruct approved candidates for the Medical Corps of the army in their duties as medical officers. The faculty consisted of : 1. A president of the Faculty, lecturing on duties in w-ar and peace ; 2. A professor of Military Surgery ; 3. A professor of Military Hygiene (Sanitary) ; 4. A professor of Clinical and Sanitary Microscopy.

In 1893 he was appointed physician to President Cleveland when in Washington, vice his regular physician Dr. Joseph D. Bryant of New York. As Surgeon General he made all possible efforts to advance the interests and standing of the Medical Corps, and yet, with a strange lack of foresight, our House of Eepresentatives in point of fact slaughtered his Medical Corps by reducing its numerical strength from 135 to 110, without making any provision for employing acting Assistant Surgeons. The sanitan' atrocities of the troop stations in the Spanish American war were due to the utter lack of preparation for war of " a proud country " [s?'c], and yet all the data needed for perfect sanitary administration were in the hands of General Sternberg. Is it to be wondered at that he was unable to render them effective among the undisciplined troops served often by poor and ill-trained medical


'New York Medical .louniat, 1893, xvii, 57.


men, one of the best known of whom scorned the value of carbolic acid and all antiseptics and the dangers contamination ? And so it happened tliat of the 6406 deaths among volunteers and regulars, 5438 were from disease, whereas only 968 fell before the human foe.- The experiences of the Civil War were repeated in a far more enlightened age.

The Spaui^Jh War afforded an added brilliant illustration of the fact that knowledge and good laws are insutiicient unless backed by a healthy informed public opinion and cooperation. The ignorance of the doctors appears in the cases of typhoid fever diagnosed as malaria, dengue fever, indigestion, or not reported at all. " In all regiments the death rate from indigestion amounted to 15 per cent of the completed cases! "

Two great lessons stand out from this war: (1) that a trained Medical Corps, suited to an army of 25,000 men in time of peace, is inadequate to take care of 250,000 men at war; (2) that physicians and surgeons taken from private life cannot suddenly undertake to discharge the duties of trained medical officers to an army in the field.

In 1900, it was due to Sternberg that a board of medical officers, including Dr. Eich and Professor Strong, was appointed to go to the Philippines to study tropical diseases, beriberi, the dysenteries, and diseases caused by intestinal parasites and malarial fevers. Here Strong found that the motile aiwxha dyscnteria was the cause of the prevailing fatal dysenteries, and isolated a bacillus in some cases, similar to Shiga's (1898). Hookworm disease (1899) was shown by Bailey K. Ashford, graduate of the army school, to be the cause of the anaemia and dropsy so prevalent in Porto Eico, instead of malaria, which up to that time had been held responsible.

In 1900 the crowning event of Sternberg's administration was the discovery of the mode of spread of yellow fever by Walter Eeed and his party, established near Havana, Cuba, thus proving conclusively Carlos Onlay's hypothesis, and setting on foot the efficient methods for the extermination of the disease, so brilliantly successful in tlie hands of that practical genius, Major Gorgas (later to be, in his turn. Surgeon General). These two pieces of work constituted the greatest achievement of American medicine, an accomplishment, as a piece of applied scientific work, equal to anything the world has yet seen. Like Moses, who viewed the promised land from Mount Nebo, so Sternberg had worked and sweated over this great subject for the best part of his busy life ; it was the one great prize he coveted and he had held it as it were in his hand, when he carefully discussed and rejected Carlos Finlay's theory and inoculation experiments in 1891; but to enter the land of promise was given not to him but to a subordinate working as head of the commission which he appointed.

In 1901 a tour of inspection of four months was made in the Philippine Islands, by order of President McKinley, to determine health conditions for the army.

On December 8, 1900, he addressed the Philosophical Society of Washington, under the auspices of the Academy of Sciences, on malaria.'


'Smithsonian Report for 1900.


From May, 1893, to June 8, 1902, when he retired, lii. years were full of intensive work.

In 1897 he became actively interested with Dr. Geo. M. Kober of Washington, in providing sanitary dwellings for people in moderate circumstances, the design being to replace the wretched alley homes. This was accomplished by first providing improved homes for the better class of wage earners, whose vacated houses were then occupied by those lower down. In this way, standard sanitary homes with individuality were secui-ed at reasonable rentals, with a dividend profit of five per cent.

General Sternberg also was interested in passing a law compelling the proper repair or removal of buildings unfit for dwellings. These activities stimulated extensive private enterprises in the erection of two-story sanitary flats.

He was a charter member of the National Association for the Study of Tuberculosis, and as President of the Society for the Prevention of Tuberculosis in the District of Columbia, from 1908 to 1915, he hammered continuously at the disgraceful conditions tolerated in the national capital by indifferent incompetent eongi'essmeu. An opportunity of making an intensive practical application of his life-long work and studies in the field, was afforded him in his appointment by President Theodore Eoosevelt with a commission of 14 on a " President's Homes Commission." The result was a pioneer report in industrial hygiene.

At the International Congress on Tuberculosis, in Washington 1908, at the dinner to Eobert Koch, he was dubbed affectionately by Koch, the " father of American bacteriology."

In part as a result of his tuliereulosis work the death rate in Washington from this disease was reduced from 492 per lumdred thousand in 1900, among the colored people, to 312 in 1917, and among the white from 188 to 93.

He died peacefully on November 3, 1915, at the age of 77 years, and his body rests beneath a massive block monument in the Arlington Cemeterj-. Thus passed away the greatest of all our Surgeon Generals up to his time, " America's pioneer bacteriologist" (Welch), a productive scientific investigator of disease, an accomplished sanitary expert, an administrator who greatly improved the organization and opportunities of the medical corps of the United States Army, a man of sterling character, a generous friend, a great humanitarian, whose greatest quality may perhaps be said to be that of unremitting industry and dogged perseverance in great causes, and who reaped rewards proportionately large.

In conclusion, I should like to emphasize the one blessing in life which Dr. Sternberg himself would have accounted the greatest, which he himself would have written first in any list in golden caj^ital letters. He had a remarkable wife, his survivor, in the fullest sympathy with all his aims, deeply interested and participating in every scientific problem which absorbed him, aiding him more especially in his microscopic work, and at the same time sharing in the pursuits which occupied his leisure hours — music, botany and archeology. It is she who has given ns a biography, profoundly sympathetic


January, 1931]


JOHNS HOPKINS HOSPITAL BULLETIN


and appreciative, yet showing a rare restraint. It recalls to one's mind another wifely biography dealing with a different field of endeavor, namely, that of Henrietta 0. Barnett, descriptive of her husband's life and work in Whitechapel, Lon


don, where too the biographer seeks in vain to obliterate her own great personality behind that of her husband. Would that life held more such sympathetic intimate cooperative fellowships.


HYDROCEPHALUS IN CHONDRODYSTROPHY

By Walter E. Dandy

(From the Department of Surgery, The Johns Hopkins Hospital and Vnirersity)

Chondrodystrophy or achondroplasia as a clinical and pathological entity needs no brief. The combination of short arms and legs, long trunk and big head at once stamps the condition as unique. The well-known changes, both gross and microscopic, in the epiphyses of the long bones make a pathological picture which is just as distinctive as that of the clinical manifestations. Though the subjects of this disease have figured in the art of the ancient Egyptians who worshipped the gods Bes and Ptah, both of whom have the characteristic iliondrodystrophic stature, and though recognized by every generation as a peculiar class of people with mental and physical shortcomings, the separation of chondrodystrophy into a distinct type of deformity really dates from Parrofs doscriptimi of tlus malady in 1878.

Prior thereto, Virchow (1856) had accurately described the disproportion in the size of the head and length of the arms, legs and trunk in dead foetuses, and regarded the disease as congenital myxoedema. Miiller (1860) accurately described the principal deformities and considered them manifestations of cretinism. Winkler (1871) felt himself forced to differentiate the condition from true rickets and called it 'rachitis micromelica." DePaul (1877-78) insisted that it was not the same as rickets. The gradual tendency to look upon the disease as distinctive reached its climax with Parrot's contribution. He completely separated the disease as a patho\/ logical entity but particularly identified the characteristic phenomena in the living, even in adults, and gave the clinical syndrome the name " achondroplasia," by which it has since been known. Additional evidence by Porak (1891) and Marie (1900) firmly established chondrodystrophy as a distinct I'linical entity. It is now generally recognized that this condition has no clinical or pathological resemblance to rickets, cretinism, micromelia, osteogenesis imperfecta or other diseases with which it had so long been confused, though quite a few writers, probably from inexperience, still fail to distingtiish rickets from achondroplasia.

Historical, histological, pathological and clinical treatises on chondrodystrophy have been so numerous and so thorough that additional repetitions are not necessary. The reader is referred to the admirable papers by Jansen, Kaufmann, and Siegert for the bibliography, the theories of the causation of the disease, the numerous cliniral characteristics and its gross and microscopic pathology.

The purpose of this paper is to present evidence bearing upon the cause of the enlarged head in chondrodystrophy. As noted above, the big head is one of the cardinal features of this disease. The explanations have been many, but proof in terms of necropsy material has been almost entirely lacking. Examinations of the skulls of persons afflicted with achondroplasia have been numerous and the descriptions very minute. A frequent observation in this material is a tribasal synostosis, as a result of which the base of the skull is frequently foreshortened, producing liraehycephaly with a receding bridge ^ of the nose. Doubtless this observation is true, but it offers no exjilanation for the increased size of the head. The prevailing ti'iiching is that the size of the head is only relative and y^ is set off liy tlie reduced stature of the individual; but this explanation js \';\r from satisfactory. In many instances this view may Ije pa.-sed over withoitt more than silent skepticism Ijut usually the head is far too large to conform to any relative standard ; there w an absolute enlargement.

It is difficult to imagine an absolute increase in the size of the cranium except as a result of pressure exerted by the intracranial contents : any increased pressure must be due to some abnormal intracranial condition. The cause could easily be explained by means of post-mortem examinations of the brain but these are singularly lacking. This is only natural, for the achondroplasia is essentially a lesion of the bones and the changes in the skull would hardly have been considered of different causation than those of the long bones.

In the volume of the " Treasury of Htmian Inheritance " by Eisclibieth and BaiTingtou, devoted to dwarfism, achondroplasia is considered at length. A number of photographs of victims of this disease are shown. One showing a group of dwarfs (Fig. 60) is particularly striking, because of the emphasis on the size of the head in the legend beneath, which reads as follows : " Large group of ateliotic cases and four cases of achondroplasia. The latter may be recognized by their large heads and adult faces." But no explanation of the enlarged head is offered. The head of an ateliotic dwarf is in proportion to the rest of the body; the head of an achondroplastic dwarf is disproportionately large.

Virchow first called attention to the shortening of the base of the skull although, of course, he did not conceive of achondroplasia as a distinct disease, regarding it as akin to fostal rickets or cretinism. Though he explained the shortening by a premature union of the tribasal bones, whence the name " triljasal synostosis," the real cause was found by Kaufmann and substantiated by Jansen and others to be a lack of development of the bones at the base of the sktdl, as of the other bones of the body. In a series of 13 cases, Kaufmann found, without exception, this shortening of the base of the skull. Parhon, Shunda and Zalplachta called attention to the increased breadth of the skull in a numter of cases taken from the literature. Taking the normal breadth of the skull to be 80 per J cent of the length, they found the brachycephalic index to be 81, 83, 87, 88, 94, and 100 in the series. They also noted an increased circumference of the head and made the important observation that the intellect is inversely proportional to the circumference of the head. Porak and Durante, also, noted that the head is often enlarged in chondrodystrophy. Jansen makes mention of hydrocephalus in achondroplasiii, saying, "the fact of the abnormally great circumference in other achondroplasts and in two cases of hydrocephalus among our five cases can be no mere accident." This is the most impressive statement and, supported by the best evidence of the existence of hydrocephalus that has come to my attention. In explanation of the hydrocephalus, he made the advanced hypothesis that the aqueduct of Sylvius or another part of the ventricular system was probably compressed and consequently the outflow of fluid was impeded. He mentioned, also, the possibility of vascular disturbances causing an increase of fluid by distortion of the vessels.

In an exhaustive treatise on hydrocephalus by D'Astros, there is a most interesting chapter on " Rachitisme cephalique," in which he concludes that an indisputable relationship exists between rickets and hydrocephalus. Boumeville supported the views of D'Astros and considered at least half of all hydrocephalic children to have rickety deformities of the thorax and vertebral column and assumed that rickets played some part in the prodiiction of the hydrocephalus. D'Astros admits the view that, in the great majority of cases of rickets, the cranial chamber is not larger than normal but he still thinks there is an increase in the amount of cerebrospinal fluid. He mentions the description of hydrocephalus in rickets by Glisson in 1651. Unfoi-tunately, these authors had not differentiated rickets from achondroplasia. D'Astros shows a photograph of a typical case of chondrodystrophy with hydrocephalus ; this photograph, which is given for a case of rickets, is reproduced here (Fig. 6). Undoubtedly, the incidence of hydrocephalus in chondrodystrophy would be much greater were the cases of ordinarj' rickets excluded, and it is evident why the arguments of these authors were unavailing in the absence of absolute proof from examinations of the brain. Many authors (Cestan, Swaboda, Kassowitz, Baylord, Lecouiiois, Eegnault. Marfan. Durante) claim that the large head is not hydrocephalic, that it is the bones that are hypertrophied, and that the size of the intracranial chamber is not increased. It should be mentioned here that there has never been any proof that an actual increase ' in the thickness of the bones of the skull exists.

The only record of a necropsy of the brain which I have found in the literature was by MaeCalluni. lie remarked in the course of a thorough necropsy report " On section, the cerebral ventricles were found markedly dilated with clear fluid." No caiise of the hydrocephalus was found and no explanation offered. The patient was 75 years old.


Recently, a boy of 19, with all the typical features of chondrodystrophy, entered the surgical service' of The Johns Hopkins Hospital for the correction of bow-legs. The very largo head was the most striking feature of the patient. It was out of all proportion to the rest of his dwarfed body and even when his body was concealed, the size of the head was scarcely less impressive. Moreover, his intelligence was far below normal.

My interest in chondrodystrophy was stimulated by this seeming paradox — a cranium larger than noiinal, but a defective mentality — paradoxical only in the light of the usual explanations offered. Were the brain of normal size or by some impossible chance hypertrophied so as to fill the increased cranial chamber, why should the function of the mind be reduced ? There must be some simple relationship between the size of the head and the mental deficiency. There is only one condition which could, at the same time, cause the head to enlarge and reduce the mental capacity and that is one of the most common of intracranial affections — hydrocephalus. The patient's mentality is little greater than that of a boy of six or seven. His large head, short arms and legs, and relatively long trunk are shown in the accompanying photographs. He is the third child; the other two being normal. Although the labor was very difficult, and the head unusually large, instruments were not used. The mother, who is very intelligent and observing, volunteered the information that for a long time after birth the head was soft and had not the resistance of a nonnal baby's head ; it was heavy and not until the patient was two years old could the head be held up. The anterior fontanelle was open until the fourth or fifth year. Eight years ago, (the patient was then 11 years old), he wore a 74 size hat. The head grew somewhat after that, but for several years tliere has been no growth. It is impossible to get hats to fit him ; his mother makes liis caps of stocking material. He learned to walk between the third and fourth year. He never crawled, but learned to move himself by rolling. He was three years old before he could talk but his speech was perfectly distinct and not abnormal. During the first three years, the patient was delicate, very restless and irritable and whined a great deal. Noises disturbed him and music made him unhappy. Teething began at the sixth month and continued at the norma] rate.

His memory is good in some ways. He carries out errand.perfectly well. He can tell the ages of all the members of the family and remembers telephone numbers very well, even those that are used only occasionally. He was a good speller and a good reader in school, but was poor in penmanship, geography, history, and mathematics. He can add, subtract, multiply, and divide very well Imt cannot grasp anything more complicated. He was in tlic sixth grade at school when he stopped, at the age of 18, but his mother thinks he had been pushed ailing n little faster than he should have been and was hardly capable of carrying work so advanced He plays with boys but gets along better with the older ones. He is quite sensitive about his stature and does not like to be teased. On the whole.



his disposition is very good. He is usually kind and agreeable, only occasionally showing evidences of temper.

Before the child was a year old, the family doctor told the mother that he had water on the brain. It was not noticed that his arms and legs were shorter than they should have been until he was 14 or 15 years of age. His growth has always been stunted but the mother thought " the condition of his head kept him small." Until throe or four years of age, the patient was troubled with enuresis, only at night, but the mother says that one of her other children has had this trouble just as badly. He is .subject to transitory attacks of unconsciousness, though without convulsions. At present, he delivers packages and is quite reliable.

The examination re\eiils a dwarf, I'.W em. in height, with the proportions as evident in the photograph. The circumference of the head is 65 cm. as contrasted with the normal of 54 cm. for his age. His epiphyses show delayed development, having tlie ajtpearance in the roentgenogram of those of a boy of 14 (Dr. Baetjer). There is a bilateral genu valgum. The hand is the characteristic mam en trident. The elbows cannot be extended beyond an angle of 160°. The Wasserniann reaction of the blood is negative, nor is there any hiistory of syphilis in the family. The genitalia are normal. Xo history indicating sexual precocity was elicited.

Evidence of HYDiiocEPHALrs by VENTKicrLOGRAPUv The determination of hydrocephalus and of its degree can be determined just as accurately by ventriculography as by a post-mortem examination of the brain. Through a ventricular puncture in the right occipital region, 350 c. c. of fluid were removed from the right lateral ventricle and an equal quantity of air was injected. Doubtless, 100 to 200 c. c. of fluid, or even more, could easily have been obtained, had I attempted to empty the ventricles completely, but, as it was only desirable to get a picture of one ventricle in profile and a view of both ventricles in cross-section, the removal of all the ventricular fluid was unnecessary.

It will be seen from the ventriculogram that the greater part of the intracranial chamber is filled with air. The picture of the enlarged ventricles is pathognomonic of hydrocephalus. But the ventriculogram shows a great deal more. It shows that the hydrocephalus is no longer progressive ; it has been arrested. This conclusion is i-eached because the air, which has been injected into the ventricle, has reached the farthermost radicles of the subarachnoid space — the cerebral sulci, which are shown as numerous wavy lines criss-crossing the roentgenogram. In other words, the air has had a free passageway from the lateral ventricle, through the third ventricl(>, the aqueduct of Sylvius, the fourth ventricle, and foramina of Luschka and Magendie into the cistema magna and the other cisternfc under the brain, and it has finally passed along the numerous primary branches and reached the cerebral sulci. It is here that cerebrospinal fluid is absorbed. If fluid (or air) reaches cdl or even many of the cerebral sulci from the ventricular system, it is proof that hydrocephaly cannot develop and, if the ventricles are already large, that the disease cannot be progressive. In those cases of hydrocephalus in which we have relieved an intraventricular obstrui-tion, whether from a tumor or an inflammatory process, the patency of the newly constructed opening can be demonstrated by the passage of air through it.

Further evidence that the subarachnoid space is yielding adequate absorption of cerebrospinal fluid in this case was shown by the quantitative absorption of phenolsulphonephthalein after its injection into the spinal canal. An absorption of 30 per cent was obtained during the first two hours following the injection. This is rather low but within the limits of normal. Furthermore, the colored fluid introduced into the spinal canal was later freely obtained from a lateral ventricle, thereby demonstrating the patency of the foramina of Luschka and Magendie, the aqueduct of Sylvius and the foramen of Monro. It should be noted that no convolutional atrophy of the skull or separation of the sutures is evident in the roent


Cause and Spontaneous Cuee of the Hydrocephalus From the accurate history given by the mother — the large head causing difficult labor at birth (the mother was a multipara and the child presented by the head), the large fontanelle with delayed clo.sure (3rd to 4th year), the delay in holding up the head and in beginning to walk — there is unmistakable evidence that the hydrocephalus was present at birth and was progressive during the early years of life. Apparently, it increased until the 12th or 13th year, the time at which the mother noticed that his head ceased to grow. During all these years, however, the accumulation of fluid must have been very slow, for had it been otherwise, the head would have assumed tremendous proportions.

In achondroplasia, we are confronted with an unusual type of hydrocephalus. Ordinarily, hydrocephalus is a progressive disease which is only occasionally cured spontaneously. But, apparently, in all the cases of achondroplasia in which the patients live past childhood — and many of them do — the hydrocephalus is arrested hut a big head and a defective brain are usually the result. This statement is not intended to imply that necessarily every case with a large head has a defective mentalitv, for a considerable destmction of the cerebral tissue may and does take place with little or no apparent mental changes. In fact, occasionally we see examples of a brilliant mind and, at times, even evidences of a kind of mental precocity in undoubted instances of hydrocephalus in achondroplasia, or in the other rarer instances of hydrocephalus in which a cure has resulted; but such instances are certainly rare. How, then, can we explain such an unusual type of hydrocephalus, occurring so constantly in achondroplasia and tending toward a spontaneous cure? From a survey of the cases in the literature, I believe there is a definite relationship between the size of the head and the intensity of the other bony changes in achondroplasia. It is generally conceded that in the most severe grades, and they comprise the greater number, the children die in utero or at birth. In these severe grades, the extremities may be small nubbins on a long trunk and the head will usually be large, though even a high grade of hydrocephalus at birth is uot always accompanied even by a striking enlargement of the head.

Two inferences are possible — if such a relationship can be proved to exist, either the hydrocephalus causes the changes in the bones, or the changes in the bones cause the hydrocephalus. It is not conceivable that injury of the brain could be responsible for the bony changes, for in hydrocephalus oi' other types, of all grades, and beginning either in the prenatal period or after birth, there are no such tendencies toward dwarfism or. to the production of micromelia. In some way, it would therefore seem that the hydrocephalus is probably secondary to the bony changes of achondroplasia. The primary changes in the bones of the skull have been recognized since the findings of Vircliow, tliough, as mentioned above, the explanation of the findings lias been materially altered. A distinct shortening of the base of the skull is probably present; it is doubtless due to osteogenetic deficiency, and is exactly comparable in its origin to the bony changes which result in the shortening of the humerus, femur and other long bones (the membranous bones apparently being exempt) . That this relationship exists. I do not doubt, but its explanation lacks the evidence of clinic;al studies of cases and necropsies. It is conceivable thai such a shortening of the base of the skull may compromise the growing Israin as to volume, but more vibilly as to position. A certain degree of kinking or bending of the brain-stem should follow, and it is possible or even probalile tliat thereby the lumen of the aqueduct would be reduced, producing a partial occlusion. It is also possible that the shortening of the base of the skull may similarly obstiiut the cistemse under the pons and midbrain, and as the cisternas form (he trunk of the tree of the subarachnoid spaces, an occlusion would produce results exactly comparable to those resulting from occlusion of the aqueduct of Sylvius. If either the aqueduct of Sylvius or the cistemse are affected in this manner, a partial obstruction might result. In the most advanced grades, the obstruction might well be complete. Sue h an inchision, either partial or complete, would inevitably cause hytlrocephalus by preventing the cerebrospinal fluid from reaching, in adequate quantity, the cercl)ral sulci, wliere all the absorption of cerebrospinal fluid is etfected. As the size of the skidl, particularly of the base, increases, it is conceivable that these occlusions may gradually lie automatically corrected. The intracranial pressure resulting from the increased amount of fluid could play such a role in correcting the hydrocephalus by stretching the membranous bones of the vault and ^lossibly even those of the base of llic skull.

Such an explanation is entirely hypothctii-al. It i> not ^^mceivable that any of the usual obstnictions at I be iujueduci of Sylvius, either tumors or cicatricial stenoses, could explain the hydrocephalus, because these pathological changes are almost universally progressive and corrections could scarcely result spontaneously. Nor, for the same reason, could the usual inflammatory changes in the cistemse or at the foramina of Luschka and Magendie produce this type of hydrocephalus.

A second patient (Fig. 4) is also a typical achondroplastic dwarf vrith an abnormally large head which, undoubtedly, is due to hydrocephalus. It will be noted, however, that the head is not brachycephalic ; it might be even classified as dolichocephalic, though the lateral enlargement is almost as conspicuous as the antero-posterior. As a matter of fact, there is no apparent shortening of the antero-posterior diameter of the head in the first case.

The history of the second patient is of little value because of the mother's lack of observation. She does not know, even approximately, when the anterior fontanelle closed, when the patient learned to hold up his head, to walk or to talk. She has two children, but had not observed anything wrong with this boy, although the neighbors frequently called attention to his large head. He seemed perfectly well and strong after birth, which followed a di7 labor. There is an added complication, the importance of which it is difficult to estimate. When three years old, the patient had a severe attack of meningitis, with characteristic opisthotonos, cervical rigidity, vomiting, etc. It is well recognized how frequently hydrocephalus follows meningitis, but the mother is confident that the baby's head was large before this illness, and that there was a quick and apparently complete recovei-y from meningitis. His mother brought him to the hospital because of stunted growth, he not having grown perceptibly in the past two years. He is 102 cm. high, contrasted with the normal of 117.4 cm. for his age. His head measures 63 em., the normal for seven years being 51 cm. During the pa.st year, he has been under frequent observation at the hospital and during this time his head has grown .3.5 cm. He is now a bright boy ; he stands well in his classes at school, ranking tenth in a class of 45 children. He complains of no headaches ; but his mother and the teacher at school have had great difficulty in getting him to hold up his liead. Whenever possible, he lies down, or when sitting, finds some oljject upon which to rest his head. The roentgenogram shows a definite increase in the intracranial pressure, evidenced by a mild grade of convolutional atrophy of the skull and by a slight separation' of the cranial sutures. A cracked-pot soimd is clearly demonstrable. In the preceding case, this atrophy of the skull is absent because the growth of the hydrocephalus has been arrested for some time. In this case, we have no absolute proof of the existence of hydrocephalus, which is demonstrated in the other case, though there can be no reasonable doubt, from the facts just enumerated, that it must' be present.

Tkeataiknt of tue Hydrocephalits Xaturally, tlii' most serious aspect of chondrodystrophy is tlic mental impairment caused Ijy tlie hydrocephalus. Can this Vie remedied in any way ? Since the introduction of the newer methods by which the diagnosis and localization of intracranial lesions are made ])ossible, icures of hydrocephalus are now frequently obtained by correction of the cause. I am confident that a careful study of each case of hydrocephalus in


Fig. 3. — Enlarged front view uf same i>atieiit.


Fig. 1. — This boy of 19 years is the victim of achondroplasia. His head is large, not only relatively but absolutely. This increased volume of the head is due to liydrocephalus. Tlie history of the patient is given in the text. The ventriculogram showing tlie degree of hydrocephalus is shown in Fig. 9. The intelligence oi tliis boy is greatly reduced.


Fig. 5. — Profile view of same child


Fig. 2. — JOnlargeJ protile slew of head of the same achondroplastic boy to show shape of head.


Vw,. 1. - All eight years with typical achondroplasia. His head is relatively larger than that of the preceding patient. His intelligence is still normal but the head is increasing in size. A ventriculogram was not obtained, but the existence of hydrocephalus can scarcely be doubted, especially after seeing the ventriculogram of the preceding case.


Fig. X. — Kacliitismecephalique. —Kt . . ., 12 ans (obs. VI). Cet enfant a la tailie d'un enfant de sept ans. Cette petite taille qui contraste avec le volume e.xagCre de la tete est due surtout au rachitisme des membres inferieurs.

Fig. 6. — This photograph and legend are copied from D'Astros' book in which he considers a form of cephalic rickets. The picture is that of a typical achondroplasiac with the characteristic large head, short arms and legs and long trunk.


Fig. 7. — Veiitrienluiiium of :i iionual lateral ventricle, lateral view.


Fig. 8. — Antwu [Hi^iei lor ventriculogram of normal ventricles.


Fig. 9. — Ventriculogram (piolile vi.\, i ..i ihe lateral ventricle of the patient shown in Fig. 1. The air has not tilled tlie entire ventricle hut the tremendous enlargement of the ventricle is strikingly demonstrated. The thickness of the cereliral corte.x is of course correspondingly reduced.



Fig. 10. — Antero-posteriur ventriculogram of the same case of droplasia (Fig. 9).


achondroplasia by these methods will accurately define and locate the cause of hydrocephalus and tliereby indicate a rational form of operative treatment which may stop the disease and prevent the cerebral destruction with its resulting mental impairment. The second case is an example in point. Undoubtedly, the hydrocephalus is still progressing; a growth of the head of 3.5 cm. in a year is sufficient indication. The separation of the sutures and the convolutional atrophy of the skull make this almost certain. At present, his mind is not noticeably impaired, but, in time, mental impairment is inevitable unless the progress of the hydrocephalus soon ceases. In order to locate the site of the cause of his hydrocephalus, he should be tested by intraventricular and intraspinous injections of air, and by the phenolsulphonephthalein intraspinous test, to determine the quantitative absorption from the suliarachnoid space and also the presence or absence of organic obstructions in the ventricular system. Since it is now possible to detect with such accuracy where an obstructive lesion lies, to tell whether an occlusion is partial or complete, and to determine whether and to what degree the subarachnoid space is absorbing cerebrospinal fluid, we should not permit the destructive sequelae of hydrocephalus to develop until every possibility of cure has been eliminated. After the cause of the hydrocephalus has been determined, it is hoped the cure of the disease may be possible and in the earlier stages, instead of awaiting the usual spontaneous correction at which time the mentality is usually ii-reparably impaired.

Conclusions

1. The large head in our cases of chondrodystrophy has been shown by ventriculography to be due to hydrocephalus. The large heads of other recorded cases presumably liave a similar cau.se.

2. Hydrocephalus in achondroplasia differs from other types of hydrocephalus in that its development tends to cease spontaneously. In some instances, at least in the two cases here reported, it progTessed very slowly and for a long period before arrest eventually took place.

3. When untreated, a defective brain, it would seem, inevitably results.

4. We have had no opportunity to observe the progression of hydrocephalus, but it may be possible, by the newer methods of intracranial study, to ascertain the cause and possibly avert the disastrous sequelae.

5. The size of the head and, therefore, the grade of hydrocephalus seems to be proportionate to the severity of the dwarf phenomena in chondrodystrophy.

BIBLIOGRAPHY

Apert, E. : Quelques remaiques sur 1' acliondroplasie. Deux obsevvations nouvelles de 1' acliondroplasie adulte. Nouv. ieonog. de Ui Saltpetri&re, Paris, 1901, t. XIV, 297.

Baylord: (Reference by D' Astros.)

Bertolottl, M. : Contribution a 1' etude de 1' acliondroplasie. Interpretation des varietes morphologiques basee sur 1' ontogen^se. Presse mM.,' Paris, 1913, XXI, 52.5-531.

Boeckh: Arch. f. Gynak., 1893, XLIII.

Bourneville: Les Hydrocephalies, par D'Astros. Paris, 1898.

Cestan, R. : A propos d' un cas d' achondroplasie. Nouv. ieonog. de la Salpetriere, Paris, 1901, XIV, 277-289.

Charpentier: Arch, de Tocologie, 1876, 545.

Dandy, W. E. : Ventriculography following the injection of air into the cerebral ventricles. Ann. Surg., July, 1918.

Idem : Fluoroscopy of the cerebral ventricles. Bull. .Johns Hopkins Hosp., Feb., 1919.

Idem: Roentgenography of the brain after the injection of air into the spinal canal. Ann. Surg., Oct., 1919.

Idem: Localization or elimination of cerebral tumors by ventriculography. Surg., Gynee. & Obst., Apr., 1920.

D'Astros, Leon: Les Hydrocephalies. Paris, 1898.

DePaul, J. A. H.: Sur une maladie speciale du systfeme osseux, developpee pendant la vie intrauterine, et qui est generalement dficrite, a tort selon raoi, sous le nom de raehitisnie. Arch, de Tocologie, d. mal. d. fern, et d. enf. nouveaux-nes, 4" annee, pp. 641-650. Paris, 1877. AUo: 5° annee, Paris, 1878, pp. 1-8, 321-332, 424-431, 449-457.

Doutrebente et JIanouvrier, L. : Le cerveau, le crane, etc., d' un nain racliitique et aliene. C'onipt. rend. Ass. fran?. p. 1' avance. de ac, Paris, 1888, t. XVII, 2» pt., pp. 405-412.

Durante, M. : Deux cas d' achondroplasie avec examen histologique des OS et du systfeme nerveux. Bull. Soc. anat. de Paris, 785. 1900.

Emerson, Charles P.: Article in Modern Medicine (Osier and ilcCrae), 1914, V, 958.

Jansen, Murk: Achondroplasia — Its nature and its causes. A study of the stunting of growth in embryonic cell groups caused by amnion pressure in the different stages of the development of the skeleton. Leyden, 1912. Published by E. J. Brill, Ltd.

Kassowitz, Max: Infantiles Myxodem, Mongolismus und Mikromelie. Wien. med. Wchnschr., 1902, XXVIII, 1358.

Kaufman: Chondrodystrophia foetalis. Untersuchungen iiber die sogenannte foetale Rliacitis. Berlin, 1892.

"LeCourtois: (Reference by D'Astros.)

MacCallum, W. G.: Chondrodystrophia foetalis. Johns Hopkins Hosp. Bull., 1915, XXVI, 182-185.

Marchand, F. .J.: Ueber die Synostose d. Schadelbasis bei sogenannter fotaler Rachitis. Tageblatt der 58. Naturforschenden Sammlung zu Strassburg, S. 422-423. Strassburg, 1885.

Marfan: Rachitisme. Traite de mkA. et de therap., 1897.

Marie, Pierre: L' achondroplasie dans 1' adolescence et 1' age adulte. Le Presse niM., No. 56. Juillet, 1900, II, 17.

Milller, H.: Ueber die sogenannte fotale Rachitis als eigenthiimliche abweichung der Skeletbildung und iiber ihre Beziehungen zu deui Cretinisuius bei Thieren, sowie zu der Bildung von Varietaten. Wiirzburger med. Ztschr., 1860, I, 221-276.

Parrot, J.: Sur les malformations achondroplasiques et le Dieu Phtah. Bull. Soc. d' Anthrop. de~1Faris, Z" s^r. t. I, pp. 296-302. Paris, 1878.

Porak, C. : De 1' achondroplasie. Nouv. Arch, d' obst. et de gyn«c. t. IV, pp. 551-573. Paris, 1889. Also: t. V, pp. 9-31, 60-68, 133141, 223-233, 303-307, 380-387, 421-439. Paris, 1890.

Porak and Durante: Les micromelies congenitales. Ieonog. de hi Salpetriere, 1905. P. 485.

Parhon, Shunda and Zalplachta : Ieonog. de la Salpetriere, 1905.

Regnault: Des alterations craniennes dans le rachitisme. Thise de Paris, 1888.

Regnault, Felix: L' achondroplasie chez le chien, pp. 386-389. Du crane de 1' acliondroplase chez le foetus et chez 1' adulte, pp. 424-420. Bull. Soc. anat. de Paris, 1901, 6« sdrie, t. III.

Idem: L' achondroplasie. (Plates.) Arch. g6n. de med., n, s., t. VII, 232-255. Paris, 1902.

Rischbieth, H., and Barrington, Amy: Dwarfism. Eugenics Laboratory Memoirs, XV, Treasury of Human Inheritance, Parts VII and VIII, Section XVa.

Siegert, F.: Der chondrodystropliispUe Zwergrvvuchs (Mikromelie) . i:ifrebn. d. inn. Med. u. Kiiiderh., Berlin. 1912, VIII, 64-89.

Swoboda, N. : Cliondrodystrophisehe.'; Kind einer chondrodystroplii schen Zwergin. Mitt. d. Gesellsch. f. Inn. Med. u. Kinderh., Wieii. 1913, XII. 141-14.->.

Virchow, Rudolf: Knochenwachstum und Seliadelfoimcn mit besimderer Riicksiclit auf Cretinismus. Virchows Arcb., 1858, XIII, .12.V357.

Idem: Zur Pathologie des Schiidels und des Gehirns. Gesammelte Abhandlungen ziir wissenschaftlichen Med.. S. 88.5-1014. Frankfurt a. M. 1856.

Wagner. G. \.: I'elier faniiliUre Cliondnidy>tro]iIiie. Arcb. f. Gynak., 1913, C. 70-134.

Winkler, X. F. : Kin Fall von fotaler Rachitic mit Mikromeli.'. Arch. f. Gvniik., Berlin. 1871, II, 101-110.


THE MECHANISM OF THE CARRIER STATE, WITH SPECIAL REFERENCE TO CARRIERS OF FRIEDLANDER'S BACILLUS

I'lV .Vkthur L. BLOOii field

{From llic llioloiiical Dirision of the Medical Clinic, The Johns Ilu/jkinn I ni


ilii and Hospital)


JJuriiig the course of experiments on the fate of bacteria introduced into the upper air passages, we became interested in tlic question of the mouth as an environment for bacterial Efrowth. 'J'he rapid disappearance of foreign organisms after experimental introduction suggested that the free surfaces of the buccal mucous membranes, when intact, were unfavorable for the colonization and growth of extraneous bacteria.' As a corollary of this conclusion the question arose whether in tlie so-called carrier state the organisms are confined solely to some acute or chronic focus of diseased tissue whence they are discharged to the free surfaces of the mouth and throat, ur whether the organisms aettially live on and grow dilVusoly over these surfaces.

We have found no experimental evidence liiMiiiig on this point, but clinical observations suggest the groiit importanee of a focus of infection in the mechanism of the iiirrier state. A brief review of these facts may be presented before detailing our experimental observations.

Cl.INICAI, ObSEKV.VTIONS on the L0C.\LlZ.\ri0N or I! M ri-KTA

IN CiinoNic Carriers

Tn the present discussion we shall consider (inly Mi-iallcd chronic carriers. By this term we mean individual? who linrbor, more or less constantly, in the upper air passages, sdino ]iathogenic organism, either following disea.se, or without any lii.storj' of previous disease due to the organism in i|iu'stion. .\ few of the main types of such carriers may lir mentioned to illustrate the principles involved.

1. Diphtheria Carriers. — The persistence of positive cultures in many instances following diphtheria is a matter of common experience. Often the organisms are present for indefinitely long periods — months or even years. In such cases they not uncommonly disap])ear following tonsillectomy, when all other measures had previously beeu imavailing. The fact that cultures made from the depths of the crypts or from beneath the capsule of the excised tonsils show numerous diphtheria bacilli suggc.«ts that tbt'.'^c glands were the breeding ]ilace of the organisms, and lluit llicy were not growing nnd nuilliplying on the free surfaces of the normal mucous membranes.

3. SireptocovcHx Carriers. — The presence of viiident hemolytic streptococci in the throats of healthy people has been fre


quently noted, especially at times when streptococcus infections are prevalent. Although the organisms may occasionally be obtained from the throat or nose, it is found in general that a much higher percentage of positive yields results if cultures are made from tonsil crypts. Thus, Pilot and Davis" found /? hemolytic streptococci in almost 100 per cent of excised tonsils. Furthermore, it ajijiears that in streptococcus carriers tonsillectomy is often followed by the disappearance of the organisms from the throat (Tongs," Van Dyke*). These observations suggest that here again the tonsil often is the breeding place of the strejitococcus whence it is discharged to the free surface of the throat without actually colonizing there.

3. Meningococcus Carriers. — In a variable number of normal individuals meningococci are found on repeated cultures. Studies such as those of HeiTold ° show that a much larger jjercentage of positive cultures can be obtained from the nasopharynx than from the tonsils, nares, or sputum. Furthermore, the application of disinfectants directly to the nasopharj'nx seems to lead to the clearing up of carriers more promptly than treatment of other parts of the upper air])assages.

in summary, then, the weight of clinical evidence in the case of carriers of important pathogens tends to show that the organisms actually colonize in a focus of diseased tissue in the upper air-passages whence they are discharged to the free surfaces. It seems probable that bacteria do not actually localize and grow upon the latter, but that they are constantly washed away only to be replaced by other organisms freshly discharged from the focus. We have been unable, howevei;, to find any actual experimental proof or disproof of this idea.

In the course of some studies of Friedliinder bacillus carriers, methods by which this point might be demonstrated suggested themselves, and the present paper deals with these observations. They are based mainly on ;ui intensive study of three carriers whose histories ;ire ap|»'n(lcd in some detail.

C.VSE I. — G., aged 50, colored, male.

Diagnosis. — Syphilis, anetirism of aortic arch, aortic insufBciency, myocardial insufficiency.

Histori/. — No history of s-evere colds, of sinus infection, tonsillitis, cough or pneumonia.


Jandary, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


11


Examination. — Nose, negative except for racial liypertropliy of turbinates. Tonsils, mo<lerately enlarged and injected. Pharynx, negative. Larynx, negative. Ears, negative.

C.4SE II. — \V. .J., aged 31, male, colored.

Diagnosis. — Acute nephritis.

History. — Frequent colds but no sore llirnats or tonsillitis. No pneumonia. No cold " this year."

Examination. — Nose, anterior ends of middle turbinates look normal. There is no discharge. Tonsils, embedded. There are numerous plugged crypts on each side. Pharynx, negative, Naso-pharynx, a moderate amount of adenoid tissue is seen. Ears, drums intact, no retraction. Sinuses, clear on transillumination.

Case III.— J. H. Hosp. Med, No, 42,846, white, aged 34.

Diagnosis. — Chronic ibeumatie endocarditis, aortic and mitral in-ufliciency.

History. — No history of severe colds, sore throats, sinus infection-. or pneumonia.

Examination. — Nose, septum deflected to right causing partial nasal obstruction. Small amount of discharge on both sides. Pharynx, clear. Ears, marked grade of retraction of drums on both sides. Tonsils, moderately enlarged and adherent. Naso-pharynx, polypoid inferior turbinate posteriorly on right. Kustachian orifices clear. No discharge from posterior sinus orifices.

Incidence of Fricdlander BaciUu^ Carriers. — Eighty-five uu-selected individuals were examined. The Friedlander Ijaeilhis was isolated from the throats of five — a percentage of 5,8.

Persistence of Friedlander Bacilli in Carriers. — In everjinstance the carrier state persisted during the entire period of ohservation (Table I), We have no idea of its previous or .-subsequent histoi-}-.

T.A^BLE I.— PERSISTENCE OF FRIEDLANDER'S BACILLUS IN CABRIERS


Name


Period of observation


Number of cultures


Number positive


Number negative


Last culture


G.


42 days.


16


16



Positive.


J.


36 days.


12


12



Positive.


W.


Four months.


15


13


2


Positive.


H.


Three months.


16


1-1


2


Positive.


Spread of Friedlander Bacilli from Garner to Contacts. — It seemed of interest to determine whether there was any tendency for contacts to acquire the organisms from the carriers and possibly to develop a carrier state themselves. Patient W. was in the ward for several months. During this period 285 throat cultures were made on 31 other patients in more or less close contact with him. In no instance was Friedlander's bacillus recovered. Subsequently more careful contact observations were made on two other patients. Tlio carrier and the contact were placed in adjacent beds. No attempt at isolation was made and they used the same bed-tal)lp and to some extent the same utensils. Cultures were made tiaily from the throats of contact and carrier (See Table II). .\t no time were Friedlander bacilli recovered from the contacts in spite of their persistance in the carrier. These observations agree with our experiments on the rapid disappear


ance of these organisms when experimentally introduced into the mouth in large numbers and afford an interesting contrast to the rapid spread of an organism which is producing disease

TABLE II.— SUMMARY OF CULTURES FROM FRIEDLANDER BACILLUS CARRIERS AND FROM CONTACTS




Bed 1


Bed 2


Bed 3




Carrier G


Carrier J


Contact T




Feb. 17.


March 20


March 20


Culture on March 23.


-1

+




" 24.


+


+




" 2.5.


-1

+




" 27.


+


+




" 29.


-1

+




" 30.


+


+

Contact T March 30




" 31.


+





April 1.


+





3.


+





5.


+



Contact W .\pril 6




7.


+





8.


+





9.


+





" 12.


+

Carrier J April 1



Contact C .\pril 5




6.


+





7.


+





8.


+





9.


+





" 10.


+





11,


+





" 12.


+





such as occurs, for example, in epidemics of streptococcus infection.

Site of Localization of the Friedlander Bacilli in Carriers. — Cultures were made from various parts of the upper air-pas TABLE III.— RESULTS OF CULTURES IVLADE FROM VARIOUS PARTS OF THE UPPER AIR PASSAGES IN FRIEDLANDER B.\CILLUS CARRIERS


Case


Date of cult.


Nares, right


Nares, left


Throat


Right tonsil


Left tonsil


Pharynx


G. lMch.27.


No F.


No F.


13 cols. F.


_



.



" 29.


No F.


No F.


00 F.


. —





Apr. 4.


2cols.F.


No F.


00 F.



. —




" 5.*


No F.


1 col. F.


X F.



. —



" 6.*


No F.


No F.



lOOeols.F


NoF.


NoF.


'• 8.*l No F.


No F.



00 F.


NoF.


NoF,


.L Mcb.27. No F.


cc F.


cc F. " 29. No F.


No F.


« F,





" 31.1 No F.


No F.


00 F,


. —




jApr. 8.*; No F.


No F.


.


3 cols, F.


13 cols. F.


4 cols. F.


" 9.*| No F.


NoF.



00 F.


6 cols. F,


22 cols. F,


" ll.*.5eols.F.


No F.


"^


00 F.


NoF.


4 cols. F.


Throat thoroughly gargled with water bc^fore cultures


sages to determine the relative number of organisms present. As appears in Table III, while the organisms were found constantly in the pharynx in large numbers, a few were occasion


12


ally recovered from the nares as well. The sequence of cultures seems to show that such organisms are introduced accidentally from the pharynx, and are promptly washed away without localizing on the nasal mucosa. Further differential cultures in two cases also showed that the organisms were constantly present on one tonsil. The tonsil, therefore, seemed to be the focus from which the bacteria were disseminated through the buccal cavity.

Re-Implantation of Carrier's Strain on His Own Mucous Membranes. — With the above observations in mind, it seemed of interest to re-introduce the carrier's own strain upon his own mucous membrane. It seemed that this might give information as to whether these surfaces behave like those of normal individuals in whom the organisms introduced are promptly washed away, or whether, in the carrier, the organisms have adapted themselves to a free growth on the open surfaces of the upper air-passages. It appeared (Table IV)

TABLE IV.— INTRODUCTION OF CARRIER'S OWN STRAIN UPON HIS OWN MUCOUS MEMBRANES


Namt


Date


Culture, right nose


Culture, left nose


G.


April 4.


2 cols. F.


No F.



One loop of solid grow lated


th B. FriedUindcr— St on left nasal septum.


rain G — inocu


Culture immediately. Culture after 1 liour. Culture after 24 hours. Culture after -18 hours.


No F. No F. No F. No F.


F.

F. No F. No F.


J.


March 29.


No F.


No F.



One loop of solid grow lated


th B. Friedlander— St on right nasal septum.


rain J I — inocu


Culture immediately. Culture after 1 liour. Culture after 1 day.


F.

V.

Several hundred cols.

F.

No. F.


No F. No F. No F.



Culture after 2 days.


No F.


that organisms introduced in this way did not persist, but disappeared at the same rate of speed as the Friedlander bacilli placed on the nasal septiun of the non-carrier."

Introduction of a Second Strain of Friedlander Bacilli upon the Mucous Membrane of the Carrier.- — It seemed of interest to determine how the carrier would react to the introduction of a second strain of B. Friedlander. Such an experiment was made possible by working with strains sufficiently different to enable one to differentiate the carrier's strain and the organism introduced. Carrier G. harbored an organism which had the following characteristics: Colonies up to 1 cm. in diameter, confluent. Greyish white, slightly opaque, sticky growth — not very stringy. Microscopically: short gramnegative bacilli with moderate capsule formation. Fermentation of sugars (24 hours) saccharose -f- , dextrose -t-,mannite -I- , lactose 0. Carrier J's strain grew with a profuse opalescent very sticky and stringy growth. Short gram-negative bacilli with very marked capsule formation. Fermentation of sugars (24 hours) — dextrose -|-, mannite-|-, saccharose 0, lactose 0.


When a mixture of these two strains was grown on the same plate it was readily possible to pick out the two different types of colonies. After control cultures had been made, each of these two carriers was inoculated with the other one's strain, and cultures were made at various intervals. The result of this experiment (Table V) is that the foreign strain replaces

TABLE v.— INTRODUCTION OF A SECOND STRAIN OF

B. FRIEDLANDER UPON THE MUCOUS

MEMBRANE OF THE CARRIER

Name G. March 28 Contro] culture before iiraculation (pharynx) = co cols, strain G. A large loopful of strain J. (fished from the original plate) was swabbed on G.'s tongue and pharynx.


Culture 1


afte


ediatcly (pharynj


) = oo cols, strain J.


— 6 cols. G.


2 hrs.

= oo cols, strain G.


- no cols. J.


24 hrs.


= CO cols, strain G.


— no cols. J.


48 hrs.


= 00 cols, strain G.


— no cols. J.


J. March 28—

Control culture before inoculation (pharynx) — oo cols, strain J. A large loopful of strain G. (fished from original plates) was swabbed on J.'s tongue and pharynx.

Culture made immediately (pharynx) = oo cols, strain G. — no cols. J.

" " after 2 hrs. " = many cols, strain G. — many cols. . J.

" '• '* 24 hrs. " = many cols, strain J. — no cols. G.

" 48 hrs. " = 00 cols, strain J. - no cols. G.

the carrier's strain in the cultures for a few hours, but promptly disappears, so that after 24 hours only the carrier's strain is recovered. In other words a carrier reacts to the introduction of a second strain of B. Friedlander just as a non-carrier does. This experiment seems to show then that there is no special alteration in the mucous membranes of the carrier which makes them a suitable medium for the growth of Friedlander bacilli in general.

Attempts at Carrier Production. — An attempt was made artificially to produce a carrier state by frequent re-inoculations. An individual (B), was inoculated by swabbing the tongue with a freshly isolated strain of B. Friedlander. Cultures were taken at various intervals following inoculation and daily reinoculations made with these cultures. This process was repeated daily for one week. Within 24 hours after the last inoculation this man was free from B. Friedlander. This result was Just what had been expected and lends some support to the view that a focus of infection is responsible for the carrier state in the case of this organism.

Discussion The present report, in summaiy, presents experimental evidence on. the mechanism of the carrier state, at least in certain instances. It has been possible to show in the case of these Friedlander bacillus carriers that the breeding place of the bacteria is in a definite focus — the tonsil. From this point the organisms are discharged into the open pharyngeal cavity, and at times may be introduced into the nose. There is no evidence, however, to indicate that any adaptation takes place between the bacilli and the mucous surfaces, leading to actual growth and multiplication on these surfaces. They react just as the normal mucous membranes do, both upon the introduction of the carrier's own strain, or the introduction of a second strain of Friedlander's bacillus.


Jancaey, 1931]


JOHNS HOPKINS HOSPITAL BULLETIN


13


Conclusions

1. Of 85 unselected individuals 5.8 per cent were found to be carriers of Friedlander's bacillus

2. The carrier state persisted throughout the period of observation.

3. There was no tendency for contacts to acquire the carrier state.

4. Differential cultures showed the breeding place of the Friedlander bacilli to be in the tonsil.

5. The carriers own strain or a foreign strain of Friedlander's bacillus implanted upon the free surfaces of the mucous membranes disappeared at the same rate of speed as in a non-carrier.


6. It was impossible artificially to produce a carrier state by repeated inoculation with B. Friedlander.

7. The general conclusion from these observations is that the carrier state depends on a focus of diseased tissue which affords a breeding place for the bacteria. They do not become adapted to growth on the free surfaces of the mucous membranes.

BIBLIOGRAPHY

1. Bloomfield, A. L.: Amer. Review Tuberculosis, 1920, IV, 247.

2. Pilot, I., and Davis, D. J.: Journal of Infect. Diseases, 1919, XXIV, p. 386.

3. Tongs, M. S.: Jour. Am. Med. Assn., 1919, LXXIII, p. 1050.

4. Van Dyke, H. B.: Jour. Am. Med. Assn., 1920, LXXIV, p. 448.

5. Herrold, R. D.: Jour. Am. Med. Assn., 1918, LXX, p. 82.

6. Bloomfield, A. L.: Johns Hopkins Hospital Bull., 1920, XXXI, 203.


TUBERCULOSIS OF THE KIDNEY IN WOMEN

By Leo Brady,

Assistant Resident Gynecologist

(From the Gynecological Department of The Johns Hopkins Hospital and Unii-ersitij)


This paper will deal precisely with the final results of surgical treatment. I shall speak briefly of diagnosis but shall not go into the pathology of the urinary tract, in view of the fact that this has been so well covered in many text-books.

Although the number of our cases is only 77, the record of our results is of interest for the following reasons: (1) The diagnosis in these 77 cases is sure because the specimens obtained from the patients operated upon presented the typical gross and microscopic pictures of tuberculosis of the kidney, and in the cases in which no operative interference was deemed available the urinary findings and cystoscopic findings left no doubt as to the pathological condition from which the patient was suffering. (2) A large proportion of our cases were treated many years ago. One patient, for instance, is alive and well 20 years after her operation, another 22 years, and quite a considerable number after fifteen years. Finally, the method of operating in this clinic has not been uniform, and it is of interest to compare the results obtained by the different methods. In some cases only the kidney was excised while in others a second incision, usually a McBurney, was made and the ureter was removed extraperitoneally down to the uterine vessels ; or the excision was complete and included a section of the bladder wall. This simultaneous extirpation of the kidney and ureter was first described in Februa:-y 1896, by Dr. Howard A. Kelly (The Johns Hopkins Hospital Bulletin, 1896, VII).

A careful study of the histories of our cases has given us the following information : In our 77 cases there was a definite family histoiy of tuberculosis in 14, or 18 per cent. By definite family history I mean that some member of the immediate family had had tuberculosis and do not refer to tuberculosis in distant relatives. In 46 cases the right kidney was affected, in 27 the left , and in 4 the disease was bilateral.


The average a^ and the majority fourth decades, cording to their average duration is given.

Age Below 20 . . Between 20 Between 30 Between 40 Above 50 . .


e of our patients on admission was 33 years, had begun to have symptoms in the third or The following table groups the patients acages on admission and in each group the of symptoms before entrance to the hospital


Number of cases

admitted to the

hospital


and 30 26

and 40 27

and 50 9

7


Average duration of symptoms before admission

16 months

26 months

48 months

36 months

18 months


The average duration of symptoms in our cases before admission to the hospital was 33 months. The oldest patient in our series, L. G. (Gyn. No. 8745), came into the hospital in her fifty-seventh year, with tubercle bacilli in her urine and a history of dysuria and polyuria that had lasted for five years. The left kidney and ureter were removed and were both found to be tuberculous. Under irrigations the accompanying cystitis cleared up entirely in two years, and the patient then had fix e years of very good health before dying suddenly of heart trouble. The youngest patient, F. B. (Gyn. No. 23676), aged 14, had had dysuria and polyuria for eight months before coming to us. She is now well, three years after the removal of a tuberculous kidney.

Of 77 patients, 71 were white and 6 colored. On our service, one negro is admitted to the hospital for every three white women; hence it would appear that, while tuberculosis of the kidney is relatively infrequent in tlie colored race, it cannot he said to be rare.

Twenty-five, or 32 per cent, of the patients complained of hematuria and in eight of these it was the first symptom. Two patients first noticed general weakness, and in all the


14


other cases dysuria aii.l \nAyuv\A wore the first evideiiees of the kidney disease.

The general physical cxaniinatioii >lioutil |iuliiioiiary tuberculosis in six cases. Four of these iiaticnts had activr. two inactive, pulmonary tuberculosis. One patient dcvrlopcd tuberculous peritonitis two years after the removal of a tulieiculous kidney. In four cases only was a marked enlargejnent of the kidney noted, and in all these cases we found at operation that we were dealing with cases of tuberculous pyelonephrosis. The routine gynecological pelvic examination showed the ureter to be thickened and tender ii] 23 cases. This nodular thickening with tenderness of the portion of the ureter which can be felt on vaginal examination has in this clinic been of great help in promptly directing our attention to the probability of tuberculosis of the urinary tract. The importance of ureteral palpation in women was brought out b\ Dr. Kelly in an article published in 1888 in Vol. VIII of the Transactions of the American Gynecological Society.

Before recording the results obtained by operative interference I shall first give a brief summary of those in patients noti operated on. In five cases surgical treatment was not advised, and in two others was refused by the patients. Pour of these women had tuberculosis of both kidneys, one with symptoms dating back eight years, the second two years, the third, one year, and the fourth only eight months. One of these women died in three months, the second in six months, the third in one year, and the fourth left the hospital unimproved and has not been heard of since. One woman had a unilateral renal tuberculosis with advanced pulmonary changes and in her case operation was not advised; she also left the hospital unimproved and has since not been heard of. In the two operable t-ases in which surgical treatment was refused the patients dird within one year after leaving the hospital.

In 70 out of the 71 cases oi>erations were performed, in 67 cases the kidney was removed and in three cases simple nephrotomies were done. The results obtained in these three last cases are veij discouraging. One woman died in three months, a second in two years, and the third left the hospital unimproved and has not been heard of since. Xephrotomies were performed on these patients for the following reasons. Two of the women had bilateral renal tuberculosis with a markedly decreased urea output on both sides. When thev entered the hospital, one in 1893, and the other in 1899, they were in a very bad condition and each had a unilateral pyelonephrosis. In the light nf our knowledge at that time it seemed that evacuation of the pus was the only justifiable operative procedure. The third case, operated upon in 189T. was thought to be a simple pyelonephrosis, and the tuberculous nature of the kidney lesion was not recognized until material obtained at operation had been carefully studied microscopically. Unfortuiuitely this patient later refused a nephrectomy and, after leaving the hospital against advice, died in a short time at her home.

In order to judge our ultimate results in the cases in which the kidney was removed we sent out letters to all of these


patient- and we now have complete records in -13 out of the (ii cases, or in 63 per cent. In all probability, of course, a nundxT of the patients from whom we could get no reconl are dead, but we feel sure that our failure to trace many of tliem is due to the known frequency with which dispensarypatients change their residence. In our series there was un instance of death under the amesthetic. There were, however. three patients that died in less than two months, one died of post-operative pneumonia on the tentli day, the second of uremia, and the third of tuberculosis of the other kidney. These two last patients were operated upon 3(1 years ago and. now that our methods of studying kidney f miction and pathology ha\e improved so greatly, to-day both cases would probably be considered inoperable. One woman wa-s not at all benefited by the operation and died four years later. Four patients lived each six years after leaving the hospital, greatly improved by their operations, and then died in the seventh year. The exact cause of death in these cases is not known, but it seems probable that tuberculosis was the main factor. This means that 8, or 19.5 per cent, of the 43 women of whom we have complete records are now dead. These eight patients lived, on an average, for three years after their operation.

Two of the living patients are unimproved, one three, the other nine years after operation. Seven may be classed as greatly improved. These seven women are all able to carry on their daily occupations and complain only of slight bladder symptoms. Twenty-five, or 59.5 per cent, of these women whose present condition we now know are entirely well, with an average of 11 years since their operation. In this series we have one woman operated on 31 years ago, another 23 years ago, and two 80 years ago. These patients have been relieved of all their symptoms by operation and report themselves to be now in good general health. The following table shows graphically the above mentioned post-operative results.

Women Fkom Whom a Tuberculous Kidnet H.\s Been Removed \.M) Whose Present Condition Is Known

Per cer.t

Total imiuber 42

Kiiiiwn to Ije now ilciul S 19.,')

.llivo an. I unini|iro\(Ml "2 4.5

.\live and improviMl 7 16.5

Alive and entirely well '2'y 59.5

We have divided all the cases in which we know the final result into two classes, one formed by those women from whom onlv the kidney was removed and the other by those from whom as much as the ureter as possible was removed at the same time. After careful study we have been unable to show 'that the removal of the ureter makes any difference in the ultimate results of the operation. Approximately 19 per cent of both groups of patients are now dead, 5 per cent are unimproved, and 76 per cent are either greatly improved or well.

Our study, however, has shown that the post-operative sinuses of the patients on whom nephro-ureterectomies were perfoi-nied healed in an average time of five months, whereas the woman in whom the diseased ureters were left drained for 11 niontlis. From this it would appear that it is better to remove tlie ureter along with the kidney when the condition


Janlary, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


15


ol' the patient warrants prolonging the anfpsthetic the short time necessary for the carrying out of tliis ])roceclure.

CONCLUSIONS

1. In our cases of renal tuberculosis in eighteen per cent (18^') there has been a family history of tuberculosis.

2. In sixty per cent (60^) of the cases of tuberculosis of the urinary tract the lesion has been in the right kidney, in thirty- five per cent (35;?^) in the left kidney, and has been bilateral in four patients.

3. Eenal tuberculosis occurs most frequently lietwoeu the ages of twenty and forty (71^).

4. The average duration of symptoms in mir women before coming to the hospital was thirty-three incmtlis

5. H«nal tuberculosis in colored •women, althnugli not as frequent as in white, is l>y no means rare.

6. In eighty-eight per cent of our cases dysuria and polyuria were the first symptoms.

7. One-third of tlie women complained <>( hematuria on admission, ami in eight patients "'smoky urine" was the first .sympton.

8. Thickening and tenderness of the portion cil' tlie ureter palpable' on vaginal examination was present in tliirty-two l^er cent of the patients and tbi< >igii is (if great bclp in the early detection of cases of renal tuberculosis.

!1. Of the seven patients not operated on, four are known to be dead and the other three left the hospital in a very bad condition and are probably now dead, although we have no definite information about them.

10. The three women on whom >im])le neplirotomies were performed all did badly.

11. The ultimate result is known in forty-two out of sixtyseven cases in which the kidney was removed, or in 62 per cent of the eases.

12. Seven of these forty-two patients may he classed as greatly improved and are now alive six years after their operations; twenty-five are entirely well wdth an average period of eleven years since they were discharged from the hospital. This means that 16. .5 per cent of the women of whom we have records have been greatly improved by their operations and .j9..") per cent have been entirely cured.

13. Comparison ol' the results obtained wlien the ureter is removed with the kidney and when it is left in situ shows that, although the ultimate results are the same following the two methods, the post-operative sinus heals more rapidly when a nephro-uretcrectomy is done, and this, therefore, seems to be the operation of choice when the patient's condition warrants a prohmgation of the anajsthetic.


CASES OF TUBERCULOSIS OF THE KIDNEY OBSERVED IN

THK GYNECOLOGICAL DEPART5IENT OF THE

.lOHXS HOPKINS HOSPITAL


Gynecological History number


Oynecolot'ic

Pathologies

number


il Gynecological History number


Gynecological

Pathological

number


4009


1017


17890


16676


4012


1018


1 7939


16754


4;i7(i


1180


18522


18361


.)0;i4


1670


18899


8143


."i.Ki:;


1902


19862


19862




19924


19860


ii(i:i."i


2310


19972


19960


tio74


2395


20058


20011


ti(i(l!l


2823


20208


19795


lilt 12


3243


20298


No specimen


7 1 s.-i


3498


20847


20868


7S0l'


4067


21625


21617


79SI


4316


21813


21813 1


sooi


4308


21859


21798 1


87 Hi


5130


22010


23001


8745


5565


22040


22002


O.'iSG


5584


22849


22858


9950


6177


22311


25625


9966


6313


23366


22281


10058


6230


23464


22803


1008S


6283


235 IS


2.3451


10;!S7


6600


23549


No specimen


10809


7021


23698


23638


11 255 J


7275


23790


No specimen


11 45 J


7696


24060


24025


1173.3


9528


24228


24178


11613


8042


24288


24318


11731


Vo specimen 24411


No s])efimen


IIOIM


8501




12108


8724




12471


9192




12866


9895 10696


Total


-

13244


Number from whom kidney


13484


10738


was removed . . .


67


13858


11535


Of these 67. 42 have been heard


13951


ll.>64


fiom — S known


to be dead.


14169


11997


34 known


to be well.


14428


12310




14467


12203




14549


12277




14767


12733




14819


12615




1 4964


1 2834




1508.">


9668




15662


4475




16006


14180




16067


14461




16144


Xo specimen



16393


14838




17217


16174


PORTAL THROMBOSIS


{From the Department of Pathology, The

Dr. Williiiiii II. \\e\vh iu his classical treatise on thrombosis refers to occlusion of the portal vein as a " well characterized although usually undiagnosed affection" caused most frequently by compression of the intrahepatic branches in cirrhosis, syphilis, or tumors of the liver, by compression of the main branches or trunk by fibrous perihepatitis, chronic peritonitis, swollen lymph glands, impacted gall-stones or tumors. With pancreatic disease, gastric cancer and ulcer, is also mentioned sclerosis of the portal vein, which latter should, he said, receive more recognition.

Two years before, Spiegelberg, in a series of " Unusual Autopsy Findings," had described a case with calcification in the wall of the portal vein. Borrmann at about the same time emphasized its importance. Sachs in his comparative study of arterial and venous sclerosis considered it a manifestation of general venous involvement.

Lissauer in an excellent summary of the cases occurring at lireslau, reported in 26,687 autopsies, 68 instances of portal thrombosis which are tabulated as follows:


By L. T. Webster

Johns Hopkins rnhersiln, lialiimore, Md.)



9 cases. 7 cases.


Cancer of panci-eas (primarv.)


5 cases.


Syphilis of liver



Carcinoma of stomach


7 cases.


Diseases of the spleen. . .


5 eases.


with metastases to



Cancer of pancreas (sec

3 cases.


liver.



ondary.) Atrophic cirrhosis


6 cases.


Cancer of liver (pr.) . .. .


2 cases.


Cancer of gall-bladder. .


6 cases.


Cancer of liver (sec.) . . .


2 cases.




Pancreatic disease


2 cases.


TABLE II.— FREQUENCY OF THROMBOSIS IN ASSOCIATED CONDITIONS


Swelling of portal lymph glands ....

Abscess of spleen

Carcinoma of pancreas

Primary cancer of liver

Perityphlitis

Primary carcinoma of gallbladder. .

Secondary carcinoma of liver

Syphilis of liver

Carcinoma of intestine

Carcinoma of stomach with liver metastases.

Cirrhosis of liver

Gall-stones

Carcinoma of stomach without liver metastases.


Portal thrombosis is mentioned as occurring 21 times in the 6050 autopsy records of The Johns Hopkins University. It was associated with (1) cirrhosis of the liver in 7 cases, (2) with carcinoma in 6 cases, (3) with cholangitis in 4 cases and (4) with amyloid disease, (5) ulcer of the stomach, (6)



Banti's disease, and (7) pylephlebitis, in one case each, respectively.

(1) Cirrhosis of the liver ^ 7 cases.

(a) Laennec: 4 cases (Cases II, V, VI, VII).

Location of thrombi.

Main portal vein and liver branches, 2

cases. Portal vein, liver branches, splenic vein, superior mesentery, 3 cases. Condition of vessels.

Sclerotic portal vein and branches, 4 cases.

(b) Syphilitic cirrhosis, 1 case (Xo. I).

Ixication of thrombi.

Main portal vein and liver branches. Condition of vessels.

Sclerotic portal vein and branches.

(c) Atypical cirrhosis, 2 cases (Cases II and IV).

Location of thrombi.

Main portal vein and Hver branches, 2 cases. Condition of vessels.

Sclerotic portal vein and branches, 1 case.

No note, 1 case.

Case I.— Henrietta B. White. Autopsy 214, July 21, 1891.

Anatomical Diagnosis. — Syphilitic cirrhosis of liver, C. P. C. ; Portal thrombosis (recent) ; acute peritonitis; colon bacillus in exudate; jaundice.

In the abdomen are alx)ut 500 cc. of turbid fluid. The peritoneal surfaces are thickened, rough. Firm adhesions bind the liver and spleen to the peritoneal wall. The splenic vein is wide, its inner circumference measuring 6 cm. There are areas of calcification and irregular thickening of the intima and here is an adherent thrombus 1 mm. in thickness, 10 mm. in length. The portal vein is also wide, its lumen is filled with a fresh thrombus adherent to the intima in spots but in general easily removed. It extends a short distance into the main branches of the portal vein. It seems to be of recent formation. The wall of the portal vein appears thickened, especially the Intima.

The liver is very much deformed by coarse lobulations or nodules which result from cicatricial depressions all over its surface. These nodules are of all sizes. On section the liver is jaundiced. Fibrous bands of connective tissue extend from the capsule into the substance of the liver, producing the lobulations above described. In and about these areas is atrophy of the parenchyma. The specimen is an excellent example of syphilitic cirrhosis.

Case II. — James S. White, 41 years. Autopsy 14, 1891.

ArMtomi<:al Diagnosis. — Streptococcus septicemia following old ulcer on left leg. Double pneumonia; axillary adenitis; cirrhosis cf liver; dilatation and atheroma of splenic artery and vein and of portal vein with parietal thrombosis.

The liver weighs 1300 grams. Tlie surface is nodular, hob-nailed, free from adhesions. Tlie capsule is thickened. The consistency is hard. On section the nodulated appearance is still evident. The portal, splenic, and mesenteric veins are greatly dilated. The intima is thickened with atheromatous and calcified patches, present espe


Jandabt, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


ir


oially in the splenic and portal vein up to the division of the portal vein into its main l)ranches as it enters the liver. Here there are small adherent parietal thrombi. The splenic artery is extraordi narily wide and tortuous with nodular patches of thickening in the intima.

Case III.— John S. Autopsy 462, Oct. 17, 1893.

Anatomical Diagnosis. — Diffuse suppurative cellulitis (streptococcus) ; lymphadenitis; ascites; chronic adhesive peritonitis; chronic interstitial hepatitis; thrombosis of portal vein.

The liver weighs 1700 grams. It is everywhere adherent. The capsule is thickened, fibrous in appearance and often 4 mm. in thickness. On section it appears mottled and smoky. Heavy bands of connective tissue extend inwards from the capsule. In this way areas of liver tissue are completely marked ofl. In the portal vein are thrombi; the main branch beginning at the junction of the principal abdominal veins is almost completely filled by a mixed thrombus which is only slightly adlierent. At the entrance into the liver the vein is covered by a firmly adherent laminated thrombus, somewhat softened, which does not fill the lumen. Some of the principal branches of the portal vein in the liver are thrombosed with masses which appear to be adherent and continuous with a laminated thrombus.

Case IV. — John M. White, 48 years. Autopsy 2706, April 13, 1906.

Anatomical Diagnosis. — Chronic splenic tumor; sclerosis of splenic and portal veins; cirrhosis of liver; thrombosis of portal branches; C. P. C. of pancreas and intestines ; esophageal varices with rupture ; hemorrhage into the stomach and intestine.

The splenic vein shows definite sclerosis everywhere, particularlv after one leaves the hilum of the spleen. Here and there it shows definite rings of sclerosis but its lumen is everywhere patent. Such areas are particularly well marked at the branching of the vessels. At the junction of the splenic vein with the mesenteric vein is seen a large thrombus mass slightly adherent to the anterior wall of the mesenteric vein, partially occluding its lumen. The thrombus is of a grey color and shows definite ridges and furrows on its surface. The portal vein, however, shows complete occlusion of its lumen by a firm thrombus mass of greyish translucent material. In this region the lumen of the vessel is narrowed. As one goes upward one finds the two branches of the portal vein obliterated completely by a similarly appearing thrombus. In the liver some evidence of thrombosis and propagated blood clot is still evident. The aorta shows moderate arteriosclerosis.

Case V. — William K. W^hite, 40 years. Autopsy 4132. May 14, 1914.

A7iatoniical Diagnosis. — Atrophic cirrhosis of liver; portal stasis; ascites; dilated collateral circulation; organizing thrombus of portal vein and its radicals. Interstitial hyperplasia of spleen; chronic interlobular pancreatitis with hemorrhages into the islands of Langerhans; chronic interstitial nephritis; jaundice.

The splenic vein is enlarged and its lumen obliterated by an organizing thrombus. Throughout its entire extent the mesenteric vein up to the point of its larger tributaries is thrombosed even into the substance of the liver. The vessel walls are slightly thickened. The thrombus, although not very old in appearance, is firmly adherent to about half of the circ\imference of the vessel, and some areas app'?ar sclerosed. The liver weighs only 810 grams. It is typically hob-nailed in appearance.

Case VI. — John W. Wliite, aged 53 years. Autopsy 5026, Feb. V, 1917.

Anatomical Diagnosis. — Cirrhosis of liver; thrombosis of splenic vein; chronic splenic tumor; congestion and hemorrhage into the stomach and intestines; ascites; hydrothorax; scar on genitals; fibrous orchitis.

The liver weighs 1100 grams, and the irregular nodules would suggest the hob-nailed type of cirrhosis. The portal vein and its


branches contain a thrombus, 6 cm. long, nearly obliterating the splenic vein after it has been joined by the inferior mesenteric vein but before it enters the portal vein. This thrombus is firmly adherent to one wall of the blood vessel and shows evidence of organization. The aorta shows no evidence of syphilis or of sclerotic changes.

Case VII.— Barbara S. White, 69 years. Autopsy 5863, March 28, 1919.

Anatomical Diagnosis. — Generalized arteriosclerosis; fibrous myocarditis; cirrhosis of the liver; enlargement and fibrosis of spleen; esophageal varices; thrombosis of splenic and superior mesenteric veins; fibrinous perisplenitis; hemorrhagic infarction of jejunum with hemorrhage into stomach, duodenum, jejunum and ileum.

The liver presents the usual hob-nailed appearance of an atrophic cirrhosis. The splenic, portal, and superior mesenteric veins show marked sclerotic changes with calcification in tlie intima and media. A thrombus is adherent to the wall of the splenic vein and superior mesenteric veins. Propagated clots fill the entire portal system.

Summary. — In about 275 eases of cirrhosis of liver, portal thrombosis is reported in 7 cases or 2.6 per cent. Usually the main portal vein and its liver branches were implicated. In every case in which a note was made as to the condition of the veins, there occurred sclerotic changes in the intima or media. A slowing of the circulation plus an injury to the vessel wall seemed to play the all important etiological role.

(3) Carcinoma, 6 cases.

(A) Stomach, 4 cases (Cases VIII, IX, XI, XII). Metastases to retroperitoneal glands and liver,

4 cases. Thrombi.

1. Type:

(a) Carcinomatous thrombi, 2 cases.

(b) Blood thrombi, 1 case.

(c) Both, 1 case.


4 cases. Location : Portal vein and liver

branches, 3 cases.

Portal vein, liver branches,

splenic vein, 1 case.


4 cases. (B) Pancreas, 2 cases (Cases X and XIII). Metastases to retroperitoneal glands

and liver, 2 cases. Thrombi.

1. Type:

(a) Blood, 1 case.

(b) No note, 1 case.

2. Location :

Portal vein and liver branches, 1 case. No note, 1 case.

Case VIII.— Otto W. Wliite, 49 years. Autopsy 175, March 4, 1891.

Anatomical Diagnosis. — Carcinoma of stomach; carcinoma of hepatic lymph glands; carcinomatous thrombus in portal vein; multiple metastases in liver.


18


Tlie portal vein is of normal size. At its entrance into the liver there is projeotinf; into it a large, smooth, careinoma nodule. This is smooth and non-ulcerated on the surface. In the portal vein around the tumor thrombus there are soft thrombi along the wall. The veins branching near the thrombus are also filled with tumor tissue, and a large mass in the left 1(iIk> is directly contlniiuus with the thrombus in the portal vein.


.\utopsy 22S. Septc


ibfV


Cask IX. — George C. Negro. .">3 y< 10, 1891.

Anatomical Diagiionis. — Primary carcinoma of stomach; metastases to liver, lymph glands and pleura; chronic diffuse nephritis; nodular arteriosclerosis; cysts in liver resulting from tumor communicating with portal vessels.

The liver weighs 3600 grams; it contains numerous soft nodules which vary considerably in size. Some of these nodules are very soft. On section some contain a large amount of hemorrhagic fluid which is apparently confined to the tumor mass, in cavities with smooth walls. Some of these cavities are evidently situated directly in the liver tissue. In other areas they are surrounded by a small amount of tumor tissue. In some of the larger cavities thrombi were seen projecting from the veins. Small thrombi were found in the minute branches of the portal vein. Branches of the portal vein could be traced directly into the cavities.

Case X. — Barbara .\. White. .")! years, .\utopsy 48:i. .January '>, 1894.

Anatomical Diuynosis. — Carcinoma of the head of the pancreas with extension into the duodenum and stomach; carcinoma of mesenteric lymph glands, retroperitoneal and gastrohepatic glands; carcinoma of the right and left adrenals, liver and lungs; thrombosis of portal vein.

The retroperitoneal glands on both sides luive been converted into tumor masses which form a chain along the spine. The portal vein is thrombosed just before it enters the liver by a partially decolorized thrombus mass.

Case XI.— Frank S. White, 02 years. Autopsy 1464. .huiuary 'A. 1900.

Anatomical Ditif/nosis. — Carcinoma of stomach with metastases to the liver, retroperitoneal and omental lymph glands and to the spleen; metastases to the hilum of liver occluding portal vein; propagated thrombus in branches of portal vein.

The splenic vein shows a dilated lumen. On dissection a metastasis is found blocking the vein completely, about 2 cm. from the junction of the splenic and portal vein, at a point where a vein enters the splenic vein from the stomach. The metastasis extends into the portal vein, obliterating its lumen completely up beyond the hilum of the liver. It is firmly attached to the vessel walls giving them a diameter of from 1 to :i cm. and making the splenic and portal veins resemble enlarged elongated, irregular lymph nodes with metastasis. On section it is found that the centers have softened. Where this metastasis ends beyond the hilum of the liver a thrombus begins extending into the main branches of the portal vein.

Case XII. — Emma T. Colored, .32 years. Autopsy 37r)2, ,Iulv 14 1912.

Anatomical Uingnosis. — Carcinonux of tlie stomach with direct Invasions into the retroperitoneal tissues, pancreas, transverse colon and mesenteric vessels; cancerous thrombosis of the portal vein; multiple metastases into the liver; cancerous thrombi in the pulmonary arteries; metastases to the intestine; anemia and emaciation.

The portal vein is dissected out of the tumor tissue but with the hepatic artery and the bile-ducts appears uniuvolved as it enters the liver. On following the portal vein, however, into the liver for a short distance one finds a large yellowish tumor mass studded here and there with hemorrhagic zones partially occluding this vessel. Other small thrombi of a similar nature are found in the various


radicals of the mesenteric veins. On section of the liver several of the portal veins are found plugged with thrombus masses similar to those described above.

Cask XIIl. — (ieorge T. White. 4.') years. Autopsy 4635, May 2.'i. 1915.

Anatonuical IJiagnosis. — Carcinoma of the head of the pancreas: metastases to the liver and neighboring lymph glands; obstruction of the common bile-duct; jaundice; thrombosis of the superior mesenteric of the splenic and ])rostatic veins; hemorrhages in the intestinal mucosa.

Siiiniiniri/. — In <;<iso,s ol' earciuoma of the stomaeh or head of tlie paucrea.a with metastases to the liver and retro-peritoueal glands, thrombosis of the portal vein may be e-xpected. Usually the main portal vein and its liver branches are involved. The thrombus may be carcinomatogenous or hematogenous. Pressure occlusion of the lumen and injury to the vessel wall seem to ])lay the all ini])ortaiit etiological role.

(.>) Cholnin/itis.

Cask XIV. — Ricky .\. White woman, aged 34 years. Autopsy 1069, March 21. 1S9S.

Anatomical Diagnosis. — Cholelithiasis; obliteration of gall-bladder ; cholangitis ; general infection (B. colij ; acute splenic tumor ; abscesses in the kidneys; thrombi in the hepatic vessels; adhesions between the gall-bladder and stomach; early peritonitis; jaundice.

Beneath the edge of the liver is a dense mass which occupies the position of the gall-bladder; about it are the adheient stomach, liver and duodenum. The bile channels are dilated and patent. In the liver the bile-dvicts are dilated by a turbid fluid which runs freel> from them. Thrombi firm and red are found in the portal veins and some of them are partially decolorized. The thrombosed veins are the smaller ones, usually under 0.5 cm. in diameter.

Case XV.— Richard T. White. 4CI year-. .Autopsy 1691, March 7. 1901.

Anatomical Diagnosis. — Cholelithiasis: calculus impacted in tlic diverticulum of Vater, only partially filling it and occluding its duodenal orifice; acute hemorrhagic pancreatitis; fat necrosis; partial thrombosis of the splenic vein ; embolism and thrombosis ot branches of the portal vein.

The pancreas is represented by a swollen black tumor mass, sofl and friable. The liver shows on section portal veins plugged and distended with red thrombi. When the vein Is followed into one of these areas it is found to have a diameter about 4 mm.; it lies in a deep red area, and is plugged with a red thrombus which stops abruptly and is yellowish white. This may be an embolus. Occupying a portion of the lumen of the splenic vein is a mixed red ami yellow thrombus mass, firm in consistency and adherent to the intima.

Case X\1.— .\Mtli.>ny C. White. 73 years. .\uto|j>y 3S99. April 3. 1913.

Aniitoniiciil Diagnosis. — Cholelithiasis with stones in the liili' papilla and gall-bladder, subacute cholangitis; icterus: biliary ci:rhosis; obstruction of the pancreatic duct; chronic and acute pan creatitis; acute suppurative poi-tal lymphangitis with beginning pylcl)hlebitis; liver necrosis; acute generalized peritonitis; intestinal ilistention; generalized arteriosclerosis; chronic dill'use nephritis: cardiac dilatation and hypertrophy.

The portal vein at the hilum shows a soft ante-mortem clot. The smaller branches of the portal vein also show many small clots.


Wliit.


•d .-)S VI


Autopsy 404S,


Case XVII.— Andrew K. January 2, 1914.

Anatomical Diagnosis. — Operative wouiul for cholecystectomy and drainage of common bile-duct. Chronic cholangitis; jaundice; throm


Jancaky, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


19


Itosis of portal vein: surgical incision of duodenum; bilateral bronchopneumonia.

Liver. Tlie portal vein at tlie liilus of the liver contains two or three friable thrombi attached to its wall. They measure about 0.5. cm. in width. The left branch is completely obliterated by a thrombus.

Summary. — In about oo cases of cholangitis, imrtal thrombosis occurred in -i, or 10.5 per cent. Usually the main portal vein and its liver branches were involved. Infection of the vessel wall, although not always definitely recorded, may be assumed to play an imiwrtant role in the etiology.

(4) Amyloid Vhmse. 1 case.

C.A.SE XVin.— Franklin R. White. 37 years, .\utopsy 262, Decemljer 19. 1801.

Aiwtomiml Duigiiosis. — Tuberculous fibrous phthisis of both upper lobes; amyloid spleen and kidneys Tuberculous ulceration of small and large intestine.

Liver. — Microscopical examination showed thrombi in the portal veins with extensive liver cell emboli in these vessels. Obstruction to the portal circulation was probable but no note was made regarding the condition of the vessel wall.

(5) Ulcer of Stomach, lease.

Case XIX. — Louis F. White. 4.t years, .\utopsy n6~, September 13, 1894.

Anatomical Diagnosis. — Perforating ulcer of the stomach; old adhesive peritonitis ai"ound the perforation ; ulceration into the splenic and pyloric artery; tlirombosis of the splenic artery; exten sion into the cceliac axis and abdominal aorta ; infarction and softening of spleen; complete thrombosis of splenic vein with extension ef thrombus into the portal vein; thrombosis of interlobular veins of liver.

The liver is small. In a number of the interlobular veins of the right lobe are thromlji. red, with white centers. These are continuous with a small thrombus in the portal vein. Tliere are also a fe\i thrombi in the interlobular veins in the left lobe, and a small thrombus enters the large branch of the portal vein running to the left lobe. The splenic vein is also thromlx)sed completely, the condition extending as far as the portal vein and into it. although only a small portion of the lumen of the portal vein is occupied. The splenic vein, liowever. is completely obliterated by a greyish tliroml)us adherent to its inner wall. The splenic artery is thrombosed throughout its entire extent; its origin is undoubtedly at the base of the ulcer. The thrombus extends through all the vessels of the cceliac axis into the aorta. Infection and circulatory obstruction in the splenic vein probably produced the thrombi in this case.

(G) Banti's Disease. 1 case.

C.VSE XX. — Xo Xanie. Autopsy 139S, August*". 1S99.

Anatomical Diagnosis. — Primary splenomegaly; thrombosis of splenic, portal, and mesenteric veins; anemic infarction of spleen.

The spleen is very soft; it weighs 2400 grams. The splenic vein is dilated to a diameter of .5 cm. and is distended with an elastic fat clot which shows points of opacity. This clot extends upwanl into the portal vein and even into the ratlicals of the portal vein. It occludes the lumen of the portal vein throughout its length. On section it is almost diffluent. The lumina of the mesenteric veins are obliterated by thrombi, largely organized.

Circulatory obstruction in the splenic vein was concerned in tluformation of the thrombi in this case.

(7) Pylephlebitis. 1 case.

Case XXI.— Helen C. White, 13 years. Autopsy 1409, Augusi 24, 1899.


Analomiral Diagnosis. — .\ppendicitis ; suppurative inflammation of a branch of the portal vein; purulent pylephlebitis; thrombosis o; the portal vein; multiple abscesses Of liver.

The appendix is covered with friable adhesions; it is gangrenous throughout most of its length and during separation of adhesions large rents appear in the wall. The branch of the portal vein in the mesentery which leads from the region of the appendi.x is distended with pus. The walls are in a large part necrotic. Traced upward this branch opens into the main portal vein behind a thrombus which is large and partially obliterating the lumen. All otlier branches of the portal vein are open. On section the liver, particularly the right lol5e, is found to be riddled by large abscess cavities, evidently in intimate relation with the branches of the portal vein.

Infectious injury to the vessel wall and obstruction to the circulation were clearly the cause of the thrombi in this ease,

CONCLUSIONS

1. In the OOoO autopsy records of The Johns Hojikins Hospital portal thrombosis has been noted 21 times.

2. It was found in 2.6 per cent of the ca.«es of cirrhosis of the liver and was always accompanied by sclerotic changes in the walls of the portal vein or its branches.

3. Portal thrombosis wa.s found to be common in cases of carcinoma of the stomach or pancreas which had metasta.sized to the liver and retro-peritoneal glands. Pressure occlusion of the lumen and injury to the vessel wall by tumor tissue were present in all the cases.

4. In 35 cases of cholangitis, portal thrombosis was noted in 10.5 per cent. Infection of the vessel wall might be inferred Inxt was not recorded in every case.

5. One case each of amyloid disease, ulcer of the stomach. Banti's disease, and pylephlebitis were accompanied by portal thromlwsis. The I'ecords, although incomplete, would lead one to infer that circulatory obstruction and infection of the vessel wall were the immediate causes of the thrombi.

6. As practical examples illustrating the combination of factors necessary to produce a thromhus. these cases are of interest,

REFERENCES Welch, William H.: Albutt's System of Med., 1899, Vol, VI, 299. Spiegelberg: Virchows Arch., 1895, CXLII, 347, Borrmann : Deutsch. Arch, f, kl. Med., No. 59, p. 283. Sachs: Virchows Arch., CXXII, 403. Lissauer: Virchows Arch,, 1908, CXCII, 301.




THE RELATION OF HISTAMIN TO LEUKOCYTOSIS

By John K. Paul {From the Department of Pathology, The Johns Ilopkins University)


Besides the actiou of histamin in producing shock, its possible relationship to some of the toxins, whose action is seen m infections and inflammatory conditions of bacterial origin, is interesting, and the possibility of its being produced in the body during these conditions seems to deserve investigation.

The question of bacterial toxins and their relationship to the systemic reactions of the body in infectious disease is an unusually complicated one, and one which is far from being clearly understood. With some organisms part of the process at least is fairly definite and we have, for example, the exotoxins of the diphtheria and tetanus bacilli and a few others. With other pathogenic organisms including pneumococci, streptococci, staphylococci, and others, the ability to produce poisons is suspected, and the profound changes in organs remote from the local infected lesions, and also changes of a general systemic nature, such as fever and leukocytosis, are supposed by many to be due to them. But the nature and character of such toxins are still obscure and although this problem has attracted a host of workers, attempts to isolate individual and specific poisons have not been successful.

Originally, Pfeiffer put forward his well-known theory of endotoxins, or poisons contained within the bacterial cell. It was assumed, that when bacteria entered the animal body and were destroyed by the action of the serum or cells, these endotoxins were liberated and poisoning resulted. But more recently the conception of endotoxins has been regarded with some uncertainty. The work of Vaughan ' and Friedberger ' suggests that with bacteriolysis we do not have the mere liberation of a preformed poison but the process is a chemical proteolysis produced by enzymes, by which poisonous groups of the bacterial protein-molecule are set free. These toxic cleavage products are the result of the reaction between blood plasma and the bacterial cell; they are not specific and may be formed from all bacterial proteins pathogenic and nonpathogenic.

Another view of the bacterial toxins, of quite a different nature, is that of Jobling and Petersen,' who believed that in infectious processes most of the toxic substances originate from serum proteins, and the bacteria act merely by removing the antiferments from the serum, thereby setting free the normal serum ferments and permitting them to act upon the serum proteins.

These views do not bring us to any definite conclusions as regards the type of toxins with which we are dealing. Chemically, they are as yet undefined, for we have no knowledge of their constitution, except in so far as it has been hitherto impossible to separate them from the protein molecule. Their relation, then, to split protein products is accepted. Vaughan ' states that, although we do not know the chemical structure of the protein poison, we are certain that it is not an amino


acid, although it may be closely related to one of these ; and it will probably be found that the protein molecule contains a whole spectrum of poisons with slight variations of structure. He also mentions the fact that in its action the protein poison seems quite similar, if not identical, with the histamin of Barger and Dale.

It seems important, therefore, to test the effect of repeated small doses of this substance upon experimental animals. If it represents one of the actual protein poisons which are produced during an infection, one might expect that such injections could give rise to some of the systemic signs which we are accustomed to see in infections, such as fever and leukocytosis. With this intention some experiments were carried out.

Fever has been produced experimentally by the parenteral administration of proteins of diverse origin (Vaughan, Wheeler, and Gidley)* and these workers have found that by modifying the dose the type of fever could be determined at will. Also, changes in the blood picture, such as the production of an eosinophilia, have been accomplished by Schlecht,' who found that on repeated injections of protein into a sensitized animal the eosinophiles were increased, and his results were also borne out by Chancellor,' who found that an increase of the same element of blood cells could be produced after injections of protein poison. Neither of these authors report any striking increase in the total number of white cells circulating in the blood stream during the course of their experiments.

The experiments described below were undertaken in an effort to determine what influence histamin, when introduced parenterally into experimental animals, would have on the number of white blood cells circulating in the blood stream and what variations in temperature it could produce.

Solutions, made up in small quantities of distilled water, of commercial preparations of histamin hydrochloride (Hoffman and La Poche Chemical Works) were employed for the injections.

Rabbits, althou*;li described by Dale as being relatively refractory to the efl'ects of histamin, were employed for this work, owing to the facility with which blood for counting purposes can be drawn from the ear veins. It is worth mentioning here, however, that the greatest care was necessary m order to secure accurate white blood counts. Counts from the ear veins of animals, from which the blood was pressed or milked, proved inaccurate, showing an erroneous increase in the number of white blood cells. Constant exposure of the ear vein to msinipulation, and cutting of the ear vessels producing localized phlebitis, some oedema and often inflammation, rendered counts inaccurate. Apparently the best results were obtained from free flowing arterial blood.


Janoary, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


21


Intravenous Injections. — Primarily single large doses (1-1.5 mg. per kilo) were introduced into the rabbit's ear vein. As a rule, this dose was sufficient to produce violent symptoms. These came on in a few (10 to 20) seconds, with primary dyspnoea, then marked unsteadiness of movements followed by severe clonic convulsions, subsequently to which the animal lay motionless with head drawn back and limbs outstretched showing shallow and almost imperceptible respirations. After this there was a period in which the animal showed symptoms of shock, the extremities were cold and the blood pressure apparently low, the flow of blood from the ear vein was sluggish and its color dark.

Leukocyte counts were made at hourly inteiTals following this injection over a period of from four to six hours and again one count on the next day. No striking changes were noted in the number of white blood cells in the blood stream in these experiments.

Again smaller doses (0.25-0.5 mg. per kilo) were administered intravenously at hourly intervals over a period of from four to six hours. These individual doses were not sufficient to produce violent symptoms and generally the animals showed little more than transient dyspnoea following the injection. White blood counts, taken in the same fashion as above, again showed no variations.

Sxibcutaneo'us Injections.- — About 15 experiments of this type were tried. It was thought that by subcutaneous injection larger doses could be given, the rate of absorption would be slower, and the effects prolonged. Doses of from 14 to 16 mg. per kilo were employed, injections being made in the region of the back. The rabbits survived large doses, 25 mg. being administered at one time to one rabbit. Within from two to five minutes after a small subcutaneous injection the animal generally showed signs of uneasiness, restlessness and often a mild diarrhoea. Following this the animal became stuporous, remaining in this condition for a period of from one to three hours with subsequent recovery which was apparently complete. During the first hour following the injection there was definite shock. The extremities were cold and marked difficulty in dilating the vessels of the ear vein was generally experienced. The blood pressure was apparently low, the flow of blood sluggish and its color dark.

In all experiments almost hourly leucocyte counts were made following the injection. The results of the counts showed little change in the number of white blood cells during the first two hours, with occasionally a slight leukopenia, but following this the counts seemed to show a constant rise, occasionally as much as an increase of eight to ten thousand cells per cubic millimeter and a return to normal in from five to six hours. This transient leukocytosis, however, did not seem to exceed physiological limits, as almost similar chan'ges were noted on several occasions after the rabbits had been eating.

One experiment was performed to test the cumulative action of histamin and two subcutaneous doses were administered, the second one being given three and one-half hours after the first, at a period when the white blood cells were increased.


A sharp drop in the number of white blood cells and a gradual return to normal with no subsequent leukocytosis were observed.

One rabbit received nine subcutaneous injections during a period of five weeks. The white blood cells always returned approximately to the same constant number during the days between experiments.

In order to observe the possible variations of temperature which histamin injections might produce, a number of experiments were tried on guinea-pigs. Primary single doses (3-5 mg. per kilo) were administered intraperitoneally. Following such an injection the guinea-pigs almost invariably showed signs of respiratory difficulty: There was often also weakness on the part of the animals and inability to stand. Generally, however, recovery was apparently complete. The temperature, taken per rectum, showed, as a rule, a fall of one or two degrees during this period of shock, but a return to normal was established in an hour's time.

CONCLUSIONS

1. Following intravenous injections of histamin hydrochloride into rabbits, no material change in the number of white blood cells circulating in the blood stream was observed.

2. Larger doses given subcutaneously were followed by a slight leukocytosis coming on about two hours after the injection and lasting from five to six hours with a return to normal.

3. This rise in the white blood count was not dependent on the size of the injected dose and did not seem to exceed physiological limits.

4. Eepeated subcutaneous injections over a period of six weeks did not cause any change in the number of circulating white blood cells.

BIBLIOGRAPHY. \. Vaughan: The Phenomena of Infection. Harvey Lecture, 1914.

2. Friedberger: Berl. klin. Wchnschr., 1910, Nr. 32, and 1911, Nr. 42, Deutsch. med. Wchnschr., 1911, Nr. 11.

3. Jobling and Petersen: J. Exper. Med., 1914.

4. Vaughan, Wheeler and Gidley: J. A. M. A. 1909, LIII, 629-632.

5. Schlecht: Arch. f. exper. Path. u. Pharmakol., 1912, LXVII, 137-169.

6. Chancellor: Zeitschr. f. d. ges. exper. Med., 1914, II, 29-37.




THE INFLUENCE OF THE ANTERIOR LOBE OF THE HYPOPHYSIS UPON THE DEVELOPMENT OF THE ALBINO RAT


liv W.VKiiEX T!. SissoN^. Boston, Mass..*


Edwin ^^ Buoyles, Baltimore, ild.

{From Die Department of I'eilidtiics. The lohita Hiipkiiis Vniversiti/ 1


Ithlrodiwtum. — It was thought of interest, in the course of a study on tlie rehition ol' tlie thymus gland to growth, to compare the changes that might be produced by feeding animals with this gland with those changes brought about by feeding animals with the anterior lobe of the hypophysis. Eobertson, " and Goetsch " had described in detail definite changes in the normal development of animals after feeding hypophysis. We, therefore, fed two rats of a litter of 8 with the desiccated substance of the anterior lobe of the hypophysis. The other rats of the litter received either thymus or the routine diet. The results of this preliminary experiment were negative. We. therefore, detenuined to eaiTy on further studies by feeding rats the anterior lobe of the hypophysis gland, using thymusfed rats and those receiving no gland as controls, with the hope of learning more exactly the relation that the hypophysis bears to early developmental changes.

ExperimentaJ Meihod. — The method emjjloyed in this study consists in the oral administration of the desiccated powdered gland. f It is prepared by drying in a vacuum at 35° C. the anterior lobe of the hypophyses of young calves. This is then extracted with ether and the dried product carefully powdered. One gram of the desiccated powder represents 4.5 grams of the fresh gland. As the experiments were in progress over a period of three years, three lots of this powder were used. The dosage varied from O.OT gin., the amount usually given by other workers, to O.!o gm. daily. The powder was mixed with small amounts of the diet and fed in small dishes placed in the compartments of the cage. The rats were kept confined until all the powder was eaten. In the early experiments, the animals were often deprived of other food foi- a time in order to insure more rapid and complete ingestion i>f the pciuder. Control and fed animals were treated alike.

Tile animal selected for these feeding experiments was the albino rat (Mus norvogicus albinus) standard stock of the Wistar Colony. Philadelphia. The data on the development of the albino rat, as com])il('d by Donaldson. were fieelv used for purpose of comparison. The animals were fed with the gland from the third week, when tiie rats were weaned, for various lengths of time \\\) to ton weeks. They were kept in specially constructed cages, which afforded protection from light and ample room for their normal activities. Precautions were taken to keep the rats under the most favoralde surroundings for their development. The diet consisted of


'2m Marlboroufrli StrciM.

t The powder was kimlly siippli


il ti> u> liv .\rmour & Co.


wheat or corn bread and milk, together with mixed grains or specially purified food products. The first six litters received liberal amounts of bread and milk twice daily with additional feedings of the mixed grains. A similar diet was given to litters seven, eight, and nine, except that each rat received an equal amount of whole milk, the amount varying from 4 to 12 c. c. according to the size of the animal. Litter 10 received a diet recommended by McCollum, consisting of 20 per cent purified casein, 2 per cent agar, 72.3 per cent dextrin, 2 per cent butter or egg-yolk and 3.7 per cent of a salt mixture made up as follows :

NaCl 0.173

NaH2P04H.O 0.347

K-HPO. 0.954

Ca lactate 1.3

Fe lactate 1.18

The rats were killed with ether and accurate measurements of body and tail-length were then made. The testes with the epididymes were weighed. In two experiments single testes of control and fed animals were surgically removed for microscopical studies after a few weeks of feeding with the gland. The remaining testes of these animals were studied at the close of the experiment. The organs of reproduction of all the animals were fixed in Zenker's neutral formalin and stained with hematoxylin and eosin for microscopical study.

Ncsiilts. — The results of the experiments include the observations of the activities, gross developmental changes, studies of the body and testicular weights, body and tail measurements and microscopical studies of the reproductive and endocrine glands.

The activities of all the rals, surli as playfulness, sexual proclivities, appetite and sleep were normal in all instances. It was not noted that the largest doses of hypophysis gland affected the activities or the nutrition. The gland produced no toxic s3'mptoms, such as diarrhoea, muscular contractions or emaciation.

No differences in gross dexelojimental changes, such as, size, color, or texture of fur, were noted between the hypophysis-fed animals and those receiving no gland. The testes descended almost synchronously. The consistency and size of the testes showed no variation. The thymiis-fed rats, on the other hand, were in most instances larger, better nourished, their fur was sleeker, thicker and had a more yellow tinge. The testes of these animals descended earlier and in most instances were larger than those other members of their respective litters. These differences were much less marked in


Januaky, 1921J


JOHNS HOPKINS HOSPITAL BULLETIN


23


the latter exjwriments where the diet was most carefully oontrolled.

Variation in tlie appearance of the nuunmae was slight ilur ing the early development of the rat and the time of the rupture of the hymen was found to be inconstant and not definitely related to conception.

A comparison of the measurements of the body and tail lengths of the hypophysis-fed and control rats shows inconstant and very slight differences.

The weights of animals in each litter are recorded in the accompanying tables and curves. Detailed comparisons between the weights of the hypophysis-fed and th<' cinitrol animals have been made in various ways.

First, the average weight of the hypophysis-fed, male and female, animals at death, has been compared with a similar average weight of their respective controls receiving no gland substance or gland other than hypophysis.

(1) Hypophysis-fed. male, 91 gms. Control, no gland, male, 88.8

gms. Hypophysis-fed. female, 86.4 gms. Control, no gland, female, 84.2 gms.

(2) Hypophysi^-fcd, male, 72.2 gms. Thymus-fed, male. 77.0 gms. Hypophysis-fed. female. 70.4 gms. Thymus fed. f.-niale. 76.S

gms.

These figures show an increase of 2.9 per cent and 'i.d per i-ent more in the weight of the hypophysis-fed animals, male .tnd female, respectively, than the controls receiving no gland, and an increase of fi.fi per cent and 9.0 per cent of the thymusfed animals more than the hypophysis-fed animals.

Secondly, a comparison of the total percentage of weight gained by the hypophysis-fed rats and their controls has been made.

(1) Hypophysis-fed. male, 411.8%. Control, no gland, male. 401.8%. Hypophysis-fed, female, 424.0%. Control, no gland, female.

401.2%.

(2) Hypophysis-fed. male, 299.6%. Thymus-fed, male, 333.1%. Hypophysis-fed, female, 314.2%. Thymus-fed, female, 331.0%.

These figures show that the hyix)physis-fed animals, male and female, gained 2.5 per cent and 5.6 per cent respectively, more than the controls receiving no gland, and further that liypophysis-fed male and female rats gained 11.1 per cent and 5.0 per cent respectively less than thymus-fed controls.

Thirdly, a comjiarison was made of the average actual weight of the hypophysis-fed rats with their controls at \arious periods in their development. The average weight of male and female rats fed hypophysis gland for 28-30 days was compared with the average weights of their controls.

( 1 ) Hypophysis-fed. male, 269.4 gms. Control, no gland, male.

273.8 gms. Hypophysis-fed, female, 279.1 gms. Control, no gland, female, 272 gms.

(2) Hypophysis-fed, male, 199.0 gms. Thymus-fed, male, 222.4 gms. Hypophysis-fed, female, 191.3 gms. Thymus-fed, female, 218.0

gms.

These figures show that the hypophysis-fed male animals gained 1.6 per cent less than the rats receiving no gland, and the females 2.5 per cent more; also that the hypophysis-fed


males gained 10.5 per cent less and the females 12.3 per cent less than the thymus-fed control during the corresponding period.

Finally, a comparison was made of the average testicular weights, both actual and their ratio to the body weight, at death and at periods during the experiments. H^•pophysis•fed, 1.618

1.002 gms. Control, no gland


(actual weights) Hypophysis-fed, (adual weights) Thymus-fed, 1.606 (relative weights) Hypophysis-fc i, [relative weights! Thymus-fed, l.G.'J


.1.30 gms

gms. Hypophysis-fed, l.riG;') gms.

1.635 gms. Control, no gland. 1..t27 gms

gms.

These figures show that the actual weight of the testes of the hypophysis-fed rats is 4 per cent more than that of the control receiving no gland, and 14.3 per cent less than of the thymus-fed animals, also that the relative weight of the testes of the hypophysis-fed animals is 3.5 per cent more than that of their controls receiving no gland and 0.9 per cent less than that of the weight of the thymus-fed rats.

Comparisons of testicular weights have been made from Experiments VIII and IX, in which one testis was surgically removed from both hypophysis and control animals some time before tlie animals were finally killed.

EXPERIMENT VIII

( 1 I Weights ok Testes After 25 Days of Observ.vtiox.

(2) Weights .-Vftek 40 Days


.\CtUill 1


ghts


f Hypophysis- fed 0.357 gms.

I Control (no gland)... 0.385 gms. mus-fed 0.421 gms.

r Hypophysis- fed 0.732 gms.

(2) -i Control (no gland)... 0.S55 gms. LThymus-fcd , 0.842 gms.


Relative weights


rHypophyais-fed 0.826%

(1) j Control (no gland) 0.908%

iThymus-fed 0.888%

rHypophysis-f ed 1.1%

(2) J Control (no gland) 1.2%

[Thymus- fed 1.2%


EXPERIMENT IX

( 1 1 Weights ok Testes After 33 Days of Observation.

(2) W'eights After 50 Days


Actual weights


Relati


lights


fHypophysis-fed 0.54 gms. rHypophysis-fed 1.02%

(1) -I Control (no gland) 0.33 gms. (2) J Control (no gland) 0.762%

Llhymus-fed 0.51 gms. [Thymus-fed 0.98%

fHypophysis-fed 0.933 gms. ' fH.vpophysis-fed 1.1%

(I) i Control (no gland).... 0.735 gms. (2) i Control (no gland) 1.15%

LThymus-fed 0.87 gms. LThymus-fcd 1.1%

These figures show that the actual weight of the testis of the hypophysis-fed rat in Experiment VIII after 25 days of feeding is 7.8 per cent smaller than the control receiving no gland and 17.9 per cent smaller than the thymus-fed control. After -10 days of observation the remaining testis of the hypophysisfed animal is 3.2 per cent and 15 per cent, respectively, smaller than the controls. A similar comparison of the relative weight shows the testes of the hypophysis-fed rat to be 9.68 per cent and 7.5 per cent respectively smaller than the controls.


24


In Experiment IX the testis of the hypophysis-fed rat is 36 per cent heavier in actual weight than that of the control receiving no gland and 5.8 per cent heavier than the thymusfed control. A corresponding comparison of relative weights shows that in the controls the testes are 25 per cent and 4 per cent respectively lighter than in the hypophysis-fed rat. Seventeen days later it will be noted that there is no difference in the relative weights of the hypophysis-fed and thymus-fed rats and that now the testis of the control rat, receiving no gland, is 0.5 per cent heavier than either.

Microscopical sections were made of the reproductive organs and endocrine glands of eight litters of rats. No differences could be detected between the sections from the hypophysis-fed and their respective controls. The testes of rats from litters 8 and 9, when seven and one-half weeks of age, were removed surgically. The tubules of the testes were completely filled with spermatogonia, spermatocytes and a few spermatids. The findings in the hypophysis-fed and the controls were identical. No ditt'erences were noted in the sections of the testes of these animals later when they were removed at death.

Discussion. — The interpretation of some of the results, such as, the activities of the animals, admits little opportunity for discussion, as the animds showed no departure from the normal. The only variation in development between the hypophysis-fed and control animals was the accelerated growth of the thymus-fed rats. The significance of this will be discussed in a later publication. The data presented in the weight tables and curves and the microscopical findings of the endocrine glands give the most satisfactory method to determine any developmental variation. It will be noted that the weight curves show a surprising similarity throughout all the experiments. This is especially well illustrated in Experiment X, in which the diet was most carefully regulated — each animal receiving approximately equal amounts of food accessories and proteins. Occasional exceptions are encountered as in litter 4. In this instance members of the litters had snuflles and the results were not included. In btter 9 the male control was much smaller than any of the others in the litter. This animal always appeared well and undoubtedly represented a variation of the species. Although the total percentage of gain of all the hypophysis-fed male and female rats was 2.5 per cent and 5.6 per cent, respectively, greater than that of the controls receiving no gland, this difference does not justify the conclusion that it was caused by a specific principle in the hypophysis gland. The difference can easily be accounted for by the normal variation in the species. Robertson ' ' has referred to certain phases of accelerated growth due to feeding the anterior lobe of the hypophysis. This did not exist in our experiments as can be seen from the weight curves. In a period of observation of four weeks the male hypophysis-fed animals gained altogether 1.5 per cent less than the controls.

Special attention was given to the variation in the weights of the testes which has been noted after feeding the anterior lobe of the hypophysis. Almost identical results were obtained as in the comparative studies of body weight. The testes of


the hypophysis-fed rats weighed 2.5 per cent more than those of the controls receiving no gland and 0.9 per cent less than those of the thymus-fed. The results of the weights of the testes surgically removed seem somewhat contradictory, but must be interpreted as showing no effect of the feeding. The discrepancy in the findings is explained on the basis that the control rat was undersized, and the weight of the hypophysisfed animal was normal. This view is confirmed by comparison with normal weight curves and by the failure to note differences in the microscopical sections of the testes.

The results of our series of experiments are in agreement with the findings of Gudernatsch,' Lewis and Miller' and Hoskins.' Clark,° Eobertson, ' and Goetsch ' have concluded that after feeding young animals with the anterior lobe of the hypophysis gi'owth was accelerated. Others, notably Pearl," and Wulzen " considered that a retardation of growth followed the administration of the gland. These contradictory results may be explained by a failure to take into consideration certain factors which in themselves may cause the changes thought to be referable to the hypophysis. It is notable, for instance, that many observers have given little consideration to the normal variation in development of the particular species of animal utilized for the experiments. Hoskins ' especially emphasized this point. Goetsch ° in his experiments used a socalled " narrow-selection " race of rats whose normal development showed marked variation as shown by the varying weights of his control. His animals were bred primarily for a constant color. The albino rat (mus norwegicus albinus) used by us, and also by Hoskins * is peculiarly adapted for feeding experiments such as we have reported. This animal has been cai'efully " standardized " by breeding and the coefficient of variation of the individual rat has been compiled by Donaldson.*

Another factor accountable in part for the conflicting results above noted is the use of too limited a number of animals. Goetsch, for instance, who reports that the anterior lobe of the hypophysis stimulates growth and sexual development refers in his article to only six animals that were fed with the anterior lobe of the hypophysis. Our results are based on a series of 68 animals, about 30 of which were fed the gland substance while tlie others were used for controls.

We are led to believe, especially from experiments still unpublished, that careful regulation of the diet is an essential factor in experiments such as have been reported, and undoiibtedly many of the discrepancies in results can be attributed to the administration of unequal amounts of egg, cream and similar articles of food. The work of Osborne and Mendel " and of McCollum has emphasized the important relation to growth of food accessories and adequate amounts of ingredients, such as protein and proper salt mixtures. These authors have shown that growth is induced by the so-called fat-soluble A and water-soluble B accessories such as are found in largo quantities in egg-yolk and milk. Essentially no consideration has been taken of these factors in past feeding experiments.

Other factors, such as the general health of the animals may explain the discrepancies in the results referred to in the


.Ianuaey, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


25


literature. Snuffles is undoubtedly tlie commonest cause for variation in the weight of albino rats.

An interpretation of the results of our experiments, as they may add to the knowledge of the function of the hypophysis, demands finally a consideration of the value of the method of experimentation. Although it is recognized that the secretion of the endocrine glands normally reaches the body fluids by means of the circulation and that digestive processes may produce fundamental changes in the substance given by mouth, this method seems to be the one of choice.

Summary. — The desiccated powder of the anterior lobe of the hypophysis gland of young calves has been fed to albino rats of a standard stock. The experiments were begun when the animals were three weeks old and lasted for periods of from seven to ten weeks. Sixty-eight animals were used for the experiments, about half of this number being controls. These animals were observed for difEerences in activity, in the condition of their fur, in their nutrition and in their skeletal development. Special emphasis has been laid upon differences in external sexual characteristics, changes in body weights and differences in the microscopical findings oi' the reproductive organs and the endocrine glands. Dietary precautions were taken in order to differentiate the effect of food and the gland substance. The hypophysis-fed animals developed normally and showed no differences beyond the variations of their species. The autopsy studies also show no differences.

Conclusion. — Feeding of the desiccated powder of the anterior lobe of the hypophysis of calves to albino rats from three to ten weeks of age in doses of 0.04 to 0.3 of a gram causes no change in their normal development.

TABLE I

(Litter 1.1

Born Apr. 29, 1910. (7 animals.) Feedings begun May 25, 1916. 26 days old. Animals killed June 24, 1916. .56 • Duration of experiment, 30 days.


Hypophysi Hypophy-si Control... Control. . . Thymus... Thymus... Thymus,,.


s



>,



1


Q


19.5


0,04


\6.i


0,04


IS.



17,



18, .1


0,2


17,


0,2


16,


0.2



'i


1 i s 1 '-i 1


Q


i


s 1 S 1


0,1


53.


64


0,1


81,


59



54,5


66



50,


62


0.3


67.


75


0,3


57.


68


0,3


SO,


63


XoTES, — No differences were noted at any time either in activities or in external characteristics. The testes of the hypophysis-fed animals descended about the sajne time as did those of the control animals. Although the weight curve of this litter is below the normal curve (Donaldson) there was no evidence of snuffles. Tlie animals took the gland rather poorly and it was often necessary to limit the amount of food given.


TABLE II (Litter 2)

Born Apr. 28, 1916. (8 animals.)

Feedings begun May 25, 1916. 27 days old.

Animals killed June 24, 1916. 57 " "

Duration of experiment, .30 days.


Sex


Feeding




^


3


o



D


c


« bo





O


S



•-a


a


3




M.


Th.vmus


21.


0.2


32.6


59


0.3


73


0.4


76.


261.9


F,


Thymus


21,


0.2


33.


58


0.3


65


0.4


70.5


231,2


M,


Hypophysis,..


20,


0.04


28.


49


0.1


65


0.2


69.


245,0


F.


Hypophysis...


20,


0.04


28.5


51


0.1


65


0.2


57.5


187.5


M.


Control


22. 5



29.


51



62



66.5


195.5


F.


Control


19.5



25.


44



51



52.5


169.2


M.


Lymph


21.


0.2


30.5


59


0.3


80


0.4


84.5


302.3


F.


Lymph


20.


0.2


28.


65


0.3


69


0.4


72.


260.0


Notes. — The fur of the thyimisfed animals is distinctly more yellow and has a sleeker appearance than that of the controls ; the latter is whiter, thinner and less coarse. These animals together with the lymph gland-fed animals are distinctly larger in every way than the controls. The hypophysis-fed animals show no difference in size from the controls. The hymen of the lymph gland-female is ruptured, the others are intact. The testes of the thymus and lymph gland-fed animals are distinctly larger than the controls. There is no appreciable difference between the size of the testes of the hypophysis-fed animals and those of the controls.

Microscopiv Findings. — Testes: (Hypophysis-fed rats.) The tubules are completely filled with cells consisting of spermatogenia, spermatocytes in all stages and in some instances spermatids. The control animal shows similar findings to that noted in the hypophysis-fed,

Oiaries: (Hypophysis-fed rats.) These show evidence of active ovulation, many Graafian follicles almost fully developed but no corpora lutea. The control animal shows similar findings.

Uterus: (Hypophysis-fed rats.) The uterine mucosa is rather fiat, shows no evidence of hyperplasia and there are a few glands in the endometrium. The control animal shows similar findings.


TABLE III

(Litter 2)

Table of Measurements of Weight of Testes, Litter 2


Feeding

Thymus

Thymus

Hypophysis

Hypophysis

Control

Control

Lymph

Lymph


26.3 23.8 27.8 27.3


Ratio of

testis to body

weight


26


TABLE IV (Litter 3)

Bom JuiK' 17, 1916. (Ten animals.)

Feedings bcj;iin July 7, 191G. 20 days old.

Animals killed July 24, 1916. S7 "

Duration of experiment, 17 days.


Feeding


Nucleic acid Nucleic acid

Thymus

Thymus

Hypophysis. Hypophysis.

Spleen

Spleen

Control

Control


Dosage


Wght. July?


Wght. July IS


0.0'


15.


20.5


0.02


12.5


19.5


0.1


15.


28.


0.1


12.5


25.5


0.05


16.


25.


0.05


14.


23.


0.1


15.5


23.


0.1


15.5


25.



13.5


24.



13.


22


Percentage wght. gained


TABLE V (Litter 3)


Feeding


Nucleic acid Nucleic acid

Thymus

Thymus

Hypophysis. Hypophysis.

Spleen

Spleen

Control

Control


Body length


Weight of testes


0.!)5 1.02


20.9 20.5 20.1


July 13: Animals taking gland well, all in excellent condition, no snuffles.

July 23: For the past ten days with the exception of liypophysisfed animal, the glands have been taken poorly. It has been necessary to feed the glands twice a day and to starve the animals for a few hours to insure that all the gland is eaten. The control animals are fed in the same manner. The first spleen-fed rat takes its gland poorly. The thymus-fed animals are larger than any of the others. The testes of these animals are distinctly larger, the scrotum redder and the testes more fully descended. There is no notable difl'erence in general appearance or in the external genitalia between the pitui tary-fed and the control animals.

Microscopic .SViirfjcs. — The testes of the hypophysis-fed rats consist of tubules compactly tilled with spermatogonia, spermatocytes and spermatids. No fully developed spermatozoa are seen. The section of epididymes shows columnar epithelium almost filling the lumen. Sections of testes and epididymes from control aninuils show almost identically the same findings.


TABLE VI

(Litter 4) Born Dec. 18, 1916. (Eight animals.) Feedings begun Jan. 9, 1917. 21 days old. Animals killed Feb. 20, 1917. 63 " Duration of experiment, 42 days.


Sex


Feeding


1

Q


U)

^




I*


S, be


i


.a


It a.


M, F. M. F. M. F. M. M.


Hypophysis... Hypophysis...

Control

Control

Hypophysis.. . Hypophysis...

Control

Control


0.05

0.05



0.05

0.05




19.

16.5 19. 19. 17.

18. 19.5 19.


22.7

19.

23.

22.7

21.

18.

23.5

23.


35.25

31.5

32.5

33.75

32.5

27.

33.75

32.


56.5

47.5

46.

44.

57.25

42.5

45.

44.5


67.

56.5

.1.

56.

67.

53.

60.

60.


86 67 77 70 81 59 74 74


116. 66. 93.5 87.5

114. 77.5 98.5 98.5


510. 434.

391.

360.

573.5

330.

405.

418.4


Hypophysis Eiven in divided doses. Notes. — Soon after the beginning qf this experiment certiiin rat>-. especially the hypophysis fed females, developed snuffles. All the animals were isolated and the results of this litter were not included. The table of weights and weight curves illustrate the effect of a mild attack of snuffles upon growth.

TABLE VII

(Litter 5)

Born Dec. 25, 1916. (Six animals.) Feedings begun Jan. 13, 1917. 19 days old. Animals killed Feb. 28, 1917. 65 " Duration of experiment, 46 days.





^






o


t~


^


J-"


~


C


.1



^





"r


Sex


Feeding



"=



•^


•-a



&H



t.


fc.



e






Q


i*


^



^


^


is


^


^



Jt.


Control


1)


14.7



29.


43.


59.


76.


97


119.5


125.


750.3


F.


Control



14.



31.


47.


C3.


75.5


93


107.5


108.


671.4


M.


Hypophysis...


0.05


14.


0.75 25.5


33.5


47.


60.


84


103.5


119.


750.


K.


Hypophysis...


0.05


14.


0.75 29.


42.5


57.


61.


82


94.5


105.5


654.


M.


Hypophysis...


0.05


13.


0.75 28.


42.2


57.


70.


97


116.


124.


853.8


F.


Hypophysis...


0.05


11 5


0.75


25.


37.


46.5


58.


77


91.


93.


708.


TABLE VIII (Litter 5)


Body Length


Control

Control

Hypophysis. Hypopiiysis. Hypophysis. Hypophysis.


15.4 15.3 14.8


17.9 16.5


Ratio of

testes to

body

weight


January, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


27


Notes. — Jan. 27. — Rats' in excellent condition, activity normal. Testes fully descended; no differences in size.

Feb. 10. Tlie hypophysis-fed are somewhat smaller than the control rats. There is no difference in size of testes or condition of fur.

FeJ). 2-i. Animals in excellent condition. No differences in activity. Fur and external genitalia of hypophysis-fed and control animals show no differences.

Microscopic Findings. — Sections of ovaries, Fallopian tubes and testes of control and hypophysis-fed animals show no differences. The testes are fully developed and the ovaries show numerous corpora lutea.


TABLE IX (Litter 6) Born Dec. 27, 1916. (Six animals.) Feedings begun Jan. 18, 1917. 22 days old. Animals killed Feb. 28, 1917. 63 " " Duration of experiment, 41 days.





2


5


M


o


t

s



•s


Se.v


Feeding


Q


1


^



SI


1





M.


Hypophysis...


0.05


24.5


47.5


71.5


90.5


116


139.5


152.


520


K.


Hypophysis.. .


0.05


25.5


51.


69.


82.5


109


123.


135.


430


M.


Control



24.6


47.7


63.


81.


105


134.5


140.5


472


F.


Control



23.5


47.5


65.5


84.


101


109.5


116.


396


M.


Hypophysis...


0.05


23.


4S.


69.5


90.


120


142.


154.


570


F.


Hypophysis...


0.05


23.5


47.5


74.


91.


123


132.5


130.


453


TABLE X (Litter 6)


Sex


Feeding


Tail length


Body length


Testes


Ratio of

testes to bodv weight


M



15.8 15.6 14.9 15.4 15.6 14.9


17.2 16.7 17.5 15.8 17.9 16.


2.7 2.35 2.43



F.




M.




F.

Notes. — Jan. 27, 1917. All the animals are in excellent condition. The testes of the hypophysis-fed and control animals descended almost simultaneously. They show no difference in size.

Feb. 10, 191~. The male hypophysis-fed rats are larger than the control. There is no definite difference in the state of nutrition or appearance of their coats.

Feb. 27, 1911. All the rats are in excellent condition. Their activities are nonnal. No precocities are noted. No appreciable variation in appearance of external genitalia is noted.

Microscopic Findings: Testes. (Hypophysis-fed.) Lumiiia of tubules are filled with mature spermatozoa. There is evidence of active spermatogenesis. Control: Findings are as noted for the hypophysis-fed rats.


Born Dec. 27, 1916. Feedings begun Jan Animals killed Feb. Duration of experiment, 38 days.


TABLE XI

(Litter 7)

(Ten animals.) 20, 1917. 24 days old. 27, 1917. 62 "


J^


Sex


Feeding


Q


"-3



•g



.a h


i


J3


c 1*






0.05

0.06



0.06

0.05

0.06



16.2

16.

15.5

15 5

14.6

13.

16.

13.


38.

35.5

35.

35.

34.6

32.

31.5

34.5

31.5

28.


59.

54.5

49.

54.

52.

49.5

50.

50.

49.

43.6


76.

71.

63.

66.

73.

64.

66.6

65.

68.5

64.


106. 94. 85. 90.5 92. 85. f 87. 81. 85. 72.


130. 115. 107. 109.5 117. 103. 105.

9,. 110

96.


136.5

122.

112.6

116.

123.

107.

111.

110.

08.6




.,.


M.

F.


Hypophysis

Hypophysis


662 649


F




F. F. F. F


Hypophysis

Hypophjsis

Hypophysis

Control


754 633 735





TABLE XII

(Litter 7)


Sex


Feeding


Tail length


Bodv length


Testes


Ratio of

testes to body weight


M.



15.4 14.4 14.4 15.3

14.5

14.3 14.5





F.





M



16.6 15.5

16.4

14.9 15.2


1.91 1.87



F.




M




F.




F.




F.




F.




F.



Notes. — These animals were observed frequently during the experiment and no differences in their development, such as sexual precocity or premature descent of the testes was noted. At the end of the experiment all the animals were active and showed no evidence of snuffles.

Microscopical Findings. — Testes (hypophj'sis-fed) . All sections show evidence of active spermatogenesis with numerous spermatids and almost fully developed spermatozoa.

Epididymis. The tubules are filled with cellular detritus and a few spermatozoa. Ovaries: Sections show Graafian follicles in various stages but no corpora lutea. LTteri (cornua) : The mucosa is moderately hyperplastic and there is active glandular proliferation.

Control: Sections taken fiom areas corresponding to those of tbi' hypophysis-fed rats show almost identical findings.


28


TABLE XIII (Litter 8) Born Feb. 24, 1917. (Seven animals.) Feedings Jjegun Mar. 17, 1917. 21 days old. Animals killed Apr. 28, 1917. 63 " Duration of experiment, 40 days.


Sex


Feeding


a


s

i


s



i


a.


<:


<


S

<


li


M. F. M. F. M. M. M.


Hypophysis... Hypophysis... Hypophysis...

Control

Control

Thymus

Thymus


0.05 0.05 0.05



0.05 0.05


15.7 15.7 16.8 16.3 16.1 15.6 15.6


25.7 27.7 27.7 27.1 27.2 28.6 27.5


31.7 31.3 32.5 33.2 31.1 31.3 33.1


0.1

0.1

0.1



0.1

0.1


36.1

38 1

37.6

37.3

37.5

42.

11.6


43.2

11.

41.5

43.1

12.4

50.

17.1


51.7

52.1

53.7

51.2

50.

63.5

56.2


66.4 66.1 65.3 62.8 61.8 78.1 69.8


322 321 285 285 286 400 3U


TABLE XIV (Litter 8)


Sex


Feeding


Tail Length


Body Length


April 12

Weight of

removed

testes


April 28

Testes


Ratio of testes to

bodv weight


M.


Hypophysis


11.1


13.4


0.357


0.732



F.


Hypophysis.'....


11.5


13.8





M.


Hypophysis


U.3


11.1



1.425


2.18


F.


Control M.





0.385


0.755 1.67 0.842



F.




U.3 14.2


2.13


M.


Thymus


11.2


0.121





Notes.— J/acc/i 31. All the animals are active; no evidence of snuflSes. The testes of the thymus-fed rats are fully descended, while those of the hypophysis-fed and control rats are but partially descended. No variation in fur or size of body.

April 6. Animals in excellent condition. Testes of thymus-fed are somewhat larger than others. Jfamma? of all females are equally developed.

April 12. Right testes of each male removed for histological study.

April 19. Animals in excellent condition, fur sleek and thick. No appreciable difference except for general increase in size of thymusfed animals.

Microscopical: Testes (hypophysis-fed rats six weeks old) removed April 12. The tubules are filled with spermatogonia and spermatocytes. An occasional spermatid is seen. Section from rat receiving no gland substance shows the same finding. Sections from the testes of the thymus-fed rats show spermatogonia, spermatocytes and many spermatids.

Sections of testes of hypophysis-fed and control rats taken at autopsy all show active spermatogenesis and fully developed organs. Similarly the female sexual organs of all animals show fully de veloped organs.


TABLE XV

(Litter 9) Born Feb. 27, 1917. (Seven animals.) Feedings begun Mar. 17, 1917. 18 days old. Animals killed May 6, 1917. 68 " Duration of experiment, 50 days.


Hypophysis Hypophysis Hypophysis

Thymus

Thymus

Control.... Control....


t:


S



_



2


S


S


.0


g


S


^


i



<


a. <


0.

<



S ^


^ &


5t


a


$


1



.a 59.


76.5


14.


22.3


26.


0.1


33.


41.


16.


I4.325.6I31.6


0.1


36.9


46.5


52.7


68.7


81.3


15.6 25.131.3


0.1


39.8


50.


58.6


72.2


87.7


14.126.131.8


0.1


39.8


48.2


62.


68.


78.7


13.8 25.8 30.8


0.1


39.8


60.


57.6


71.6


82.6


14.2 21.1|25.8



29.


37.2


43.3


52.8


63.5


13.8 26.


31.2



36.6


11.5


51.2


61.4


74.


TABLE XVI

(Litter 9)


Hypophysis Hypophysis Hypophysis

Thymus

Thymus....

Control

Control....


12.1 12.8 12.9 12.2 12.7


15.8 14.6 11.6 14.1


April 20, removed

testes


0.933 1.555


Notes : March 28. Animals in excellent condition. The testes ol the hypophysis-fed animals partially descended, of thymus-fed fully descended. Testes of control not felt.

April 7. Animals in excellent condition; no differences in activities. Fur of fed animals and control animals alike. The testes of the thjTnus-fed animals are slightly larger than those of the control animals.

April 12. Testes of each pair removed for microscopical study.

April 28. The controls are smaller than the gland-fed animals. All are well nourished and active. No differences can be made out in fur or genitalia.

May 5. Rats seem well; no evideiue of snutUes made out. Feedings as last noted.

Microscopical: Testes from hypophysis-fed rats removed at six weeks of age show tubules completely filled with spermatogonia, spermatocytes, and an occasional spermatid generally situated in the outer zone of spermatocytes.

The testes of the rats fed no gland show similar findings. Sections of testes of hypophysis-fed and control rats removed at autopsy show fully developed organs. Evidences of spermatogenesis are equally active in both. Ovaries, Fallopian tubes, uteri of the hypophysis-fed animals show fully developed organs. The control animals show similar findings.


i."


THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1921



Fig. 4.— rh..t,.,i;r;iiiliuf (1) liy|»,|,li\ si>-fed male rat, \veij;lit (i'.l yins., (2) ccmtrol male rat, weight 06.5 gms., of litter 2.



Fig. 5. — I'liutugraiili of testes of { 1 ) control rat, (2) hypophysis-fed rat, of litter 1. Weight of testis of control rat, 2.20 gms., of hypophysis-fed rat 2..'?2 gms.


THE JOHNS HOPKINS HOSPITAL BULLETIN. JANUARY, 1921



Fig. C. — Mieropliotographs of testes of (1) ainl (lA) liypopliy-sis-foil rat, (2) niiil (2A) control rut of litter !), showing no ililTereiioes in spormatogenesis after 35 ilavs of feeding.


January, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


29


TABLE XVri (Litter 10) Boru Feb. 23, 1917. (Seven animals.) Feedings begun Mar. 16, 1917. 21 days old. Animals killed May 12, 1917. 78 " Duration of experiirient, 57 days.




s


CO


S


n


la


o


2


n


2


S


^



a



Sex


Feeding


S

a


.a 24.


1 22.


ti) 32.


< 43.4


a <

ti O


a <i

.o 62.5


<

a



<

61.


a <

72.1


s

87.


a




bo a!


M.


Control



106.


341.7


F.


Control



20.


IS. 6


22.8


29.6



35.6



46.6


54.6


66.5



83.6


318.


M.


Hypophysis.


0.05


23.


22.


33.


38.7


0.1


45.1


02


49.


66.8


80.8


0.3


107.1


365.6


F.


Hypophysis.


0.05


19.


16.5


27.5


34.6


0.1


43.3


0.2


50.6


64.8


76.2


0.3


89.2


368.5


M.


Thymus


0.05


23.


21.7


31.


38.4


0.1


42.1


0.2


57.


69.6


83.7


0.3


106.


360.8


F.


Thymus


0.05


22.


20.5


34.


40.


0.1


44.9


0.2


Killed, by accident, Apr. 15




F.


Thymus


0.05


23.


21.


28.5


34.2


0.1


38.1


0.2


45.658.4172.210.3


91.


295.5


Notes: March 2tl. Animals have done very poorly; not especially vigorous. All ha,ve a diarrlicea. Testes not descended.

April 11. Marked improvement in condition of all animals, no diarrhoea. Testes descended; no differences in genitals noted.

April 25. Animals observed daily since last note; no differences in activity, fur or size noted. No snuffles.



Weeks


AGE


Fiu. 1. — Showing combined weight curves of hypophysis-fed and control male rats of litters 1-6, on diet of mixed grains and bread and milk, fed in unlimited amounts.



Weeks '"


Fig. 2. — Showing combined weight curves of hypophysis-fed and control male rats of litters 7-9, on unlimited amounts of mixed grains and equal amounts of milk.


qw


Ol 50 3


WeeKs'°




j




1 / 1



I / /


' j 1 'O


A



,^


<?

i? <




'A


^


'-^






/



/






1


^-^


/





AGE


Fig. 3. — Showing weight curve of hypophysis-fed and control male rat of litter 10, on balanced diet of purified casein, dextrin, salts and food accessories, given in equal amounts to each rat.


30


BIBLIOGRAPHY

1. Robertson, T. B.: Jour. Biol. Chera., 1916, XXIV, 385.

2. Ibidem, 397.

3. Goetsch, E.: Johns Hopkins Hosp. Bull., XXVII, 29.

4. Donaldson, H. H.: Wistar Institute of Anat. & Biol., Memoir No. 6.

5. McCollum, E. V.: Jour. A. M. A., 1917, LXVIII, 1379.


6. Gudernatsch, J. F,.: Am. Jour, of Anat., 1913-14, XV, 431.

7. Lewis, D. D., and Miller, J. L.: Arch. Int. Med., 1913, XII, 137.

8. Hoskins, E. R.: Jour. Exp. Zoologj-, 1916, XXI. 295.

9. Clark, L. N.: Jour. Biol. Chem., 1915, XXII, 485.

10. Pearle, R.: Jour. Biol. Chem., 1916, XXIV, 123.

11. Wulzen, R.: Amer. Jour. Phys., 1914, XXXIV, 127.

12. Osborne, T. B., and Mendel, L. B.: Publications of the Carnegie Institution of Washington, 1911, Bull. No. 156.


SYPHILITIC RUPTURE OF A PAPILLARY MUSCLE OF THE HEART


By Edward D. Spalding and William C. Vox Glaiin

(From the Pathological Department, City Hospitals, Baltimore, Md.)


The followiug is a case report of one of tlie rarer cardiac accidents.

S. H. (6650MI, colored, male, laborer, age 31, admitted and died March 23, 1920,

F. H. and P. U. — Unessential except for a small venereal sore 1905, and one miscarriage by wife.

P. J. — Following a three weeks' attack of hoarseness 15 months before admission, the patient began to be noticeably dyspna?ic and orthopntpic, and developed a nocturnal cough with blood-streaked sputum. This subsided spontaneously, but returned more severely a year later, when he was admitted to the University of Maryland Hospital, January 5, 1920, at which time the following data were recorded :

P. E. — The heart was not enlarged to the right, but the ape.x was in the sixth interspace, 14 cm. to the left, where an indefinite presystolic thrill was felt. There was a diffuse precordial heave. At the apex, the cardiac sounds were replaced by a well transmitteil, blowing systolic and short diastolic murmur. At the base and down the sternum a short diastolic was heard, replacing the aortic second sound. The second pulmonic was accentuated. The pulse was regular, Corrigan in type. B. P. 130/50.

Slight dullness was present at the extreme base of the right lung behind, and the liver was three fingerbreadths below the C. M. but not tender. There was some oedema of the ankles.

Laboratory Findings. — ^Urine, S. G. 1.011-33, negative for albumin and casts. Phthalein excretion, 24 per cent first hour. Blood.- .Slight secondary anamia; Wassermann, + + + -|-.

X-Ray Findings. — Enlarged heart and aorta ; clouding at the base of right lung.

Course. — Gradual restoration of compensation, with two miiuir remissions. Discharged February 27, 1920.

Subsequent Course. — After discharge the patient gradually went down-hill again, and after one month was admitted to the City Hospital for treatment.

On admission he was moderately (edematous, and dyspnoeic. His pulse was rather rapid, and collapsing in character but regular and of fair quality. He did not appear to be in a grave condition and was given a tub-bath on the ward. Seen immediately afterward by the ward physician, he complained of feeling badly. He was cyanotic, sweating, and very dyspnoeic, with a very rapid, thin, w-eak pulse. He was wheeled to his bed, and three minutes later was frothing at the nose and mouth. His heart was found to be greatly dilated, chiefly to the left. Venesection was immediately done, strophanthin administered intravenously, and morphin and atropin given sub(^itaneously. The pulse became somewhat stronger, the respirations were slow and very labored with tracheal rhonchi. The patient was turned on his face and artificial respiration resorted to, but in spite of these measures he very shortly died. The blood Wassermann was subsequently reported as -|- + + +.

Clinical Impression. — 1. Syphilis. 2. Aortic insufficiency (syphi litic). 3. Acute myocardial insufficiency with pulmonary (ederaa.


Autopsy No. 1625. Anatomical Diagnosis. — Syphilis; syphilitic aortitis with involvement of aortic valve; aortic insufficiency; fibrous myocarditis; cardiac hypertrophy and dilatation; chrc.iic passi'e congestion of viscera; oedema of legs; necrosis of posterior mitr.il papillary muscle with rupture; pulmonary oedema.

Heart. — The pericardial cavity does not contain an excess of fluid and its surfaces are smooth and glistening. On the anterior surface of the ventricles are several tendinous patches. The heart weighs 560 grams. The right auricle is slightly dilated. The foramen ovale is closed. The right ventricle is hypertrophied and dilated. It measures 10 cm. fiom the tricuspid ring to the apex. The tricuspid and pulmonary valves are normal and their rings measure respectively 12 and 6.5 cm. in circumference. The wall of the ventricle is 1 em. thick.

The left auricle is hypertrophied and dilated. The mitral valve is thin and delicate and its ring measures 9 cm. in circumference. The cavity of the ventricle is much enlarged, nijeasuring 12 cm. from the mitral ring to the apex. The columnae carnete stand out prominently. The wall of the ventricle is 2 cm. in thickness. The posterior (cr inferior) papillary muscle is Y-shaped, being divided into two large pillars. That pillar to which the chordie tendineae from the right half of the aortic leaflet of the mitral valve are attached, has ruptured close to the point of the division (Fig. 1.) The fragment attached to the valve is yellowish white in color and the endocardium over it is ^looth but opaque. The torn end is rough, irregularlj' conical in shape, and is covered with a firmly adherent clot. In the central portion there is still recognizable a core of muscle encircled by a j-ellow opaque ring, which lies just beneath the endocardium. The stump is likewise cos'ered with smooth endocardium and is opaque and quite yellow in color. The line of demarcation * is very sharp and is emphasized by a narrow zone of hemorrhage. The central part of this fragment is softened. The other pillar cf this papillary muscle and the anterior papillary muscle are covered with opaque endocardium, beneath which are a few petechiae. On section there are numerous yellow flecks and silvery grey streaks in these muscles. The endocardium is thickened below the aortic valve and also over some of the columnse carneae, where there are many small subendocardial hemorrhages. The myocardium is greyish red in color and the muscle fibres are hypertrophied. In the wall of the aorta just above the attachment of the left posterior and the anterior leaflets of the aortic valve, is a large, oval, corrugated plaque, which extends dow^lward, involving these two cusps. The anterior half of the left posterior leaflet has been entirely destroyed, though the line where it was attached is still visible as a little ridge. The remnant of this cusp is moderately thickened. The left half of the anterior leaflet is also eroded but to a less extent. The margin of this cusp is thickened and rolled over. The aortic ring measures 7 cm, in circumference.

The orifices of the coronary arteries are not encroached upon by the plaque in the wall of the aorta, and these arteries appear normal as far as they can be followed.


THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1921



Fig. 1.— Paipture of Papilhu-y Muscle. No'.eulso the erosion of the aortic valve.




Flc. 2. — Levailiti preparation. Spiroehoete at niaruin of tlie necrotic tissue. X 820.


Januahy, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


31


Microscopic Examination. — The section is from the stump of the ruptured muscle. The central part is made up of a large area of coagulative necrosis in wliich is much nuclear dust, and about the margin of this necrotic area leucocytes have accumulated. Just l)eyond the leucocytes, the muscle fibres are shrunken almost to threads and the striations and nuclei have disappeared in them. Small hemorrhages are found among these atrophied fibres. Next to these atrophic fibres is a zone of muscle fibres containing fat droplets. In many of these fibres the nuclei are pyknotic; in others, the nuclei are large and hyperchromatie with irregular outlines. Tlie blood vessels in this zone are greatly engorged. Here the ])roress ends abruptly.

Beneath the endocardium is a small amount of hyaline material into which a few fibroblasts are gro\^ing. A very few plasma cells and small round cells are seen here.

Tlie muscle fibres elsewhere are greatly hypertrophied and tliere is an increase in connective tissue.

Tn Levaditi preparations a moderate number of spirochaetes are found in the tissues just beyond the necrotic area (Fig. 2).

The histological changes seen in the ruptured muscle differ in many respects from the classical picture of a gumma. In the area of eoagulative necrosis, all outlines of the preexisting tissue are completely obliterated. Neither are there any epithelioid or giant cells. Accumulations of small mononuclear wandering cells are entirely wanting and the connective-tissue capsule so commonly seen about gummata is also absent.

In a section of 'the anterior papillary muscle, there is atrophy with hyalinization of some of the muscle fibres and hypertrophy of others. Small hemorrhages are found among the atrophic fibres. The connective tissue is increased. There is no plasma or smallround-cell infiltration.


Literature — Wankel, in 1911, reported a case of ruptured papillary muscle, and in a review of the literature foujud only four other cases. Teacher the same year also reported a case. In all of these, the ruptured muscle was in the left ventricle.

In four of the cases — those of Bertin, Dennig, Wankel and Teacher — there was sclerosis of the coronary arteries, and in two of these (Dennig, Wankel) there was thrombosis of these vessels. In the case of Corvisart, no mention is made of the condition of the coronary arteries, while in Legendre's case they were normal. In none is there any reference to a syphilitic infection, Init an aneurysm of the aorta was present in Bertin's case.

Concliision — In the case reported here, the Treponema pallidum was the etiological agent in the production of the necrosis of the papillary muscle which subsequently ruptured.

We are indebted to The University of Maryland Hospital for the abstract of their history, and to Dr. E. H. Terrill for tlie photograph.

BIBLIOGR.APHY

Wankel: Ein Fall von spontaner Papillarmuskelzerreissimg. Dissertation, Giessen, 1911 (Lit.).

Teacher: Case of Rupture of a Papillary Muscle of the Left Ventricle of the heart. Glasgow Med. Jour. 1911, LXXV, 374-376.


NOTES AND NEWS


Dr. John S. Billings, Jr., is Director of the New York Tuberculosis Association.

Dr. Kenneth D. Blackfan is Professor of Pediatrics, University of Cincinnati, and Pediatrician-in-Chief, Cincinnati General Hospital.

Dr. E. Bates Block is Professor of Neurology and Psychiatry, Atlanta Medical College.

Dr. Arthur L. Bloomfield is Assistant Visiting Physician to Tlie .lohns Hopkins Hospital.

Dr. George Blumer is Clinical Professor of Medicine at the School of Medicine, Yale University.

Dr. Harold M. Bowcock is associated with Dr. J. E. Paullin in work in Atlanta, Ga.

Dr. H. Hays Bullard is Professor of Pathology, Western University Medical School, London, Ontario, Canada.

Dr. Montrose T. Burrows is Associate Professor of Experimental Surgery, Washington L^iversity Medical School, and Director of Research Lal)oratories, Barnard Skin and Cancer Hospital, St. Louis.

Dr. C. N. B. Camac is Assistant Professor of Clinical Medicine, College of Physicians and Surgeons, Columbia University, New Y'ork; Medical Director, Gouverneur Hospital of the Bellevue and Allied Hospitals, New York, and Consulting Physician to the City and (o St. Andrew's Hospitals.

Dr. C. Macfie Campljell is Professor of. Psychiatry, Harvard Medical School, and Director of the Boston Psychopathic Hospital.

Dr. J. Julian Chisolm is in private practice in Baltimore.

Dr. Ernest K. Cullen is Attending Gynecologist in charge of the Department, Harper Hospital, Detroit, and Acting Head of the Department of Gynecology in the Detroit College of Medicine and Surgery'.

Dr. Edgar E. Duncan is Assistant Resident at the Hospital for the kVomen of Maryland, Baltimore.


The


Dr. William A. Fisher, Jr., is Associate in Clinical Surger Johns Hopkins Medical School.

Dr. Henri Flournoy is a lecturer (Privat-docent) of Psychopathologj' of the Faculty of Medicine of the University of Geneva.

Dr. Hildegarde Germann is practicing medicine in Quincy, Illinois.

Dr. David K. Henderson is the Deputy Physician-Superintendent of the Glasgow Royal Asylum, Gartnavel, Scotland.

Dr. J. Gardiner Huck is E.xaminer of the Medical Department of the Textile Benefit Association, LaGrande, Ga.

Dr. Henry Hun is in private practice in Albany, N. Y.

Dr. Stewart V. Irwin is in private practice in Oakland, California.

Dr. Carl F. .Jordan is connected with the Y'angchow Baptist Hospital, Yangchow, China.

Dr. J. Edwards Kerney is Director of Venereal Diseases for the State of Rhode Island, and is located in Providence.

Dr. Dabney Kerr is at the School of Language, Peking, China, under the Presljyterian Board of Foreign Missions.

Dr. J. H. Kite is Resident Surgeon, LTniversity Hospital, and Instructor in Surgery, University of Georgia, Augusta, Ga.

Dr. Fred H. Kruse is Instructor in Medicine, University of California Hospital.

Dr. Frederick H. Lintliicum is in private practice in Los Angeles, California.

Dr. Kenneth F, Maxcy is Director, Kansas State Public Health Laboratory, Topeka, until January 1, and after January 1 Rockefeller Scholar at The Johns Hopkins School of Hygiene and Public Health.

Dr. Charles W. Mills is Medical Director, Tucson, Arizona, Sanatorium, Tucson.

Dr. W. L. Moss is Assistant Professor of Preventive Medicine and Hygiene, Harvard Medical School.

Dr. I. W. Nachlas is in private practice in Baltimore.


32


Dr. Ralph E. Powell is Associate Genito-Urinary Surgeon at the Montreal General Hospital, Montreal.

Dr. George H. Preston is First Lieutenant, Medical Corps, U. S. Army, Pacific Branch, U. S. Disciplinary Barracks, Alcatraz, California.

Dr. Alexander Randall is Associate in Surgery, University of Pennsylvania Medical Department, Philadelphia.

Dr. Augusta R. Scott is in private practice in New York City.

Dr. Rjilph B. Seem is Director, Albert Merritt Billings Hospital, Chicago, and Hospital Consultant for the State School of Medicine for the State of Kansas.

Dr. Andrew W. Sellards is Assistant Professor of Tropical Medicine, Harvard Medical School, Boston.

Vt. W. G. Sexton is on the Surgical Staff of St. Joseph's Hospital, Marshfield, Wisconsin.

Dr. Henry N. Shaw is in private practice in Los Angeles, California.


in private practice in Los Angeles, Cali


Dr. J. Morris Slemons fornia.

Dr. F. Janney Smith is Assistant Chief Physician, Henry Ford Hospital, Detroit.

Dr. Richard P. Strong is Professor of Tropical Medicine, Harvard University Medical School, Boston.

Dr. Margaret Tyler is Resident in Obstetrics and Gynecology, New Haven Hospital, New Haven.

Dr. Karl H. Van Norman is First Assistant Superintendent, The Johns Hopkins Hospital.

Dr. William C. Von Glalin is Instructor in Pathology, College of Physicians and Surgeons, Columbia University, and Resident Pathologist, Presbyterian Hospital, New York.

Dr. Milton C. Winternitz is Dean, as well as Professor of Pathology, in the Y'ale University Medical School.


NOTES ON NEW BOOKS


PUBLICATIONS


The following twelve mouographs :


Benzol as a Leucotoxin. By Laurence Selling, M. D. 60

pages. Price, $1.00. Primary Carcinoma of the Liver. By M. C. Winternitz,

M. D. 42 pages. Price 75 cents. The Statistical Experience Data of The Johns Hopkins Hospital, Baltimore, Md., 1892-1911. By Feedeeick L.

Hoffman, LL.D., F.S.S. 161 pages. Price, $2.00. Venous Thrombosis During Myocardial Insufficiency. By

Frank J. Slaben, M. D., and Milton C. Winternitz,

M. D. Price, 75 cents. The Origin and Development of the Lymphatic System. By

Florence E. Sabin. 94 pages. Price, $2.00. Leukaemia of the Fowl: Spontaneous and Experimental.

By Harry C. Schmeissee, M. D. Price, $2.00.

are now on sale by The John's Hopkins Press, Baltimore. Other monographs will appear from time to time.


The StruL-ture of the Normal Fibers of Purkinje in the .\dult Human Heart and Their Pathological Alteration in Syphilitic Myocarditis. By 0. Van Der Steicht and T. Wingate Todd. Price, $2.00.

Tlie Operative Story of Goitre. The Authoi-'s Operation. By William S. Halsted, M. D. Price, $3.50.

Study of Arterio-Venous Fistula with an Analysis of 447 Cases. By Curle L. Callander, M. D. Price, $2.50.

Ligations of the Left Subclavian Artery in its First Portion. By William S. Halsted. Price, $2.00.

The Pathology of the Pneumonia in the United States Armv Camps During the Winter of 1917-18. By William G. MacCallum. Price, $1.50.

Pathological Anatomy of Pneumonia Associated with Influenza. By William G. MacCallum. Price, $1.50. (This monograph will be on sale within a short time.)



Vol. XXXH— No. 360]


BALTIMORE, FEBRUARY, 1921

Contents

  • The Significance of the Bacteria Found in tlie Throats of Healthy People. By Arthur L. Bloojifield
  • Experimental Inoculation of Human Tliroats with Aviruleiit Diphtlieria Bacilli. By \V. L. Moss, C. G. Guthrie and B. C. Marshall . .
  • A Clinical Method for the Quantitative Determination of Caliiuni and Magnesium in Small Amounts of Serum or Plasma. By Benjamin Kramer and Frederick F. Tisdall . . .
  • The Surgical Treatment of Rhinophyma, with Report of a Case. By Edward M. Hanrahan, Jr
  • The Isolation of B. Dyscntcrur (Flexner) from the Urine of an Infant with Dysentery. By Catherine Creighton, C. E. Wagner, and Wilburt

C. Davison 50

A Contribution to the Staining of Phagocytes and Exudates.

By Howard B. Cross 51

A Clinical Study of Tuberculous Salpingitis, Based Upon 200 Cases.

By J. P. GreenbeRG 52

Books Received 55

Titles of Papers Appearing During the Year, 1920, Elsewhere than in the Bulletin, by the Present and Former Members of the Hospital and Medical School Staff 57


Entered as Second-Class Matter ai the Baltimore, Maryland, Postofflce Acceptance for mailing at special rate of postage provided for in Section 1103, Act of October 3. 1917. Authorized on July 3, 1918.


THE SIGNIFICANCE OF THE BACTERIA FOUND IN THE THROATS

OF HEALTHY PEOPLE

By Arthur L. Bloomfield

{From the Biological Division of the Medical Clinic, Tht Johns Hopkins University and Hospital)


In studying the etiology and pathogenesis of infectious diseases tlie problem is simplified vastly by the existence of a lesion from *hicli the virus may be recovered in pure culture. Meningitis and sepsis, conditions which previously were but incompletely understood, immediately became intelligible from the bacteriological standpoint following the introduction of spinal puncture and blood cultures which made it possible to study the organisms derived in pure culture from the seat of the disease. The causal agents of respiratory disease, on the other hand, have proven much more elusive, and the proof of their relation to particular lesions is much more difficult, since the ground is already occupied by organisms not primarily causing the process, or at least is open to secondary invasion from the upper air passages by a host of unessential organisms. It required several years to establish the pneumococcus as the cause of lobar pneumonia, and a generation later we find the problem of the etiology of influenza even more perplexing and thus far insoluble. In reviewing the history of the latter disease it becomes apparent tliat confusion has arisen through the focussing of the investigator's attention upon one or another organism without due consideration of the flora as a whole both in health and in disease.

During the course of studies on the fate of bacteria introduced into the upper air passages it became apparent that


foreign organisms were rapidly eliminated. It seemed probable, therefore, that the true normal flora of these regions might be relatively simple and constant, and that, if it could be clearly defined, a background would be obtained against which the flora present in various disease conditions might reasonably be contrasted with less chance of misinterpretation. For example, should it turn out that the green streptococcus is constantly present in normal throats, its presence in disease would have to be interpreted with great caution, whereas an organism not normally present in healthy throats, if persistently found in a given individual, would indicate disease or at least an abnormal carrier state. It immediately became clear tliat a large number of single cultures from various individuals would help but little in the solution of this problem. The literature already affords ample information as to the great variety of organisms which may be recovered from the apparently normal throat. Thus, it appeared more hopeful to study the flora of a few individuals repeatedly at frequent intervals over a considerable period of time, as by this means one could determine not only the organisms present, but their persistence as well as their relative predominance. Moreover, chance temporary invaders could be distinguished from bacteria actually dwelling in the moutli cavity.


34


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 360


Methods

Six healthy individuals were selected for study. They included the physicians and personnel working in the bacteriological laboratory, and being constantly and intimately exposed to infectious diseases of all sorts. In addition, a few patients not suffering from disease of the respiratory tract were investigated. Cultures were made about once a week from each of these individuals over a period of from one to three months. A swab was systematically passed over the tonsils, pillars, soft palate, and posterior pharjTigeal wall and immediately plated. Aerobic methods only were used. The media consisted of plates of 5 per cent blood agar (human or rabbit) and of Avery's oleate hemoglobin medium. Four plates were made from each swab, a system of dilutions being employed which yielded a good spread of colonies on the plates. Cultures as ordinarily made, resulting in a confluent growth, are useless in this sort of work. The plates were studied after 24 and after 48 hours from two points of view. First a careful search was made for the presence of B mfiuenzcB, Strept. hemolyticus, the meningococcus, pneumococcus and staphylococcus albus and aureus. Then a study was made of the other organisms present. . Every tj'pe of colony present was fished and the numbers of each estimated as accurately as possible. The cultures were worked out in great detail, about four hours being found necessary for the complete study of one set of plates.

Eesults

It soon became apparent that certain organisms were almost constantly present from day to day. Before analyzing the results in detail a few general remarks may be made about each of the groups of organisms present.

(1) The Gram-Negative Cocci. — In practically eveiy plate the predominating organisms were found to belong to the group of Gram-negative cocci. At first an attempt was made to differentiate several varieties and strains on the basis of colony size and consistency, pigmentation, and growth on various media. This task was soon abandoned as impossible, inasmuch as every variation, was found, from small translucent grey colonies to large, dry crinkly pigmented ones. Finally, the study of this group was confined to the elimination of the meningococcus, the remaining organisms being classed simply as Gram-negative cocci. As one becomes familiar with the appearance of plates made by a constant method, the colonies of these bacteria stand out as a characteristic background. With the exception of a few cases which will be discussed in connection with the protocols they were present in every culture and undoubtedly are a constant and normal inhabitant of the upper air passages.

(2) The Non-Hemolytic Streptococci. — These organisms as well as the Gram-negative cocci were present in nearly every culture. Undoubtedly many strains exist — as evidenced by variation in appearance of the colonies, and in the morphologj' of the organisms. The usual type is a small grey semi-transparent colony 0.5 to 1 mm. in diameter with a slight greenish zone of clearing; microscopically, the bacteria are usually in long chains and show considerable pleomorphism. Organisms belonging to this group are undoubtedly constant inhabitants


of the normal throat, although temporarily they may be replaced by other bacteria.

( 3 ) Influenza Bacilli. — Members of the group of hemophilic Gram-negative bacilli were foimd in most of the cultures. The position of this organism is still in doubt, and inasmuch as these studies were made at a time when respiratory disease was prevalent one hesitates to draw final conclusions. A special study of this problem is now in progress. It may be said, however, that Gram-negative hemophiles may be present in large numbers in the throats of healthy people constantly and over considerable periods of time.

The above three groups seem to comprise very definitely the constant normal flora of the mouth when cultures are made by this method. We are inclined to believe that the presence of any other organism demands a special explanation — either the presence of disease, a focus of latent infection, or accidental introduction. Before presenting the protocols a few general remarks may be made about the other organisms considered in this study.

Hemolytic streptococci of the typical beta type were not obtained in any case. This is of interest, as the cultures were made from people who were in intimate contact with patients suffering from sore throats due to these organisms. We believe that their presence in normal throats, as reported by some writers, indicates the recent presence of widespread infection among large groups of people with a virulent type of the germ. Hemolytic streptococci of the alpha type were occasionally found but never as constant inhabitants. Their significance will be discussed in connection with the individual cases.

Pneumococci were occasionally found. Inasmuch as mouse inoculation was not employed, their presence may have been overlooked in some cases. All suspicious colonies seere carefully studied, however, and this organism is certainly not a member of tlie normal flora in the strict sense.

Meningococcus was found in no instance. This was to be exjjected as there was no meningitis in the environment at the time.

Staphylococci were found occasionally, but never constantly, in the same normal throat. This organism, therefore, when present, is an accidentally introduced transient unless associated with a local infection.

Diphtheroid bacilli. Gram-positive cocci of various sorts, and other organisms, as described in the protocols, are not uncommonly present, but only as transients.

The non-pathogens in the throat may, therefore, be divided into the members of the constant normal flora — Gram-negative cocci, non-hemolytic streptococci. Gram-negative hemophiles ( ?) — and a group of organisms commonly present about the body such as staphylococci, diphtheroids, and others, which not infrequently may be introduced into the mouth but are transients and are promptly eliminated.

Protocols

A scrutiny of the protocols herewith presented will bring out more clearly the points discussed above.


February, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


35


CASE I.— MO


Date of culture



c o


33 a. O


Pneumo



S"


Remarks


Mar. 13..


00 *


A few.



A Gram-pos. diphtheroid, 20 cols.


" 23..


100


Many.



Type IV, a few cols.


A few.






" 31..


Many.


Many.



Type IV, a few cols.


00






Apr. 6..


CO


=0





Many.






' 21..


Many.


» 00




•' 26..


CO


CO





Many. Comment. — The nonhemolytic streptococci and Gram-negative cocci were constantly present. Influenza bacilli were recovered in four of six cultures. A Type IV pneumococcus was temporarily present, and on one occasion Staph, albus was recovered. A diphtheroid was present in the first culture, but was never isolated again.

In this case, therefore, we have the constant normal flora, with the occasional transient presence of other non-pathogenic organisms.

CASE II.— CA



• '





a


n


•,





Date ot culture


j:to =


c o

OS >


|£g


S

3 a,



a.


£ 3


Remarks



z;-""


O*"


5JH«0


Q. "



M


S"



Feb. 24..


200






200





A large Grampos. coccus, 200 cols.


" 27..


Few.


00





300





A large Grampos. coccus, a few cols.


Mar. 3..


10


CO





A few.





A yeast, 1 col.


• 10..


00


Many.





A few.






" 17..


CO


« 


Many cols, alpha tvpe



A few.






" 24..


00


CO





100 Comment. — The non-hemolytic streptococci, the Gram-negative cocci and influenza bacilli are constantly present. An alpha type hemolytic streptococcus was recovered in one culture, but not before or after. A large Gram-positive coccus was present for a few days and then disappeared. We have, therefore, in this case the normal flora plus the transient presence of other organisms.

CASE III.— BL



jjo


a.

„g


6


.a


J3


s



Date of culture


1:1




1


i.


§,


6

£ 3


Remarks



z.""


O"


a " "


a, "


^ ^


W


S "



Mar. 4..


QO


00


Alpha type 100 cols.



A few.





A Gram - pos. diphtheroid, many cols.


" 8..


A few.


00





100






" 24..


00


00





Many.






Apr. 1..


00


00





Many.





A Gram - pos. diplitheroid, many cols.


" 8..


CO


00





Many.





Many cols, of a Grara-neg. hemolytic bacillus.


" 26..


Many.


Many.


Alpha type a few cols.



Many. Comment. — Non-hemolytic streptococci. Gram-negative cocci, and influenza bacilli were constantly present. Alpha hemolytic streptococcus was present as a transient on two occasions, as well as a grampositive diphtheroid and a Gram-negative hemolytic bacillus. The significance of the hemolytic streptococcus is uncertain. It may have been harbored in the tonsil whence it was discharged from time to time.

CASE IV.— V


Date of

culture


>.6

If.



-1


1

a. "


J3 3 « 


jQ


1

c:


Remarks


Feb. 28..


cc


80





00






Mar. 1..


00


00





Many.


1




" 3..


00


Many.





100





1 col. hemolytic staph. Many cols. Gram-pos.

diphtheroid. 100 cols, coarse Gram

" 6.. " 9..


Many.

00


00

Many.






Many. 50






pos. coccus. Many cols. Gram-pos.

diphtheroid. 00 cols. Gram-pos.

diphtheroid.


Comment. — Non-hemolytic streptococci, Gram-negative cocci, and influenza bacilli were constantly present,. From time to time various other organisms were isolated, especially a Gram-positive diphtheroid.


CASE v.— AX


Date of culture


"o o.


a"


a""


1


XI

OJ 3 3^


^


i is


Remarks


Jan. 3..


00


00





A few.


Manv.



Gram-pos. diphtheroid


Feb. 23..


»


Several hundred.





Several hundred.





many cols. Gram-pos. diphtheroid many cols.


" 26..


00


00





« 






" 28..


00


CO





Many. Comment. — Non-hemolytic streptococci, Gram-negative bacilli, and influenza bacilli were constantly present. Staph, albus was isolated on one occasion, and a Gram-positive diphtheroid twice.


CASE VI.— CA


Date of culture


>.6

Its

do g

2*^ ^


= 2


a " "


1

3 at


.2

V 3 3 —


XI


I


Remarks


Feb. 24. .


200


00





200





Huge Grampos. coccus, 200 cols.


" 27..


A few.


CO





Several hundred.





A few of the above.


Mar. 3. .


10


CO





A few.





A yeast, one col.


" 10..


CO


00




" 17..


00


00


Alpha type



.4 few.






" 25..


00


« 


many.




Many. 36


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 360


CASE VII.— BV


Date of culture


ft. "= « o


si

a"


>.2


1

a.


J3

h to 23


3 .£3

.3

a.


1



Remarks


Feb. 22..


Many.


00





00


Gram-pos.diphtlieroid, 20 cols.


" 25..


00


00





CO






' 29..


00


00





»





A pigmented staph., 20 eols.


Mar. 2..


00


CO





Many.





A large Grara-pos. coccus, 50 cols.


CASE X.— GI


CASE VIII.— JIA


Date of culture


id


is


II

its


1

1

3 „

0. "


i

S 3


.a

.3


i


Remarks


Mar. 10..


00


00





A few.


3




" 29..



00





Many.


150




April 7. .


00


00





A few.


2




" 27..


00


oo





Many.





A Gram-poa. coccus, not S. albus, many cols.


" 30..


Many.


"





Many.





About 50 cols, of a minute Gram - pos. organism (?).


Comment.- — The normal flora is present. In addition Staph, albus was recovered in small niimbers in three consecutive cultures, after which it disappeared.

CASE IX.— ER


Date of culture


>.6

Hi


11


ss§


1

1


3 2



g

3 £ 3


Remarks



a" "


£"


x" "


£ "


£"


-j:


s "



Mar. 4. .


oo


00




" 9..


00


50



A Gram-pos. diphtheroid, many cols.


" 16:.



00


Alpha type many cols.


Type IV many

cols. A coarse Grampos. coccus, many cols.


" 25..


00



Alpha type many cols."



100






Apr. 5..


CO


00





A few.






" 13..


00




Sev. hundred colonies of a Grara-neg. bacillus, large grey cols.with hemolysis.


" 16..


50


Many.



Many cols, of a coarse Grampos. coccus, not S. albus.


" 20..



00





Many.


3



50 cols, of same Gram-neg. bacillus asfound in culture of Apr. 13.


" 25..


00


00





Many. Comment. — Tlie normal flora is present. In addition, influenza bacilli and other bacteria were transiently present. A mild pharyngitis lasting two days preceded the appearance of the alpha hemolytic streptococcus recovered on March 16 and March 25.


Date of culture


o a. 1o|



Hemolytic Btreptococ*


I


OS


1

a



liemarks


Mar. 1 . .


00





00 Friedlander.


" 5..


Many.


A few.



00 Friedlander. CO Gram-pos.diphtheroid. 50 cols, of a coarse Gram

" 12..


CO


A few.


Alpha type


pos. coccus. 00 Friedlander.


" 17..


« 


A few.


many.

o"


00 Friedlander.


Comment. — This patient was a carrier of the Friedlander bacillus, which tended to supplant the normal flora.





CASE XI.— DO





Date of culture


If,


Is


si


1

= 3


c'S


2 8 1 i.3


Remarks


Mar. 12..


Many.' 20





3


00 1



' 15..



100



Type II inanv?



oo 1

1



" 20..


CO


CO 50



A yeast, 50 cols.


" 27..


Many.


CO


Alpha type manv.



Many.


100




Apr. 2..


Few.


l-'ew.





Few.


CO




" 12..


Many.


00 50{



" 22. .


00


CO 20^


Many cols, of




a Gram-pos.




coccus — not




Staph, al



bus.


Nov. 4..


CO


OD





A few.



1



Comment. — This person was affected with a subacute rhinitis and pharyngitis following an acute cold. In the first culture the normal flora was practically replaced by a white staphylococcus. As this organism decreased in numbers, the normal flora reappeared in the usual proportions.

Discrssiox

It appears that cultures made repeatedly from the throat of the healthy individual over a considerable length of time reveal two groups of organisms. In the firet place there is a group — non-hemolytic streptococci, and Gram-negative cocci — which is constantly present and seems to constitute the true normal flora of the throat in the sense of actually living its complete life histor}' in that environment. In addition to this group many other organisms may be recovered in cultures from normal throats but their presence seems to be only transient. They disappear within a few days, as a rule, just as foreign organisms do when exjierimentally introduced. It is possible that some of these organisms such as pneumococci and influenza bacilli are really constant inhabitants, but are present in such small numbers that tliey were missed in some of the cultures, but this seems unlikely. We may picture, therefore, in addition to the true basic flora a constant influx of various bacteria from the .-^kin, the nose, the air. and from external olijects.


February, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


37


These, unless they are pathogenic and set up disease, seem to be promptly disposed of by the normal protective mechanism of the upper air passages (chiefly mechanical flui^hing.) The idea, then, that bacteria in general, when introduced into the upper air passages are likely to colonize and live tliere indefinitely is erroneous. It is now clear, both from these studies and from the experimental work, that the normal surfaces of the upper air passages afford a veiy unfavorable environment for foreign organisms, both pathogenic and non-pathogenic, and iliat special conditions are needed to make possible their prolonged or permanent presence. ^ Such conditions as a rule consist of the production of disease, or at least a focus of diseased tissue in which the organisms may colonize.

With these points clearly in mind it seems that one is in a much better position to study the bacteriology of infections of the upper respiratory tract. Knowing the normal flora, and the possibility of transient invaders, unessential organisms


may be readily discounted. A study of the bacteriology of colds is now being taken up from this point of view.

COXCLUSIOXS

I. The organisms present in the throats of healthy people, as revealed by this method, fall into two groups :

(a) The true normal flora including non-hemolytic streptococci and Gram-negative cocci, and

(b) Pathogenic or non-pathogenic organisms which are accidentally introduced and are present usually only a short time in a given individual.

II. A true picture of the normal flora is obtained only by making repeated cultures from the same individual.

REFERENCE

1. Bloomfield, A. L. : American Review of Tuberculosis, 1920, IV, p. 247.


EXPERIMENTAL INOCULATION OF HUMAN THROATS WITH AVIRULENT DIPHTHERIA BACILLI

By W. L. ^loss, C. G. Guthrie and B. C. Marshall (From the Division of Clinical Fathology of the Medical Clinic, The Johns Hopkins University and Hospital)


For a proper appreciation of the relation of the healthy diphtheria bacillus carrier to the community it would be helpful to know which persons are actually carriers or at least the approximate proiwrtiou of carriers in the population at large. 'Next it obviously would be of practical importance to ascertain whether any cases of clinical diphtheria develop among the associates of these carriere.

In a previous communication on this subject' we have reported that a single examination of a large series of indi\iduals (2.50?), both children and adults, in the winter and .spring of 1911, revealed an incidence of healthy diphtheria bacillus carriers of about 3.55 per cent. It was also found that a second examination of a large series of persons practically doubled the number of carriers discovered, while a third examination still further increased the original number. It should be pointed out that the percentage of carriers probably varies in different localities in the same year or in the same locality in different yeare. We found that in the same locality it also varied considerably ^vith the time of the year, being somewhat higher during the winter than in the summer months. Making all allowance for such variation, however, there still exists a number of diphtheria carriers so great as to be out of all proportion to the number of clinical instances of the disease.

With regard to the second point, namely, the relation of these carriers to the occurrence of clinical diphtheria in the community, we were quite unalDle to discover any instances of the disease among the associates of the carriers studied by us. One hundred and sixty additional carriers were studied the


^Moss, W. L., Guthrie, C. G., and Gelien. J.: Diphtheria Bacillus Carriers. Trans. XV Internat. Cong, on Hvo;. & Dem., 1912, IV, 156.


following year (1912) and during the three and a half months covered by our observations no cases of diphtheria were foimd among their associates."

Investigation also showed that of the total number of healthy carriers under observation — over 200 in all — only 11 per cent (1912) to 18 per cent (1911) harbored virulent diphtheria bacilli. Even 11 to 18 per cent of the total, however, constitutes a number of carriers disproportionately large when compared with the reported incidence of the disease. Despite the fact that we were unable to incriminate any of the carriers under observation in the actual spread of diphtheria, it was recognized, nevertheless, that those who harbored virulent organisms constitute a potential menace to the community.

With regard to the healthy carriers of non-virulent diphtheria bacilli, however, the condition is quite different. Here we have no evidence whatever that any danger exists as a result of the carrier state and on this point we have expressed our conviction strongly.

Two questions are raised from time to time which have a distinct bearing upon the validity of our conclusions concerning the hannless nature of the healthy carrier of non-vinilent diphtheria bacilli. The first question concerns the reliability of the guinea-pig test for toxin production by the diphtheria bacillus, with the suggestion that an organism which is nonvirulent for the guinea-pig may be in reality virulent for man. The second question is based upon the assumption that a nonvirulent strain of B. diphlheriw from the throat of a healthy carrier may become virulent on longer residence in the tliroat


Guthrie, C. G., Gelien, J., and Moss, W. L. : Diphtheria Bacillus Carriers, Second Communication, Johns Hopkins Hosp. Bull., 1920. XXXI, 38S.


38


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 360


of that carrier, or may acquire virulence when introduced into the throat of another individual. It was to put these and certain other questions to experimental test that tlie present work was undertaken.

In another place ' were reported the results of animal experiments designed to show whether the previous injection of diphtheria antitoxin had any effect in preventing the lodgment and growth of diphtheria bacilli, either virulent or non-virulent. Among the facts which seemed apparent from this work were the following:

(1) The production of nasal infection or infestation of cats, rabbits and guinea-pigs with B. diphtherim was quite inconstant even when the organisms were introduced directly into the nose.

(2) The duration of infection was usually quite short but may have been variable in this respect, as some of the animals still harbored diphtheria organisms at the end of the experiments.

(3) The occurrence and duration of infection were independent of the virulence of the strain of organism used for inoculation and (4) were wholly unaffected by the previous administration of antitoxin.

It was found that certain conditions in these experiments with animals were quite different from those which obtain with human beings ; notably that in a considerable series of animals (112) none was found spontaneously infected with diphtheria bacilli and that the carrier state was difficult to induce. Feeling, therefore, that the results of this work might not be entirely applicable to man, further experiments were earned out, this time with human beings instead of animals as subjects.


1. To determine whether the introduction of avinilent diphtheria bacilli into the throats of healthy human beings will result in tlie production of the carrier state and, if produced, how long it may last.

2. To determine whether tlie lodgment and growth of the bacilli may be prevented by the previous injection of diphtlieria antitoxin.

3. To determine whether the organisms introduced are capable of producing (a) clinical diphtheria; (b) any subjective symptoms; (c) any objective signs in the appearance of the throat.

4. To determine whether any cases of clinical diphtheria develop among the associates of artificially produced "' health v carriers"* of virulent diphtheria bacilli.

5. To determine whether the organisms introduced into the throats of normal human beings are in any way changed by this procedure, particularly as to (a) morphology; (b) stain


'Gelien, J., Moss, \V. L., and fiuthrie, C. G.: The Effect of Diphtheria Antitoxin in Preventing the Lodgment and Growth of the Diphtheria Baoillug in the Nasal Passages of Animals, Johns Hopkins Hosp. Bull., 1920, XXXI, 381.

'The term "healthy carrier" is used in distini'tion to "convalescent " or " contact " carrier.


ing characteristics; (c) cultural characteristics; (d) ability to produce toxin (virulence).

PROCEDURE

Five physicians (W. L. M., C. G. G., S. E. M., A. W. S. and W. A. B.) volunteered to be subjects of these experiments. These individuals, designated for the sake of bre\'ity in the following pages as .4, B, C, D and E — were healthy men varying in age from 28 to 30 years. Oidy one had had clinical diphtheria and only one had previously received antitoxin; D had had a severe attack at the age of five, before the introduction of diphtheria antitoxin; E had received a prophylactic injection of antitoxin in 1911. Only one of the five has had diphtheria or received antitoxin since the close of these experiments; B had a definite attack the following year (1914) as the result of experimental inoculation with virulent organisms obtained from the throat of a healthy carrier ; at this time he received three injections of antitoxin.

Preliminary throat cultures on these five persons were made daily over a period of two weeks to ascertain whether any had diphtheria bacilli in their throats at the beginning of the experiments.

At the end of this preliminary fortnight three members of the group {C, D and E) received a subcutaneous injection of 250 units of diphtheria antitoxin before being inoculated with the non-virulent diphtheria bacilli. The two remaining members of the group {A and B) received no antitoxin.

The strain of diphtheria bacillus employed in this work (Culture 48) was obtained by us from a healthy canier during an investigation of public school children in 1912 and at the time of the experiments reported in the present paper (1913) it had been growing on Loeffler's blood serum for 12 months. When first isolated the strain proved to be non-virulent; repeated tests over a period of a year — 15 or more, including those made just at the beginning of tliis work — in each instance confirmed the original result. Moi-phologically, tinctorially and culturally the strain was typical B. diplitlieria and was indistinguishable from our virulent strains except by the animal tests for the production of toxin.'

The inoculations were made from transplants of this strain grown on Loeffler's blood serum for 24 hours and then suspended in normal salt solution. By using the growth from several tubes, this saline suspension was rendered quite thick and almost milky in appearance.

The inoculations were made by soaking a cotton throat swab in the bacterial suspension and then rubbing it over both tonsils and the posterior phaiyngeal wall. As none of the five individuals yielded positive cultures on the following day, a second inoculation was made two days after the first. For this purpose a freshly prepared bacterial suspension was used similar in all respects to the other. This time, however, the suspension was placed in an atomizer and with this the throats of the five individuals were thoroughly sprayed.


° For further details concerning the methods employed in the identification of this and other strains of B. diphtheria' see reference cited I above, " Diphtheria Bacillus Carriers, Second Communication."


February, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


39


Daily cultures were made from four members of the group (.4, B, and E) from February 4, 1913, to May 28 of the same year, a period of 114 days or a little over 16 weeks, and then at intervals until July 9, a period of six weeks more. From the other member {D) daily cultures were made from February 4, when the experiment began, imtil he left on an expedition to South America on April 28. Beginning the next autumn, occasional cultures were made from each member of the group until January 12, 1914, when daily cultures were begun again and continued for several months.


The residts of the cultures taken from February 4 to July 9, 1913, are shown in the accompanying chronological table (Table I). The blanks in the earlier part of the table indicate days on which members of the group were absent from the laboratory. The table has been condensed from the 120th day onward by omitting the days on which no cultures were taken. In this table a positive culture is indicated by + ; a negative culture by ; A. T. indicates a subcutaneous injection of diphtheria antitoxin; Inoc. indicates inoculation of the throat with avirulent diphtheria bacilli.


TABLE I


Day


Date


A


B


c


D


E


Day


Date


A


B


c


D


£


1


Feb. 4



62


April 6





...



2


5





n





63


" 7



+


+


4-'


4

3


" 6



64


" 8




4

4

4

4


" 7



63


" 9




4

4

4

5


" 8



66


" 10




4

4

4

6


" 9 67


" 11




4

4



7


" 10



68


" 12




4

4

4

8


" 11



69


" 13 9


" 12



70


" 14



b


+



4

10


" 13



71


" 15




4


4

11


" 14



72


" 16 12


" 15


73

" 17


+


+


+



+


13


'" 16




A.' T.


A.' T.


A.' T.


74 75


" 18 " 19




4


4

14


" 17



70


" 20



Inoc.


Inoc.


Inoc.


Inoc.


Inoc.


77


" 21



b'


+


+


+


15


" 18


n


78


" 22






4

4

16


" 19



+



+



79


" 23





+


4

4



Inoc.


Inoc.


Inoc.


Inoc.



80


" 24





4

4

+


17


" 20



-1

+


+


Inoc.


81

82


" 25 " 26 18


" 21



-f


-t

+



83


" 27





4


19


" 22


+


-1

+


+



84


" 28





4

4

20


" 23


G


-f




+


85


" 29 21


" 24



+


-1

-t



86


" 30



b


4



22


" 25


+


+


-f


-f


4

87


May 1 4

23


" 26



+


+


-f


4

88


" 2 24


" 27



-1

+


+


+


89


" 3 25


" 28


-f


-t

+


+


4

90


" 4 26


Mar. 1



+


+


-1

4

91


" 3




+



+


27


' 2


+


+



-1

4

92


" 6



4

4



28


" 3


+


+


+


+


4

93


" 7 29


" 4 94


" S


4



4


b


30


" 5


+


+


+


+


+


95


" 9





4


4

31


"


+


-1

-f


+


4

90


" 10




4




32


" 7


+


-f

-+

+


4

97


" 11 33


" 8


-f

+


-f


+


4

98


" 12


b


b


+




34


" 9


-f


-t


4

4

99


" 13


4



4




35


" 10


+


+


+


4

4

100


" 14 4

36


" 11


4

-1

+


4

4

101


" 15


4



+



4

37


" 12


-H


+


-f


+


4

102


" 16 4

38


" 13


-1

+


+


4

4

103


" 17




+



4

39


" 14


-1

4

-1

4

4

104


" IS


40


" 15


4

-i

-1

4

4

105


« 19 4

41


" 16


+


+



4

4

106


" 20





+



4

42


" 17


-1

+


+


4

+


107


' 21 43


" 18


-t

+


-t

4

+


108


" 22


b


b


4



44


" 19


-1

+


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4

4

109


" 23


4




+


45


" 20


-1

+



4

4

110


" 24 4

46


« 21






4

4

111


" 25 47


" 22


-1




4

4

112


" 26




4



48


" 23



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4

113


" 27





4


+


49


" 24





+


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4

114


" 28




4



50


" 25



+



4

4

115


" 29 51


" 26


-1

-t


4

4

116


" 30 52


" 27





+


4

4

117


" 31 53


" 28





-1

4

4

118


June 1 54


" 29





+


4

4

119


" 2




4


+


55


" 30


+





4

120


" 3 56


" 31


+


-f


+


4

4

134


" 17





+



4

57


April 1


+


+


+


4

4

143


" 26





4


4

58


" 2


-f



4

4

4

144


" 27




+



4-.


59


" 3



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+


4

4

148


July 'l


1 ^



4




60


" 4



-1

-t


4

149


" 2 61


" 5




+



4

156


" 9



40


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 360


From Table I it will be seen that the prelimiimr}- cultures taken daily over a period of two weeks (from February i to Februar}- 17 inclusive) were negative. We therefore felt that the five individuals who had volunteered for these experiments were not already carriers of diphtheria bacilli.

On February 17, three members of the group {C, D and E) received 250 units of diphtheria antitoxin subcutaneously. Six hours later these three together with the other two members (A and B). who had received no antitoxin, were inoculated by swabbing the throats with a saline suspension of avirulent diphtheria bacilli, as described above. Cultures taken on the day following this inoculation proved to he negative in each case, but owing to the time necessary for incubation, the result of these cultures was not known until the day after they were taken, that is, the second day after inoculation of the throats. The negative results having led lis to suppose that the inoculation had been ineifective, we reinoculated the entire group by spraying a thick suspension of bacilli into the throat with an atomizer as previously described. Cultures made on the second day after the first inoculation and just before the second inoculation were positive in the cases of two members of the group {B and D) and it seems not unlikely that the first inoculation alone woiild have sufficed to establish the carrier state in all five members of the group. Following the second inoculation, the cultures of B. C and D were regularly positive for many days.

In the case of A, the first positive culture did not appear until three days after the second inoculation and regularly positive cultures were not established until eleven days after the second inoculation.

In the case of E, the first positive culture was obtained three days after the second inoculation. This was succeeded by one negative culture, after which the cultures became regularlv positive.

It is seen, therefore, that as the result of experimental inoculation with avirulent diphtheria bacilli the carrier state was established in all five members of the group, in those who had received a previous inoculation with diphtheria antitoxin {C, D and E) and in those who had not (.-1 and B).

The results obtained from the beginning of the experiment on February 4, 1913, to the end of the first series of observations on July !) of the same year may bo summarized from Table I.

From Table II it is seen that the apparent duration of the carrier state as determined by these observations was as follows : A, 91 days; B, 77 days; C, 132 days; D, 39 days; and E, 125 days. For A and B this probably represents approximately the actual duration of the carrier state, as cultures from their throats were continued for from six (A) to nine weeks (B) after the last positive result had been obtained and no further positive cultures were found either during this period or on examination made subsequently to the present series. D was a carrier from FebruaiT 19 until April 28, the date on which he left Baltimore. That he probably remained a carrier for a long time thereafter was shown bv the result of cultures taken


upon his return in the succeeding fall. A and E continued to yield positive cultures practically to the end of the first series of observations, recorded in Table I. The last positive culture from C was obtained on July 1, followed by one negati\'e ou July 9 ; from E the last positive culture was obtained on .Tune 27, followed by negatives on July 1 and 9. That both of them were carriers for a very long time was shown by the result of cultures taken at intervals during the fall of 1913 when those from E were occasionally and those from C regularly positive.

As mentioned before, daily cultures on the entire group were begun again on January 12, 1914, and continued until 'Slay 29 of the same year. In this series D showed only one


Cultures


A


B


C


D


E


Total


74


99


81


64


92



12 62


13

86


12 69


11 53


10


After 1st inoculation with


82


B. diphtherur. After Ist inoculation, be

4


1


3


1


3


fore 1st positive. After 2d inoculation with


60


84


67


51


80


B. diphtherine. After 2d inoculation, be

2 1


fore 1st positive. Date of 1st positive


2-22-13


2-19-13


2-20-15


2-19-13


2-2.3-13


Date of last positive


5-23-13


5-6-13


7-1-13


4-28-13


6-27-13


Date of last culture


7-1-13


7-9-13


7-9-13


4-28-13


7-9-13



32 58


39 85


66 67


52 52


70


Total cultures after and


79


including 1st positive. Per cent positive cultures


51.61%


45.34%


95.65%


98.11%


8.->.36%


after 1st inoculation. Per cent positive cultures


55.17%


45.88%


98.50%


100%


88.60%


after and including 1st positive.

positive culture — that taken on January 17 — whereas the cultures from C and E were frequently positive up to the very end of this series of observations. With regard, then, to the duration of the carrier state as judged from the combined observations extending over 15 months — (February 4, 1913, to May 29, 1914) — it may be said that in A it was 91 days, in B 77 days, in D 11 months, while C and E were still carriers at the end of 15 months.

It is obvious that the previous administration of 250 units of diphtheria antitoxin did not prevent the lodgment and growth of the non-virulent diphtheria bacilli in the throats of C, D and E. Indeed, the actual number of positive cultures obtained from them in the first series of observations was much greater (T, 66, D, 52, E, 70) than from .4. and B, who had received no antitoxin (.4, 32, B, 39). The same point is emphasized when we compare the percentage of positive cultures (P. 95.60:1;, D, 98.11^, E, 85.36^; A, 51.61-?, B, 45.34^). The duration of the carrier state also was markedly less in .4 and B who did not have antitoxin (.4, 91 days, B, 77 days) than in C, D and E who received it (D, 11 months, C and E,


February, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


41


15 months plus). We do not wish to imply, however, that the previous administration of antitoxin renders an individual more liable to become a carrier when inoculated with avirulent diphtheria bacilli or that it is responsible for a prolongation of the carrier state when thus induced, but merely to emphasize the fact that in our experiments antitoxin did not prevent tlie development of the carrier state nor shorten its duration.

Throughout our observations an effort was made to indicate in a general way the relative numbers of the diphtheria organisms seen in the stained preparations from the positive cultures. This was carried out in our records of all but 12 of the 359 positive cultures encoimtered up to July 9, 1913, by the use of a rough, comparative scale, as follows: (1) Only one or two diphtlieria bacilli seen. (2) Very scanty. (3) Scanty. (4) Moderate number. (5) Numerous. (6) Very numerous. (7) Almost pure culture. These comparative figures are omitted in Table I since they distract attention from the much more important point as to whether a given culture is positive or negative and might be interpreted as implying much more than we feel they deserve or intend to suggest. A study of these records, however, revealed certain points of interest, confirming general impressions which we had gained from previous studies of carriers. When the carrier state was once firmly established and the cultures were regularly positive each day, the organisms were recovered in great abundance. Before the carrier state was firmly established, as evidenced by occasional negative cultures, the organisms were recovered in fewer numbers. After what might be called the height of the carrier state and when occasional negative cultures were obtained, there were great fluctuations in the number of organisms recovered. Finally, it appeared that before the organisms disappeared entirely from the throat they became scanty, were consequently much less apt to be recovered and considerable intervals elapsed between the positive cultures.

When we come to consider the effect of the inoculation with avirulent organisms on the health of these five men, we are at once confronted by the question whether any of them possessed natural immunity against diphtheria toxin and so may have escaped harmful effect, not because the organisms were hannless, but because of efficient protection. This question is, of course, of much less importance in so far as it concerns V, D and E who were passively immunized by the injection of antitoxin than it is with regard to A and B who received no such injection. Although it had been known for some time that certain persons had a natural immunity against diphtheria toxin due to the presence of circulating antitoxin in the blood, the methods of testing for this natural immunity were so tedious as to render their application infrequent. It was not until the introduction of a more simplified method by Scliick that large series of persons were tested and some knowledge was obtained as to the comparative frequency of natural^ immunity to diphtheria toxin. The preliminary report of the work done by Schick appeared in 1908 and this was followed by other reports


from time to time." Our attention was not directed to his work, however, until the publication of liis papers in 1913, some time after the beginning of these experiments; consequently skin tests were not made on the five volunteers to determine the presence or absence of natural imnnmity prior to inoculation. Tests performed on them some months later, however, showed that four {A, 0, D and E) had some amount of circulating antitoxin in the blood, whereas B on numerous occasions showed a complete absence of antitoxin as indicated by a strongly positive test at each trial. This lack of natural immimity in B was later confirmed bj' the fact that he developed a frank attack of diphtheria the following year (1914) as the result of experimental inoculation with virulent diphtheria bacilli.

It is the opinion of those with wide experience in the use of the Schick reaction that when natural immunity against diphtheria toxin, as manifested by a negative skin test, is once developed in persons beyond the age of five or six years, this immunity is probably life long.' If this impression is correct we may infer that B was without natural immunity to diph ' Schick, B,. : Kutanreaktion bei Impfung mit Diplitherietoxin. Vorliiufige Mittheilung, Miinchen. med. Wehnsehr., 1908, LV, 504. Also, Ueber Diphtheriekutanreaktion. Verhandl. d. Gesellsch. f. Kinderh., Koln, 1908, XXV, 330.

Schick and Novotny, J. : Ueber Diphtheriekutanreaktion beim Meeischweinchen. Ztschr. f. Inununitatsforsch. u. exper. Therap., 1910, Th. 1, Orig., IV, 550.

Schick and Michiels, Jules: Die intrakutanreaktion des Menschen auf Diphtherietoxininjektion als Ausdruck des Schutzkorpergehaltes seines Serums. Festschrift fiir Kassowitz, Julius Springer, Berlin, 1912, p. 2.32.

Schick and Magyar, Fritz : Versuche mit intrakutaner Injektion von Diphtherietoxin beim Menschen,. Verhandl. d. Gesellsch. f. Kinderh., Munster, 1912, XXIX, 9.

Schick: Spezifische Therapie der Diphtheric. Centralbl. f. Bakteriol., 1913, Div. I, Ref., Suppl., LVII, 16.

Schick and Michiels, Jules: Uelwr die Wertbestimmung des Schutzkorpergehaltes menschlichen Serums durch intrakutaner Injektion von Diphtherietoxin beim Menschen. Ztschr. f. Kinderh., 1913, Orig., V, 349.

Schick: Die Diphtlierietoxin-Hautreaktion des Menschen als Vorprobe der prophylaktischen Diphtherieheilseruminjektion. Miinchen. med. Wehnsehr., 1913, LX, 2608.

' Personal communication from Dr. W. H. Park, Director of the Research Lal)oratory of the Department of Health, New York City:

As a general statement one can say that a child developing antitoxin and therefore giving a negative Schick test will remain negative for life. We have, however, followed children in institutions from year to year and found that each year about 2 per cent of those who have given negative tests changed to positive. There is undoubtedly some fluctuation from time to time in the amount of circulating antitoxin and also some difference in the toxin dilution employed for the test in the different years, so that I am not quite sure how much to ascribe to the change in the child, and how much to the technique of the injector and the strength of the toxin used. This is equally true for those who have developed a negative Schick test after artificial immunization by means of toxin-antitoxin injections, as indicated by the results of our observations extending over five years. It should be mentioned, however, tliat some of these apparent changes from a condition of immunity to one of susceptibility are possibly to be explained by mistakes in the records resulting from the fact that two or more children may bear the same name, thus rendering it difficult to avoid confusion."


42


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 360


theria toxiu at the beginning of our work, but although we cannot state with certainty that B had no protection and that A,C,D and E had circulating antitoxin and therefore natural immunity against diphtheria toxin at the time these experiments were begun, we know that this was the case when tested some months later, at a time when all the passive immunity conferred by the antitoxin injected in C, D and E would have long since disappeared. We do not know when any of these persons developed their immunity. In the case of D, we know that he was not immiuie at the age of five, for at that time he had a severe attack of diphtheria. Moreover, just as we cannot say positively that A, C, D and E were not immune at the time these experiments were begun, so we are ujiable to say whether any of them developed their immunity as a result of the experimental inoculation with avirulent diphtheria bacilli. That it did not have this effect in the case of B, however, has been indicated. The selection of C, D and E as control individuals to receive antitoxin, all of whom were immrme when tested some months later and who probably had homemade antitoxin circulating in their blood at the time our experiments were liegun, was entirely due to chance. That B, the only individual in the group who was presumably without natural protection, was chosen as one of the two without artificial protection, was chance also.

The clinical effect of experimental inoculation M'ith nonvirulent diphtheria bacilli could, of course, be judged only on the two individuals — ,1 and B — ^who did not receive a preliminary injection of antitoxin. Of these, A had antitoxin present in his blood when tested at a later date — quite possibly this was present before our experiments began — thus leaving only B without natural or artificial protection. That B was later susceptible to the effect of diphtheria toxin has been pointed out ; that he was susceptible, at the time of our work, to whatever ill effect these non-virulent organisms were capable of producing, is most probable.

Viewed in retrospect two shortcomings are quite apparent in the plan of our experiments. First, only individuals without natural immunity should have been selected for this work, certainly for that portion of the group which was not to receive passive immunization; second, there should have been a larger series of these individuals without natural or passive protection, from which to draw conclusions. Bearing in mind these limitations, such facts as we have are presented.

Careful observation of the five persons fonning this group failed to reveal any imtoward effect resulting from the carrier state thus artificially established by the inoculation of nonvirulent diphtheria bacilli into their throats. i\Iore specifically, (1) none of them developed clinical diphtheria; (2) none had any subjective symptoms such as sore throat except when due to the attempts at eradication of the bacilli to be described shortly; (3) none showed any objective signs such as redness of the throat, pharyngitis or tonsillitis except when due to the cause just mentioned.

The daily life of these five persons was not restricted in any way. No one outside of the laboratory knew them to be diph


theria bacillus carriers. No cases of clinical diphtheria developed among their associates.

To determine whether any change had taken place in the bacilli as the result of their residence in the human throat, the organisms were isolated at intervals from the positive cultures obtained from these five individuals and tested culturally, tinctorially and by guinea-pig inoculation. Morphologically the organisms were unchanged and their staining characteristics were the same as before they were introduced into the throat. On cultural tests, also, no difference was observed in the character of the growth on Loeffler's blood serum, plain agar or in bouillon, while the changes in litmus milk and in the tests for fermentation of the various sugars were the same as with the original organisms.

Each time an isolation was made the pure culture was tested for virulence. None of the cultures so tested killed a guineapig or even rendered one ill. Thus it will be seen that after months of residence in the human throat (15 months in the case of G and E) there was no evidence of acquisition of virulence.

The question may be raised as to how we know that the organisms harbored by these carriers and recovered by ns from time to time were of the same strain that we originally put into the throats. We do not know that they were, but there were certain facts which made us feel relatively sure on this point. In the first place none of the subjects of these experiments were carriers at the time the bacilli were placed in their throats but all of them became carriers shortly thereafter, so shortly as to leave little doubt concerning the relation of the artificial inoculation to the positive cultures obtained from the five individuals. In the second place, the carrier state, once established, lasted for a long time in all — longer in some than in others — but from each individual regularly positive cultures were obtained over a considerable period. These positive cultures, for the most part, showed not one or two organisms to a slide but myriads, indicating that the diphtheria bacilli were not merely persisting but actually multiplying in the throats. Thirdly, the identity of the strain of organisms recovered from the throats with that originally introduced was strongly suggested by the results of the tests applied to the pure cultures isolated at intervals from each of the individuals in the series. The agreement with the original strain was so definite as to render it highly improbable that these five persons had all gotten rid of the original strain and had all picked up another exactly like it.

A very definite carrier state having been established in all five of the subjects of these experiments, an attempt was made to eradicate the bacilli from the throats of A and B. The work of Churchman ' has shown the very definite inhibitor^' action exerted by Gentian Violet on the growth of many of the Grampositive organisms in vitro, among others B. diphthcri^ce., and this we have confirmed with the strain (No. 48) used in tliese experiments and with many other strains, virulent and non


' Churchman. J. W. : The Selective Bactericidal Action of Gentian Violet, Jour. Exp. Med., 1912, XVI, 221.


February, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


43


virulent. Accordingly we endeavored to ascertain the effect in vivo of tliis dye upon B. diphtherice. An aqueous soln-" tion of Gentian Violet was prepared in dilution of 1 to 1000 and with this the nose and throat of A and B' were thoroughly sprayed on the evening of March 13, 1913. Within an hour there developed in both individuals the symptoms of an acute coryza. The mucous membrane of nose and throat became congested and there was experienced the raw, burning sensation which characterizes an inflammation of these surfaces. Headache and pain behind the eyes followed and the backache and joint pains of grippe were present. This condition gradually wore off but persisted in less pronounced degree for several days, thus discouraging the further use of an aqueous solution of the dye in a strength of 1 to 1000. The cultures from A and B, moreover, continued regularly positive. Three days later, after a partial recovery from the discomfort of the first application of Gentian Violet, the treatment was resumed, a more dilute solution, 1 to 3000, however, being employed. The nose and throat were sprayed night and morning for two days with a return of the same unpleasant symptoms which had followed its first use. Two daj's later (March 31) positive cultures were obtained from both A and B : in the succeeding eight days, six positive and three negative cultures were obtained. The cultures from C, D and E, who had not been treated with Gentian Violet, remained regularly positive.

At this time we made a dilution of the dye in normal salt solution in 1 to 10,000 strength and began using it daily on all members of the group-, spraying the nose and throat just after the daily culture ; this was continued for about ten days. After the inauguration of this treatment:

(1) A had eight positive cultures (March 31 ; April 1, 2 and 17; May 8, 13, 15 and 23) and U negative cultures (April 22. 23, 24 and 28; May 1, 9, 12, 20, 22, 24 and 27; June 17 and 26; July 1).

(2) B had seven positive cultures (ilarch 31: April 1, 3, 4, 7 and 17; May 6) and 39 negative cultures, 17 prior to his last positive on May 6 and 22 from this date to the time of the end of the series of observations on July 9.

(3) C continued regularly positive imtil after July 1.

(4) D continued regularly positive until after April 28, at which time he left the city.

(5) E continued regular 1}^ positive, with the exception of one negative culture obtained on April 11, until after May 5. The majority of his cultures after this date were positive but from time to time a negative culture was obtained (14 positive and 7 negative from May 5 to July 9).

The results obtained on cultures of these individuals in the succeeding fall, winter and spring will he recalled ; C, D and E continued to be carriers for many months; .4. and B did not.

Although the figures might seem to indicate that the Gentian Violet may have had some effect in eradicating the bacilli from the throats of A and B, the discomfort arising from the use of the more concentrated solutions was so great that the procedure could hardly become popular. It is, moreover, quite possible that the apparent disappearance of the bacilli at about this time was spontaneous and merely coincident with


the use of Gentian Violet. It should be pointed out, also, that while occasional negative cultures were first obtained from both A and B following the employment of Gentian Violet, positive cultures from each of them were encountered at intervals thereafter over a long period (71 days in the case of A : 54 days in the case of B) .

There was no evidence that the use of 1 to 10,000 dilution of Gentian Violet sprayed into the throat once daily had any effect in causing the disappearance of diphtheria bacilli from the throats of carriers.

The two chief difficulties in the use of Gentian Violet for this purposes are (1) its irritating effect upon the mucous membranes and (2) its lack of penetration, the latter, perhaps, depending to a certain extent upon the former. When applied to the throat, there is produced almost at once an abundant secretion of mucus wliich intervenes between the tissues and the dye, lifting the latter from the surface and preventing penetration."

From the results of some subsequent work — to be reported in another paper — concerning the actual location of the dipjitheria bacilli in the throats of carriers, we should not expect that the eradication of these organisms could be accomplished by the use of Gentian Violet or any other substance introduced into the throat by means of swabs, sprays or gargles.

With regard to the symptoms experienced by A and B following the use of too concentrated solutions of Gentian Violet we feel very definitely that these were not caused by the diphtheria bacilli in the throat. The 1 to 1000 and 1 to 3000 solutions were very irritating and the irritating effect was experienced right after the application and did not recur except when a strong solution was again employed as a spray. The diphtheria bacilli, it is true, were present in the throat at the time, but they had been there from three to four weeks before any symptoms developed and remained for six to ten weeks after the symptoms subsided without causing any difficulty whatever, either objective or subjective." (7, D and E, who had no applications of the stronger solutions, the use of wliich was followed by unpleasant results in A and B, had neither symptoms nor local signs in the throat although they were cai'riers for many months.


" That similar observations have been made by others is seen from tlie following quotation concerning the treatment of a diphtheria carrier with Gentian Violet. " The results were somewhat suggestive but an unexpected obstacle was met in the secretion of the mucous glands of the pharynx in a thin slimy layer, which was renewed by fresh secretion as rapidly as it was removed and which prevented intimate contact between dye and mucous membrane as effectually as a layer of grease would have done." Churchman, J. W., and Herz, L. F.: The Toxicity of Gentian Violet and its Fate in the Animal Body. Jour. Exp. Med., 1913, XVIII, 579.

'" Other conceivable but improbable explanations of the symptoms produced by the stronger solutions of Gentian Violet might be men tioned :

( 1 ) Destruction of some of the avirulent diphtheria bacilli by the Gentian Violet, with the liberation of an endotoxin capable of producing the symptoms. ( 2 ) Disturbance in a balanced, antagonistic flora produced by Gentian Violet, with production of symptoms by the unopposed group.


44


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 360


SUMMARY From the results of the experinients herein reported certain facts seem sufficiently important to warrant repetition for the sake of emphasis.

(1) The carrier state was easily produced in human beings by inoculation of the throat with avirulent diphtheria bacilli.

(2) When thus produced the carrier state lasted for a long time; two of the carriers still harbored avirulent diphtheria bacilli after 15 months.

(3) The previous administration of diphtheria antitoxin subcutaaeously did not prevent the lodgment and growth of the organisms.

(4) Inoculation of avirulent diphtheria bacilli into the throats of human beings did not produce: (a) clinical diphtheria; (b) any subjective sjinptoms : (c) any objective change in the appearance of the throat.

(5) The results of the guinea-pig test for virulence were confirmed when thus tested with human beings.

(6) No cases of clinical diphtheria developed among the associates of these artificially produced " healthy carriers " of avirulent diphtheria bacilli.

(7) When isolated in pure culture after prolonged sojourn in the human throat, the bacilli were not altered in morphology or in their staining or cultural characteristics.


(8) The bacilli showed no tendency to become virulent as a result of this type of animal passage, either in the carriers who had received diphtheria antitoxin or in those who had not.

(9) Spraying the nose and throat with Gentian Violet in a strength which could be tolerated seemed to be without effect in eradicating avirulent diphtheria bacilli.

The results of this experimental inoc\ilation of the throats of human beings with avirulent diphtheria bacilli are in entire accord with those obtained in our previous work with healthy diphtheria bacillus carriers. The same general conclusions drawn from our earlier work have merely been confirmed and somewhat amplified.

COXCLUSIONS

1. Avirulent diphtheria bacilli retain their characteristics despite long residence in the human throat or transfer from one human being to another.

3. Avirulent diphtheria bacilli are devoid of pathogenic importance for man.

3. The carrier of a\irulent diphtheria bacilli does not constitute a menace to the health of the community.


A CLINICAL METHOD FOR THE QUANTITATIVE DETERMINATION

OF CALCIUM AND MAGNESIUM IN SMALL AMOUNTS

OF SERUM OR PLASMA

By Benjamin Kramer and Frederick F. Tisdall {From the Department of Pediatrics, The Johns Hopkins Vniversitt/. Baltimore)


The McCrudden method for the quantitative determination of calcium and magnesium in biological material ' is considered the most reliable procedure for this purpose. The material to be analyzed is ashed and then dissolved in dilute hydrochloric acid. The solution is heated to boiling and the calcium precipitated by adding an excess of oxalic acid to the acid solution. It is then cooled and the acidity of the solution is diminished by the addition of a large amount of 20 per cent sodium acetate, thereby neutralizing the mineral acid and replacing it with a bufl'er solution of free acetic acid and sodium acetate in which calcium oxalate is practically insoluble. In the original description of the method the final determination is made by ashing the calcium oxalate imtil it is completely converted into calcium oxide. The latter is then weighed. The oxalate may, however, be titrated directly by means of acid potassium permanganate.

The latter procedure is to be preferred when determining calcium in small amounts of blood, serum or plasma, since one is here dealing with quantities of calcium too small to be weighed accurately. Under these conditions the amount of calcium oxalate has also been determined colorimetrically or by means of the nephelometer. Of such methods several have been reported. Most of these have been discussed elsewhere and hence will not be reviewed here. All have one


disadvantage in common, namely that the protein of the serum must either be removed by a preliminary precipitation or the organic matter destroyed by ashing.

We have succeeded in precipitating calcium and magnesium quantitatively from unashed serum by means of a modified McCrudden technique. This precipitation is the basis of the methods described below for the quantitative estimation of these elements in serum or plasma.

The Sample to be Analyzed The method may be applied to serum or plasma. If sodium citrate in 0.9 per cent sodium chloride be used to prevent clotting, its final concentration in the blood should not exceed 1.5 per cent. Samjiles showing moderate or marked hemolysis cannot be used.* Although we have obtained good results


The addition of oxalic acid or ammonium oxalate to a very dilute solution of ferric chloride yields a precipitate which is only slightly soluble even in glacial acetic acid.

To determine the calcium content of hemolyzed serum dilute 2 c. c. of serum with 2 c. c. of water, then add 1 c. c. of 30 per cent ammonium acetate. After one hour make the volume up to 6 c. c. Centrifuge for 15 minutes, syphon off the supernatant fluid. Use 5 c. c. of this and proceed as for non-hemolyzed serum or plasma. Since the calcium determination is performed on .5/6 of 2 c. c. of serum, the proper correction should be made in the final calculation.


Februakt, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


45


with several sera analyzed at intervals over a period of two weeks, it is preferable that the determination be done within 24 hours. Blood may be obtained by venipuncture or by the Blackfan method.' The clotted blood is centrifuged and the serum poured or pipetted off.

The Calcium Method

One or two cubic centimeters of serum or plasma are measured into an ordinary 15 c. c. graduated centrifuge tube containing from 2 to 3 c. c. of distilled water. The tube should be gently agitated after the addition of each drop of serum. Two drops of .01 per cent phenolsulphonphthalein are added followed by 1 drop of n/1 sulphuric acid. One drop of 30 per cent ammoniiun chloride is then added followed by 1 c. c. of approximately n/1 oxalic acid. The sample should be shaken after each addition.* One-half of 1 c. c. of a saturated solution of sodium acetate is added and the tube allowed to stand for at least one hour. The pH of the .sample at this point is about 5.4 (di-brom-cresol). The sample is then made up to a definite volume, pireferably 6 c. c, and centrifuged'for at least 20 minutes at 1300 revolutions per minute. All but 0.2 c. c. or 0.3 c. c. of the supernatant ftuid is syphoned off through a glass tube, the lower end of which is drawn out to a bore of about 1 mm. and curved so that the opening is directed upward. The lower opening in this tube should be at least 3 or 4 mm. above the precipitate. The precipitate is suspended in the residual liquid by stirring with a glass rod. Enough 2 per cent ammonia (2 c. e. of concentrated ammonia diluted to 100 c. c.) is then added to bring the volume to 4 c. c, care being taken to wash the rod and the sides of the centrifuge tube free from adherent oxalic acid. The tube is then centrifuged for 10 minutes. This procedure is repeated twice, thus making three washings in all. After the third washing the supernatant fluid is syphoned off, the tube is shaken to suspend the precipitate, 2 c. c. of approximately n/1 sulphuric acid are added and the tube is warmed in the boiling water-bath for a few minutes and titrated with n/100 potassium permanganate until a defixiite pink color persists for at least 1 minute when viewed under a good light against a white background. The strength of the permanganate solution is determined by titrating against an n/100 sodium oxalate (Sorensen).

Calculation.- — The number of cubic centimeters of n/100 potassium permanganate used diminished by 0.02 c. c. (the blank) times 0.2 equals the mgms. of calcium in the sample. If 2 c. c. of serum are used, this figure multiplied by 50 equals the number of mgms. per 100 c. c. of serum. Thus, if the titration is 1.02 c. c. of n/100 potassium pennanganate then (1.02 — .02) X0.2x50 = 10 mgms. calcium per 100 c. c. serum.

Preparation of Reagents. — n/100 sodium oxalate (Sorensen). This is the only reagent that must be quantitatively accurate. An n/10 sodium oxalate (Sorensen) is prepared


The precipitate which forms on the addition of ammonium chloride disappears on adding oxalic acid.


in the usual way. Six and seventh-tenths grams of sodium oxalate (Sorensen) are dissolved in water. Solution is facilitated by the addition of 5 c. c. of concentrated sulphuric acid and the volume made up to 1 liter. This is diluted ten times to make an n/100 solution. The former solution will keep indefinitely while the latter has been found still unchanged after the lapse of two months.

Approximately n/1 oxalic acid is prepared by dissolving 63 grams of oxalic acid (Kahlbaum or J. T. Baker, C. P. — calcium free) in a liter of water. The acid need be weighed only roughly.

Approximately n/1 Sulphuric Acid. — Fifty cubic centimeters of concentrated sulphuric acid (C. P.) are diluted with water to 1 liter.

Thirty Per Cent Ammonium Chloride. — Approximately 30.0 grams of ammonium chloride are dissolved in 100 c. c. of water. A sample of this should be diluted, an excess of ammonium oxalate solution added and the solution allowed to stand in order to rule out the presence of calcium.

Saturated sodium acetate solution is made by adding an excess of the salt to water and allowing it to stand over night. The supernatant fluid is then filtered.

Sodium acetate (J. T. Baker, C. P.) does not contain calcium.

PROTOCOLS

(1) Samples containing 0.236 mgm. of calcium as CaCl„, .041 mgm. of magnesium as MgSO^ and 0.615 mgm. of phosphorus as KH2PO4, were treated as above described for the calcium determination except that no oxalic acid was added. No precipitate appeared at the end of 24 hours. The pH of this solution was about 6.0 — 6.2 (di-brom-cresol). This indicates that neither calcium phosphate nor NH^MgPO^ is precipitated at this pH under the given conditions.

(2) Similar samples without calcium were treated as described in the method. Here again no precipitate appeared, indicating that magnesium oxalate remains in solution under these conditions.

(3) Solutions containing known amounts of calcium, magnesium and either potassium or sodium phosphate in concentrations corresponding to the maximum which we have found in serum were analyzed. The results given in Table I show that quantities of calcium varying from 0.096 mgm. to 0.386 mgm. can be recovered with a maximum error of 5 per cent.

(4) Known amounts of calciuln were added to sera in which the calcium content had already been determined. The added calcium was quantitatively recovered (Table II).

(5) A series of parallel determinations on the sera of humans and animals was made by this method and by the method of Kramer and Howland. The results given in Table III show a satisfactory agreement between the two methods.

DISCUSSION

The investigations of Richards * and his collaborators have defined the necessary conditions for a quantitative separation of calcium from magnesium and for the exact gravimetric estimation of the former. The dangers in this procedure lie


46


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 360


in the possible occlusion of imdissociated magnesium oxalate in the calcium oxalate precipitate when precipitation occurs in a neutral solution in tlie presence of a large excess of highly ionized ammonium oxalate. The degree of occlusion varies with the concentration of undissoeiated magnesium oxalate. In a solution of an electrolyte an equilibrium exists, as represented by the Mass law, betwen the undissoeiated magnesium oxalate and the free magnesium and oxalate ions, thus :


MgxC„0, ,. , ,

— ,^— „-;^ - =iv = a constant. MgCoO^


The maximum concentration of free magnesium and oxalate ions is determined by the solubility product constant of this salt." This is the product of the ionic concentration of these two ions in a saturated solution of the salt at a given temperature. Thus, if the molar concentration of magnesium oxalate in a saturated solution is .0027 gm. mol. per liter, then if this is 80 per cent dissociated we have the concentration of Mg=.0022 gm. mol. and that of oxalate = .0022 gm. mol., and the solubility product would then be .0000484 or 4.8x10^^ gm. mols. per liter.

The addition of a solution which contains a greater concentration of oxalate ions to a saturated solution of maguesiiun oxalate would so increase the concentration of this ion as to exceed the solubility product constant." The concentration of free magnesium ions is therefore decreased through the formation of more undissoeiated magnesimii oxalate. But the solution is already saturated as regards molecular magnesium oxalate, hence the excess of undissoeiated magnesium oxalate precipitates. The concentration of magnesium in serum is too small for even a great excess of oxalate ion to bring about precipitation but such an excess can so increase the concentration of molecular magnesium oxalate as to favor its occlusion by calcium oxalate." The dilution of the serum and the addition of a mineral acid counteracts this tendency, the former by decreasing the concentration of both ions, per unit volume, the latter by decreasing that of the free^ oxalate ion, an effect to be attributed to the large excess of H ions which the mineral acid contributes, thereby repressing the ionization of oxalic acid." The mineral acid also keeps calcium phosphate in solution by forming the more soluble acid calcium phosphate (CaHPO^).

McCrudden' has shown that in the separation of calcium from solutions containing this element along with magnesium and phosphates the precipitate of calcium oxalate may be contaminated with phosphates, presumably ammonium magnesium phosphate or tertiary calcium phosphate, unless the solution is sufficiently acid during precipitation. The required H-ion concentration is not stated. The proper degree of acidity for complete precipitation of pure calcium oxalate can be best obtained by the addition of a concentrated solution of sodium acetate. We have found that solutions whose pH's vary from 5.2-6.6 will permit complete precipitation of calcium oxalate if sufficient excess of oxalate ions be present.


CONCLUSIONS

I. A method has been described by means of which calcium may be determined directly in 2 c. c. of serum or plasma with a maximum error of it 5 per cent.

II. No special apparatus is required, except an accurately calibrated 2 c. c. pipette and a micro-burette graduated in 1/50 of a c. c.

III. A determination may be completed within 2 hours after the sample of blood is obtained.

IV. The sources of error in the determination of calcium in small quantities of biological fluids have been discussed.

V. Comparative studies using this raf)id method and the method of Kramer and Howland have shown that the former method yields results that agree well with those obtained by the latter.

The Magnesidm ^ilETHOD

In 1871 Pribram ' precipitated completely calcium as calcium oxalate and magnesium as ammonium magnesium phosphate from 100 c. c. samples of serum which had been previously rendered alkaline with ammonia, without preliminary destruction of the organic matter. Gerlach and E. Drechsel' stated that this precipitate contains phosphates unless preeipitalion is accomplished in acid solution. McCrudden' demonstrated that fairly accurate results can be oI)tained when magnesium is precipitated in the filtrate from the calcium determination without oxidation of the organic substances with nitric acid. We have obtained excellent results when omitting this step. Marriott and Howland ' described a method for the determination of magnesium in small quantities of serum. The essential features of this method are first, the oxidation of the organic matter in the filtrate derived from the calcium determination, second, the precipitation of magnesium as NHiMgPO^ by the addition of (NH4)2HP04 and concentrated ammonia, third, the separation of the NH^MgPO^ from the supernatant fluid by centrifuging and washing five times, and fourth, the comparison of the degree of decolorization of a solution of Fe (SCN), with the decolorization produced by a known amount of NH^MgP04. We have simplified this method by eliminating the first step entirely, by using only one-fifth the amount of (NH4)2HP04, and by filtering the precipitate through a Gooch crucible and washing thoroughly. The colorhnetric determination was not changed. The results obtained by the procedure as outlined above are more constant than those obtained by the method of Marriott and Howland.

PEEPARATIOX OF REAGENTS

(1) Ammonium Magnesium Phosphate Standard. — This solution is made by dissolving 0.102 gm. of air-dried magnesium ammonium phosphate (MgNH^PO^.eH.O) in 100 c. c. of 0.1 N hydrochloric acid and diluting to 1 liter with water. Of this solution 1 c. c. is equivalent to 0.01 mg. of magnesium. Magnesium ammonium phosphate loses water of crystallization when heated and must therefore be dried at room temperature. Commercial preparations of the salt are generally


i


February, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


47


unreliable; it should be prepared by precipitation of pure solutions. (See Jones, W., J. Biol. Cliem., 1016, XXV, 87.)

(2) Ammonium phosphate solution is made as follows: 25 gm. (NHJoHPO^ are dissolved in 250 c. c. H,0. 25 c. c. of concentrated ammonia are added and the mixture is allowed to stand over night. The following day. it is filtered, the iiltrate is boiled to remove the excess of ammonia, cooled, and made up to 250 c. c. This solution is diluted 5 times with water.

(3) The ferric thiocijanate soludon is made from two solutions which are mixed an hour before use. Solution A is 0.3 per cent ammonium thiocyanate. Solution B is 0.3 per cent ferric chloride, made up from the salt with its contained water of crystallization, adding a few drops of acid, if necessary, to clear the solution. Five cubic centimeter portions of Solutions A and B are mixed and the whole is diluted to 40 c. c. with water.

(4) 10% Ammonia. — One hundred cubic centimeters of concentrated ammonia is diluted to one liter.

THE METHOD

Five cubic centimeters of the supernatant fluid from the calcium determination corresponding to 1.66 c. c. serum is measured into a 30 c. c. beaker, 1 c. c. of (NH4)„HP0^ solution is added and then 2 c. c. of concentrated ammonia. Next day the sample is filtered through a well packed Gooch crucible, washed ten times with 5 c. c. of 10 parts of concentrated ammonia to 90 parts of water, then twice with alcohol 95 per cent made alkaline with ammonia. The crucible is returned to the beaker and dried for a few minutes at 80° C. in the oven.

Ten cubic centimeters of u/100 HCl are added to the crucible and after a few hours the entire material is transferred to a test tube, centrifuged, and 5 c. c. of the supernatant fluid is measured into a flat-bottomed colorimeter tube graduated for 10 e. c, which contains 2 c. c. of the iron thiocyanate solution. The volume is then made up to 10 c. c. with n/100 HCl, ' a rubber stopper inserted and the fluid mixed. A series of standards is prepared by adding varying amoimts of a known NH4MgP04 solution to the thiocyanate solution and bringing the volume up to 10 c. c. a.s in the unknown samples. The color is compared by looking through the entire length of the liquid column against a white background.

Calculation. — The calculation is the same as in the orginal method: Eeading (c. e. of standard solution) x. 01x2x6/5 X50 = mgms. magnesium in 100 c. c. serum when 2 c. c. of serum are used.

PROTOCOLS

(1) A solution containing an amount of Mg per c. c. as the sulphate corresponding to the amount found in 2 c. c. of serum was analyzed. Magnesium was recovered quantitativel)' (Table V).

(2) Samples containing Ca, Mg and P in concentrations equal to those found in serum were analyzed both for Mg and Ca and both elements recovered within 5 per cent of the quantity actually present. Table VI.


(3) Magnesium added to serum was quantitatively recovered (Table VII).

(4) A series of determinations on normal adults, normal children, and children suffering from various diseases yielded results that agree well with those found by Marriott and Rowland using the more elaborate procedure (Table IV).

CONCLfSIONS

A simplified method for the quantitative determination of magnesium in small quantities of serum or plasma ha5 been described.


TABLE


I.— ANALYSES OF SAilPLES OF SOLUTION B


Calcium



Spec. Xo.


Found mg.


Present mg.



1

2

3

4

Average . . .


0.093 0.093 0.096 0.0!J2

0.094

0.186 9.193 0.193 0.182


0.090 0.192 0.386


Note : Composition of


a




NaCl 4.634 gm.


8.


KH,PO, 0.039



MgSOi 0.758


Average . . . 9


0.188

0.383 0.375 0.385 0.381


CaCOa 0.241 HCl cone. 10.0 c.c. H,0 to 500 c.c.


10



U



12





Average . . .


0.381



TABLE IL— RECOVERY OF CALCIUM ADDED TO SERUM Authors' Method


Spec. No.


In serum


.Wded


Total found


Total present


1


m<7. 0.187


mff. 0.096


mg. 0.286


mg. 0.283


2


0.1C9


0.236


0.408


0.405


3


0.200


0.236


0.434


0.436


4


0.194


0.236


0.430


0.436


TABLE III,— COMPARATIVE DETERMINATIONS ON SERUM


Spec. No.


Method of Kramer and Rowland


-Authors' method


1 2 3 4


10.5 10.5 10.6 10.8


10.6 10.5 10.4 10.2


48


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 360


TABLE IV.— CALCITO'I AND MAGNESIUM DETERMINATIONS IN NORMAL AND PATHOLOGICAL SERA


X:


Age


I


Adult.


2


"


3


"


4


"


5


"


6


Sheep.


8


"


9


17 yrs.


10


8 mos.


11


8 mos.


12


2 yrs.


13


8 mos.


14


3 yrs.


15


2i yrs.


16


11 yrs.


17


8 mos.


Osteogenesis imperfecta. Tetany

Tetany (after CaClj)

Rickets


Female. Male.


Authors' method


9.5 10.6 10.3 10.4 9.2 9.5 10.0 10.4 12.1


7.2 9.5 10.2 10.6


TABLE VI.— ANALYSIS OF 1 C. C. SAMPLES OF A SOLUTION CONTAINING Ca = 0.236 Mg. Mg = 0.041 Mg. P = 0.62 Mg.


2.7 2.9 2.9

2.1 2.1 2.1 1.9 1.8 1.6 1.8 2.3


2.8 2.2


-ANALYSIS OF SAMPLES OF A SOLUTION OF MAGNESIUM SULPHATE


Spec. No.


Present


Found


1


0.044


mil. 0.046


2


0.088


0.092


3


0.044


0.044


4


0.044


0.042


Calcium



Magn


esium


Found


Present


Found


Present


0.230



0.236


0.043



0.044


0.233




0.040




0.230




0.041




0.244




0.046




TABLE VII.— RECOVERY OF MAGNESIUM ADDED TO SERUM




Magnesium



Present


Added



Total found


Total present


0.038


mi). 0.044



mg. 0.080


mg. 0.082


0.044


0.088



0.137


0.132


0.044


0.044



0.086


0.088


0.042


0.044



0.089


0.086


BIBLIOGRAPHY

1. McCrudden, F. H.: The Quantitative Separation of Calcium and Magnesium in the Presence of Phosphates and Small Amounts ol Iron Devised Especially for the Analysis of Foods, Urine and Feces. Jour. Biol. Chem., 1909-10, VII, 83.

2. Kramer, Benjamin, and Howland, John: A Method for the Quantitative Determination of Calcium in Small Quantities of Serum. Jour. Biol. Chem., 1920, XLIII, 35.

3. Blackfan, K. D.: Apparatus for Collecting Infants' Blood for the Wassermann Reaction. Am. Jour. Dis. Child., 1912, IV, 33.

4. Richards, T. W., McCaffrey, C. F., and Bisbee, H.: The Occlusion of Magnesic Oxalate by Calcic O.xalate and the Solubility of Calcic Oxalate. Proceedings of the Academy of Arts and Sciences, April, 1901, XXXVI, No. 22, 375.

5. Stieglitz, J.: The Elements of Qualitative Chemical Analysis. Vol. I, p. 139. The Century Co., New York, 1916.

C. Ibid., page 144, Influence of a Common Ion.

7. Pribram, Richard: Eine neue Methode zur Bestimmung des Kalkes und der Phosphorsaure in Blutserum. Berichte iiber die Verhandlungen der Koniglich. Sachsischen Gesellschaft der Wissensehaften zu Leipzig, 1871, XXIII, 279.

8. Gerlach, L., and Drechsel, E.: L'eber die Bestimmung der Minerale des Blutserums durcli directe Filllung. Berichte iiber die Verhandlungen der Koniglich. Sachsischen Gesellschaft der Wisseaschaften zu Leipzig, 1872, XXIV, 349.

9. Marriott, W. Mekim, and Howland, John: A Micro Method for the Determination of Calcium and Magnesium in Blood Serum. Proc. of the American Soc. of Biological Chemists, 1917, XXXII, 233.



February, 1921


THE SURGICAL TREATMENT OF RHINOPHYMA, WITH REPORT

OF A CASE


By Edward JI. IIanraiian, Jr.

{From the fiurgical Department of The Johns Hopkins Eospitrilj


Two papers on the surgical treatment of rhinopliyma have a])peared in the current year. Seelig in Surgery, Gynecology and Obstetrics, of April 1920, gave an account of a procedure by which he secured an excellent result. His operation consisted in the excision of the tumor mass and allowing healing to take place by epithelialization proceeding from niduses of ei)ithelium which were left after the main part of the growth liad been removed. He states that in the shaving off of the redundant tissue one should bear in mind two things, (1) not to shave so deeply as to remove all niduses of epithelium, and (2) to preserve a thin rim of epithelium around the nares to prevent cicatrization at this point by scar tissue. Bleeding in his case was controlled by pressure. Healing, that is, epithelialization, took place under imbricated strips of sterile zinc oxide adhesive plaster and was complete in ten days. Skin grafting was not found necessary.

Grattan in the Journal of the American Jledical Association, May 22, 1920, describes an operation the basis of which is the utilization of skin flaps made by two U-shaped incisions over the tumor. The skin was dissected from the tumor, the mass dissected from the nasal structure aiid the flaps adapted to the new contour. Healing in his case occurred per primam and this patient left the hospital on the 10th day. The problem of improving the appearance of the flaps was met by the application of trichloracetic acid until the higher prominences of the skin were levelled. Eoentgen rays were also used subsequently and the result as shown by his illustrations was most satisfactory.

A case of rhinopliyma was lately o])erated on in this clinic by Dr. Mont E. Reid. The technique used was similar to that of Seelig in so far as the entire mass, including the skin, was excised, but differed in that a Thiersch graft was used to cover the denuded surface.

Eeport of the Case

T. M., a white man, aged 42, was admitted to the hospital on October 8. 1919. The family history was negative. His past history was interesting in the fact that the patient had been troubled with acne vulgaris of the face since boyhood and that he gave also an unusual history of furunculosis. The patient had used alcohol in moderation between the ages of 20 and 40. He had also used chewing tobacco and snuff immoderate!}-.

The first manifestation of the present condition had begun three years before admission during the latter part of 1916. At that time the patient had noticed that his nose was increasing in size. This enlargement had started on the left and spread gradually over the tip of the nose, finally involving the right side. The growth had been very gradual, almost imperceptible, painless and without obstruction to breathing. The patient now sought relief only because of the unsightliness of his appearance. The physical examination was negative except for the condition of the nose and skin. There was a bulbous enlargement of the nose the size of an English walnut,


which involved both alae and the tip. The skin was red, ])ittod and greasy to the touch. The mass felt firm, not oedematous nor fluctuant. The skin was closely attached to the underlying tumor mass. There was a small wart on the right ala.

The skin of the chest, back and particularly of the forearms was covered with small white scars and comedones. The patient said that the latter became affected only after doing work in which the arms became spattered with oil during the last two years, and that the onset of nasal enlargement had preceded this other condition.

The Wassermann was negative. The blood count was practically normal. The blood pressure was IBS/IO,"). The urine contained a trace of albumin and a few granular casts. S. G. 1018-1027.

Operation. — October 11, 1919. The nose was sterilized with alcohol. The hypertrophic skin was entirely cut away, healthy skin being left above the line of incision and a border of skin about the nares, about one-eighth of an inch wide. The base was then carefully curetted in order to remove all epithelium, care being taken not to injure the perichondrium. Bleeding was controlled by pressure, hot saline solution and adrenalin, a few catgut 00 ligatures being used on the large vessels, A Thiersch skin graft taken from the thigh was then applied to the denuded area, and a silver foil dressing placed over it. It should be noted that the manipulation during the removal of the tumor expressed large plugs of sebaceous material upon the operative field.

Postoperative Care.—rThe recovery was complicated by a short attack of acute tonsillitis during the second week. The nose was dressed on the fifth day. Generally speaking the graft was in good condition except in two small areas on either ala, the larger on the right being about as large as one's little finger-nail. The nose was now kept moist and clean with Dakin's solution applied on compresses moistened every two hours. Healing was complete by the fourteenth day.

Mirroseopic Study of Excised Tiss^ue. — There is thickening of both layers of the skin — particularly in the stratum corium. Tliere are many papillary downgrowths of epidermis, particularly in the stratum germinativum, with areas of keratinization. The corium is extensively infiltrated with small round cells and shows a great increase of fibrous connective tissue. The ducts of the sebaceous glands are dilated and are lined with tliickened epidermis. The glands are dilated and hypertrophied. The corium measures about 1 cm. in thickness and is of the same character throughout as described above. The thickened squamous epithelium of the ducts is present deep in the corium.

The microscopic pathology of this condition was fully described by Wende and Bentz in 1904. They noted the cystic enlargement of the sebaceous glands due to dilatation and hypertrophy of the excretory duct, the connective-tissue hypertrophy and round-cell infiltration and also the hy|)ertropl'.y and cellular infiltration of the superficial layer of the epidermis. They described the stratum mucosum (germinatum) as thickened, with proliferation of some of the edges.

From a study of the microscopical sections it would seem that the disease is a mild chronic inflammatory reaction brought about by the accumulation of large quantities of selium in dilated and hypertrophied glands. This inflammatory reaction manifests itself by hypertrophy of connective tissue and


50


JOHNS HOPKINS HOSPITAL BULLETIN


[Xo. 360


round-cell infiltration in the corium and to a lesser extent is seen in the epidermis — particularly in the germinativum. This being the case, it would seem that the most logical procedure would be the removal of this diseased tissue in its entirety. This is the method employed In' Warren and White, and advocated by Seelig and Gibbon who remove all but small niduses of epithelium from which epithelialization proceeds. Grattan leaves only the oiiter layer of the skin, relying on his dissection of the skin from the deeper layers to remove all sebaceous gland tissue. It was noted, however, by Dubreuilh that in partial excision of slices and union by suture of the remaining portion the latter usually continued to grow and to produce more hypertrophic tissue.

Eeid attempts to remove all diseased tissue, even the niduses of epithelium, with the idea of avoiding the development of retention cysts; and tlien relies on grafts to cover the defect. Either Reid's method or that of Seelig may be followed safely. The graft of healthy skin appears to be a more logical procedure than the use of flaps of skin which should not b'e considered healthy, and if one fears any injury to the nasal cartilage due to curetting too deeply, the healing from niduses of epithelium offers a very satisfactory result.

BIBLIOGRAPHY Dulneuilh. \V.: L'acne hvpertrophique <hi nez et son traitemeiit eliirurgical. Ann. de dermat. et syph., Paris, 1903, 4 s., IV, 785-810.


Gibbon, J. H.: Rliinophvnia. Ann. Surg.. Phila . 19!9. LXX, 169171, 4 pi.

Grattan, ,J. F. : Rliinoi)hyma. A cure by a plastic operation with a good cosmetic result. J. .Am. M. .\ss., 1920, LX.XIV, 1450.

Seelig, M. O. : Rliinopliynia. Surg,. Gyn. & Obst.. 1920. XXX. :!94.

Warren. J. C. and White. C. .J.: Tlic treatment of rhiiiophyma. St. Paul Med. .J.. 190.3. V, 887.

Wende, G. W., and Bentz. C. A.: Rhinophyma. A pathological analysis of five separate tumors occurring in the same patient. J. Cut. Dis., 1904. XXII. 447.


EXPLAXATIOX OF PLATES

Figs. 1, 2. — Case of Rhinophyma. Duration of growth three years. Patient's age is 42. Acne vulgaris since boyhooil.

Figs. 3. 4. — Ten (10| days after operation. The Thiersch graft has taken.

Figs. 5. 6. — Photograph forwarded by the patient four months after operation.

Fig. 7. — Photomicrograph magnified 18 times, showing a large dilated duct lined with .squamous epithelium. At X a small nidus of epithelium could be left, and from such points the wound may be epithelialized.

Fig. 8. — Photomicrograph magnified .36 times, round-cell infiltration and overgrowth of fibrous connective tissue are apparent. The hypertrophied glands connecting with obstructed and dilated duct are well shown.


THE ISOLATION OF B. DYSENTERI/E (FLEXNER) FROM THE URINE OF AN INFANT WITH DYSENTERY

By Catherine Creightox, C. E. Wagner axd Wilbuet C. Davlsox

{From the Ilnrriet Lane Home of The Johns Uopkins Hospital and the Department of Pedkitrics of The Johns Hopkins rnirersity,

Baltimore, Maryland)


True dysentery bacilli have rarely been found in the urine of patients suffering from dysentery.' Fraenkel ' in a large series of urine cultures in adult cases of dysentery recovered dysentery bacilli in only four instances. In one of these patients B. typhosus as well as the dysentery bacillus was recovered from the urine. Hilgers ' among a total of 82 ea.ses of pyelocystitis found B. dysenterm in the urine of two patients, the first one being a man with chronic prostatitis and the other a child suffering from enteritis follicularis. Foerster* isolated B. dysenteria in another case of pyelocystitis. Sonne' found dysentery bacilli in the urine of a patient convalescent from typhoid fever. The organisms recovered in all of these cases were mannite-fernienting dysentery bacilli of the Flexner group. Organisms resembling but not identical with B. dysenterm have occasionally been isolated from the urine of individuals with other diseases.' Haemorrhagic vaginitis ' has also been noted as a complication of dysentery.

Our case illustrates that a typical B. dysenteriw (Flexner) ( Tallies I and II) may be found in the catheterized urine of a child with bacillary dysentery without vaginitis, pyelitis.


cystitis or other urinary complication. The organism was discovered as the result of routine cultures.

Case Report

Female, white. No. 2.3721, aged 27 months. The onset of diarrhcea was rather gradual. The temperature reached 10.3° F. and there were from ten to fifteen bloody stools on the third day, passed with pain. After one week the patient began to improve and was admitted to this hospital on the fourteenth day of the disease with the complaint of persistent abdominal pain and dysuria. There were two to three bloody stools a day. All the symptoms subsided two days later.

The physieal examination was essentially neg-ative; there was no microscopic vaginal discharge.

Laboratory Findings. — W. B. 0. 10.400; microscopic examination of a eentrifuged specimen of uncatheterized urine on the sixteenth day of the disease showed pus cells in clumps (probably from the vagina), but no pus cells were found in catheterized specimens on the sixteenth and nineteenth days. B. dysenteriir (Flexner) was isolated in pure culture from both of these latter specimens. Three weeks later the catheterized urine was sterile. Stool cultures on admission and on the three following days as well as three weeks later were negative for B. dysenteriw. The absence of dysentery bacilli in the stools does not invalidate the diagnosis of bacillary dysentery, for


HE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1921




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stool cultures are frequently negative at this late stage of tlu^ disease.

Blood culture one week after admission was sterile.

The agglutination reactions of the patient's serum with cultures of the dysentery bacillus isolated from her urine and also with stock cultures of B. dysenteriw (Flexner) were positive on the seventeenth and thirty-eighth days of the disease (Table III).

Diagnosis. — Bacillary (Flexner) dysentery.


TABLE I.— BIOLOGICAL CHARACTERS OF THE DYSENTERY BACILLUS ISOLATED FROM THE PATIENT'S URINE 0)




J_





OJ


V





o



f:^


=


_



s


£


•s


1


- £


•"2


E


s



^


-a


•Tj


^


£


<4


"rt


rt £


3


A


"^


o


B



o


J


o


s


^


M


Q


« 




+


+


+ (4th) (day)


indicates negative Gram-staining ; non-motillty ; non-forniation of indol (8 days) ; non-liquefaction of gelatin (28 days) ; non-fermentation of carbohydrate media (28


+ indicates production of acid without gas and serological technique, see reference. ^


rbohydrate media. For cultu


TABLE II.— AGGLUTINATION REACTIONS OF THE DYSENTERY BACILLUS ISOLATED FROM THE PATIENT'S URINE


Polyvalent


Shiga serum


Polyvalent Flexner serum (Rockefeller

Institute)


Flexner diagnostic type sera (Murray)"


(Rockefeller Institute)


V


W


X


Y


Z


+ 1250


100


+ 1000


100


+ 252


100


+ 250


100


-I- in Tables II and III indicates complete agglutination at the lilucion (endpoint) noted after the sign. indicates no agglutination at the dilution noted after the sign.


TABLE III.— AGGLUTINATION REACTIONS OF THE PATIENT'S SERUIM



Cultures of

dysentery

bacillus

isolated from

patient's

urine


Formolized standard stock cultures


Day of the disease


B. dvsenteniae (Shiga)


B. dysenteric (Flexner) Murray's Types"



V


w


X


Y


z


17 38


+ 100 + 50


20 20


+ 20 + 100


+ 20 + 50


20 20


+ 200 + 200


+ 20 + 20


BIBLIOGRAPHY

1. Stitt, E. R. : Practical Bacteriology, Blood Work and Animal Parasitology, 5. ed., Phila., 1918, p. 139.

2. Fraenkel, E.: Researches on Pseudodysentery (Y dysentery), Deutsche Med. Woch., 1915, XLI, 1182.

3. Hilgers, E. W. : Pseudodysentery bacilli as a cause of cystopyelitis, Centr. f. Bakt., Jena, 1919, orig., LXXXIII, 1. Abt., 414.

4,. Foerster, A.: A Case of Cystopyelitis caused by dysentery bacilli (type Flexner), Munch. Med. Wchnschr., 1918, LXV, 205.

5. Sonne, C: On the bacteriology of the paradysentery bacilli, Centr. f. Bakt., Jena, 1915, orig.. LXXV, 1. Abt., p. 408.

6. Bayne- Jones, S. : Personal Communication.

7. Ryder, C. T., Richards, E. T. F., Peabody, A. H., Canavan, M. M., Southard, E. E., and McGaffin, C. G.: Report of an epidemic of bacillary dysentery at the Danvers State Hospital, Massachusetts, in 1908, Boston M. & S. J., 1909, CLXI, 679.

8. Davison, W. C. : Bacillary Dysentery in Children, Johns Hopkins Hosp. Bull., 1920, XXXI, 225.

9. Murray, E. G. D. : An attempt at classification of B. dysenteriae based upon an examination of the agglutinating properties of 53 strains. Jour. R. A. M. C, 1918, XXXI, 257; 353.


A CONTRIBUTION TO THE STAINING OF PHAGOCYTES AND

EXUDATES

By Howard B. C'ko.ss (From tlie Department of Pathology ayid Bacteriology, The Johns Hopkins University)


The object of this communication is to place on record the formula of a stain which has been used in this laboratory throughout the last year for the study of phagocytosis and exudates. The preparation and application of this stain are so simple 'and rapid, the results so uniformly successful, that it seems generally a more satisfactory stain than those commonly used for staining phagocytic preparations. In composition the stain is somewhat similar to the one originally employed by Pappenheim ' for staining plasma cells. The stain described in this paper, however, has been preferred because with it the nuclei and bacteria are more sharply and constantly stained, annoying precipitates are generally absent, while the uniformly shaded cytoplasm makes possible a clear definition of the cell configuration, and permits a rapid and accurate enumeration of even the smaller and most irregular orijanisms.


' Pappenheim, Arch. f. path. Anat., Berl., 1899, 157, 19-76.


Preparation of Stain. — The following solution is made up using neutral distilled water :

Distilled water (neutral) 100 c. c.

Glycerine 20 c. c.

Alcohol 95% 20 c. c.

Phenol 2 c. c.

To this is then added :

Crystal violet 0.060 gr.

Pyronin 0.200 gr.

The flask is agitated to insure complete solution. This requires not more than two or three minutes. The stain is not filtered and is ready for immediate use. It may be preserved indefinitely if direct sunlight is avoided and the container is kept tightly closed to prevent evaporation of the alcohol.

Method of Using.- — ^The smears of the material to be examined are made upon well cleaned glassware and allowed


52


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[No. 360


to dry in the air. Any further fixation is only an unnecessary addition to the technique without any compensatory advantage. Smears prepared in this manner stick well and if the slides axe slightly warmed before the smears are applied it is often possible to preserve the ameboid form of the cells. The slide is then flooded with the stain and after five to ten seconds is thoroughly washed in a jet of distilled water. As direct blotting often injures the cells, it has been found desirable to withdraw the water that may adhere to the smear by touching the side of the slide with a blotter. Stains made in this fashion have been kept in the laboratory for eight months without any marked alterations in the appearance of the preparations.

The best results are possible only when the slides are thoroughly cleaned. It is quite impossible to make a satisfactory smear upon an unclean slide. The presence of grease and other foreign substance presents a precipitating focus which often makes it necessary to discard the smear altogether. Stiffs suggestion of passing the slide slowly through a flame to remove grease and lint before making the smear has proved exceedingly valuable.

Stains made with the above technique present about the following appearance. The cell nuclei are stained violet, the cytoplasm a uniformly delicate lavender. Often a reticular structure can be made out in the extranuclear substance but granules are never present to interfere with the bacterial enumeration. The cell limits are clearly aud sharply defined. The bacteria are colored a deep purple and can readily be


distinguished from detached nuclear material that may resemble them morphologically. When, however, the intracellular organisms are being digested they gradually lose their staining qualities, appearing as shadowed outlines, and finally disappear leaving only a vacuole filled with granules. Bacteria such as gonococci, which vigorously resist digestion, retain their staining characteristics for days after being ingested. Erv'throcytes, when present, appear as pale lavender shadows. Plasma and mast cells exhibit a characteristic structure and stain darkly throughout, so they are at once recognized. Unformed albuminous and mucoid extracellular constituents of exudates seem to possess little affinity for the stain so that the field appears quite clear. There is a total absence of the annoying precipitates too often associated with the staining of phagocytes.

The above stain has also been used as a routine in this laboratory for the preliminary examination of exudates. Its sharp bacterial staining qualities together with the slight aflSnity of the stain for the extracellular material make possible the demonstration of organisms even when they are present only in exceedingly small numbers. The use of this stain has been found most advantageous in exudates where an excess of cellular debris and serum produce precipitation with resulting confusion when the more common bacterial stains are used. The exact demarcation of cell outUnes enables oue to determine at a glance the presence of intracellular organisms.


A CLINICAL STUDY OF TUBERCULOUS SALPINGITIS,* BASED

UPON 200 CASES


Bv J. P. Greexberg


{From the Gynecological Clinic

Tuberculosis of the female reproductive organs was formerly considered a very rare condition. Up till the time that Hegars monumental monograph appeared in 1886 tuberculosis of the female productive organs had been looked upon as a rarity. After the appearance of Hegars communication, interest in the subject was aroused and since then an enormous literature has appeared. The actual incidence of the disease is still underrated, and there is little wonder that many cases are overlooked when we stop to reflect that the diagnosis is in the majority of cases made only after careful microscopical examination. As recently as 1909 the disease was considered uncommon enough to justify the reports in the literature of individual uncomplicated cases.

In discussing tuberculosis of the tubes, we are really considering the large majority of the cases of tuberculosis of the genital tract, for in nearly all the latter cases the tubes are involved. Furthermore, in a discourse on tuberculous salpingitis we must of necessity make constant reference to tuberculous peritonitis, for the two cannot be separated.


The complete article, of which this is an abstract, will appear in The Johns Hopkins Hospital Reports.


of The Johns Hopkins Hospital i

Incidence. — We liave analysed all the cases of tuberculous salpingitis which have occurred on tlie Gynecological ser^'ice of The Johns Hopkins Hospital during the last 30 years^ (1890-1919 inclusive) . In this report we shall give a clinical study of those cases only which showed definitely, upon microscopic examination, that tuberculosis was present. Fulfilling this requirement we found exactly 200 cases. This, of course does not give the actual morbidity of the disease; for many patients having tuberculous peritonitis with tubal involvement did not have their tubes removed. We had 67 such patientb; and if we agree with Osier and Menge that about 35;^ of these patients have tuberculous salpingitis, we find that among the 67 patients, 23 had tubal tuberculosis. Hence instead of 200 cases of tuberculous salpingitis we have had in all probability 223. Our clinical study, however, is based only on the 200 cases in which the tubes were without doubt tuberculous.

During the 30 years there have been 24,1.55 patients suffering from gynecological disorders. The incidence of tuberculous salpingitis therefore is 0.83^, or considering the number of patients as 223, we find that the incidence is 0.92^?^.

Incidence of Tuberculous Salpingitis Compared u\th All Diseases of the Tubes.— Tturmg the last 30 years there have


THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1921


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^F.SWK^,>^^'20


Si


Fig. 1. — Illustrating the apiieanitice of pliafrocytes and bacteria in smears prepared according to tlie tecliniiiue descriljed in this paper. (A) Pus cell from a lung aViscess in a multiple infection. (Bl Polymor])honucIear leucocyte from the blood of a guinea pig twcntv-five minutes after the ingestion i>f P.. )>iiitcus. The bacteria arc ^urniuiKled liy vacuoles. One bacillus, partially dii^csliMl. h.is l,,,t ils .tiiiniiii; clKiraclcri-tirs. The cell is associated with erythrocytes. ( (_' i Smc;ir from a luni; aliscc-^ cuntaininj; incci. bacilli, and spirochetes. (Dl Polymorphonuclear leucoi'yte containing a colon bai'illus within a digestive vacuole.


February, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


53


been 3382 salpingectomies at The Johns Hopkins Hospital. Of this number, in 423 the tubes proved to be normal. There remained then 2959 cases in which the tubes were pathological. Since there were in this period of time 200 cases of tubal tuberculosis, the incidence of tuberciilous salpingitis as compared with the abnormal tubes is 6.76^. This figure however does not give us the actual incidence. We must take into consideration the 23 cases before mentioned, in which there was peritoneal tuberculosis but in which the diagnosis of tubal tuberculosis was not verified because the tubes were not removed. Considering therefore 223 cases, we find that of the 2959 pathological tubes, 7.5;^ were tuberculous, a figure that more nearly approximates the truth. This means that out of every 13 abnormal tubes removed, one was tuberculous.

Affe. — Our youngest patient was 14 years old: while the oldest was 55. The greater number (73.5^) were in the childbearing period (between 20-40 years).

Fertility. — In our series there were 159 (79.5^) married and 41 (20.5^) immarried women. Of the former, 101 (63.5^) had never been pregnant, and since about 90^ of them had been married at least two years, which may be accepted as a reasonable period for the determination of the sterility or fertility of a married woman, we may assume that about 60;^ of our patients were actually sterile. Of the 41 single women, six had been pregnant (14.6^).

Symptoms. — The various symptoms are considered in full in the complete report. AVe shall here briefly refer only to those of major importance.

On admission to the hospital, more than 80^ of the patients complained of pain in the lower abdomen, and about 30^?: had concomitant pain in the back. Pain around the iimbilicus, wMch is so often quoted as being characteristic of tuberculous peritonitis, was elicited in only H^, although, as will be pointed out, 63^ of the patients had peritoneal tuberculosis.

The following menstrual disturbances were noted ; dysmenorrhea (62^), menorrhagia (41. 5f/), oligomenorrhea (24;^) and amenorrhea (6.5;/) Among the 200 patients, 72^ had a leukorrheal discharge and all the patients with tuberculosis of the cervix had leukorrhea.

Predisposing Causes. — An appreciable number of patients attributed the onset of their infection to some special uterine activity. Seventy-four patients gave a history of a definite onset, and of this number 46 or 63.2,'^ (23;?^ of the 200 patients) , dated their trouble from some uterine function or disturbance, as may be seen from the following table :

Time of onset No. %.

Menstrual period"! 22 ] 11.0%"]

Childbirth Uterine 15 7..5

Miscarriage |- Activity 6 Ue .3.0 123%

Pregnancy 2 1.0

Induced abortion J 1 J 0..'5 J

Marriage 9 4. .5

Acute illness 9 4. .5

Operation 4 2.0

Injury 4 2.0

Menopause 1 0.5

Fright 1 0.5


74


37.0%


Physical F.vamitiation. — For the complete data bearing on the physical examination, the reader is referred to the more extensive article. Mention may here be made, however, of the more important findings.

Pulmonary tuberculosis occurred in about one-fourth, and tenderness in the lower abdomen was elicited in about threefourths of the patients. Of interest in the pelvic examination was the fact that although 7 patients had tuberculosis of the cervix, the condition was recognized only once. In 70^, masses were found in the fomices, replacing the normal adnexa.

Elevation of Temperature. — Considering a temperature of 99.2° or above as fever, we found that 125 of our 200 patients (62.5;?) had a pre-operative elevation of temperature. Among the patients having peritoneal involvement, 65.8;? had preoperative fever, while of those having apparently no peritoneal involvement, it occurred in only 34.2;?.

Leukocyte Count. — The leukocyte count was recorded 50 times. Only 34;? of these patients had a count of more than 9000, while 22;? had an absolute leukopenia. Whereas the remainder apparently had a normal count (between 60009000), they in reality had a relative leukopenia. For most of them had fever at the time the count was made and in conditions other than tuberculosis a definite leukocytosis should have been found.

Eemoglobin. — In 63 patients the hemoglobin was determined by the Sahli method. If we consider 70;? as the lower normal limit, we find that 50;? of these patientsi presented too low a hemoglobin.

Pre-Operative Diagnosis. — N'o diagnosis was recorded before operation in 34 instances. Tl'e correct diagnosis was made before operation in only 26 instances (13;?). However, 15 of these patients had ascites which made the diagnosis an easy one. The most frequent diagnosis was " Pelvic Inflammatory Disease," by which was meant in practically all instances, a gonorrheal or puerperal affection. Myomata were diagnosed 29 times and were actually found associated with tuberculosis in 25 cases.

Treatment. — ^All the cases but two which are here reported were operative cases and in every instance the operation was performed by the abdominal route. In 10 patients this was combined with pelvic puncture. A radical operation was performed 106 times (53;?). The uterus was removed in 124 cases (63;?), while there were 166 oophorectomies (83;?), unilateral or bilateral. Salpingectomy alone was performed 18 times (9;?). Exploratory laparotomy was done in five cases, in all of which the autopsy showed tuberculous tubes.

Drainage. — Among our 200 cases 104 (52;?) were drained. Recourse was had to abdominal drainage in 28 instances (14;?), to vaginal drainage 58 times (29;?:) and to combined abdominal and pelvic drainage in 18 cases (9;?). In the 104 patients who had been drained, there were 18 fecal fistulse, an incidence of 17.3;?. JTone of the 96 patients who were not drained developed a fecal fistula.

Order of Frequency of Organs Involved. — The order of frequency of involvement of the various pelvic organs in the tuberculous process is as follows :


54


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 360


Tubes 200

Uterus 90

Ovaries •

Cervix "

Vagina 1

Tuberculosis of the Uterus. — The utenia was involved 90 times {io^). If we seek the incidence of uterine tuberculosis among the hysterectomies, we find it to be 72. G^. Tiiis figure more nearly represents the actual occurrence of tuberculosis of the uterus. The following table shows the distribution of the disease process in the uterus :

Endometrium 86

Myometrium 12

Endometrium alone 7S

Myometrium alone 4

Endometrium and myometrium 8

As may be seen, tuberculosis limited to the myometrium is rare. Of the 86 patients with tuberculous endometritis, all but three were in the menstruating age and among them amenorrhea occurred in only 7 (SA^) ; menorrhagia in 37.2'*'.

Tuberculosis of the Ovary. — The ovaries were found to be tuberculous 55 times; hence the incidence based upon the number of oophorectomies (16G) was 33. If/.

Tuberculosis of the Cervix. — In our 200 eases of tubal tuberculosis, tlie cervix was involved seven times (3.5). lu addition to these, two other cases of tuberculosis of the cervix were noted but not associated with tuberculosis of the tubes.

Among tlie cervical cases associated with tubal tuberculo.-^is other portions of the uterus were involved as follows :

Cervix and endometrium together • ^

Cervix, endometrium and myometrium 3

Cervix alone 1

Tuberculosis of the Tagina. — Vaginal tuberculosis was found in only one ease (0.5^) .

Tuberculosis of the Peritoneum and Appendi.v. — Peritoneal tuberculosis was found in 126 of the 200 patients (63;t). In most of our cases the appendix was removed. We found six cases of tuberculosis, making our incidence at least 3^'.

Combinations of Organs Involved. — The following list indicates the manner in which the various organs were associated together in the disease.

Tubes involved alone .37 18.5%

Tubes and peritoneum 49 24.5

Tubes and uterus 23 1 1 .5

Tubes, uterus and peritoneum 33 16.5

Tubes and ovaries 3 1.5

Tubes, ovaries and peritoneum 19 9.5

Tubes, uterus and ovaries 8 4.0

Tubes, uterus, ovaries and peritoneum . . 20 10.0

Tubes, ovaries and cervix 1 0.5

Tubes, ovaries, uterus and cervix 1 0.5

Tubes, uterus and cervix 1 0.5

Tubes, uterus, cervix and peritoneum . . 1 0.5 Tubes, uterus, ovaries, cervix and

peritoneum 3 1 .5

Tubes, uterus and vagina 1 0.5

200 100.0%


Deaths in the Hospital. — In our 200 cases there were 17 deaths in the hospital (8.5^). Of this number, however, only 15 of the patients had been operated upon; hence the operative mortality in 198 cases was 7.6;^.

Of the 17 patients who died, 7 had definite signs of pulmonary tuberculosis on physical examination, while in 3 others the diagnosis was questionable. Or, considered differently, 9 of our 58 patients with definite or suspicious phthisis died immediately after operation (15.5^), as compared with 7 (5^) in 142 patients without pulmonarj' involvement.

Out of our 125 patients with an elevation of temperature, there was 14 deaths (11.2^), while in the 75 patients without fever, there were only three deaths (4^).

In the 126 patients with peritoneal involvement, the operative mortality was 11.1^; in the 74 patients without peritoneal tuberculosis the mortality was only 2.7,^.

It appears, therefore, that the prognosis is graver when there is tuberculosis elsewhere, when a pre-operative elevation of temperature exists, and when the peritoneum is involved in the tuberculous process.

Late Results. — An effort was made to communicate with the 183 patients who were discharged from the hospital, but unfortunately information could be obtained only regarding ninety (66 white and 24 colored women). To draw conclusions from these is not only hazardous but is also erroneous, as only half the patients are represented. However, the results are interesting.

Of the 90 patients, 12 had died; but 3 deaths had had no relation to the tuberculosis. (One after a gall-bladder operation, one after an automobile accident and the third following an operation for carcinoma of the abdominal wall.)

Among the 78 living patients who responded, the general health had markedly improved after operation in 73, somewhat in 2 and not at all in 3. There had been a gain in weight in 73 patients, which in many instances was very marked. The pain had been absolutely relieved in 72, partly in 4 and not at all in 2. Eleven patients complained of bladder disturbances. Ten patients who were discharged from the hospital with open wounds, reported that the wounds had subsequently closed, at intervals varying from 2 weeks to 2 years. In 3 patients the wound, which was healed at the time of discharge from the hospital, reopened, but closed again spontaneously. Post-operative hernia occurred in T patients.

COXCLUSIONS We may summarize the findings of our 200 eases of tuberculous salpingitis as follows:

1. Tuberculous salpingitis occurred in nearly 1^ of all women admitted on the gynecological service of The Johns Hopkins Hospital.

2. It was found one and a half times as frequently among the colored women as among the white.

3. Out of every 13 abnormal tubes removed at operation, one was tuberculous.

4. Nearly three-fourth of the jwtients were between 20 and 40 years of age.


February, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


55


5. Sixty per cent of the married patients were sterile.

6. A family history of tuberculosis was reported in 22.5^ while in an additional 2.5;?; the consort had active pulmonary tuberculosis.

7. The chief complaint of the patient was pain (7-1.55^) usually situated in the lower abdomen (82.5;^).

8. Not miich information was obtained from the menstrual history. However, 62'i of the patients had dysmenorrhea and 41.5;^ menorrhagia. Amenorrhea occurred in only 6.-5^ of the patients.

9. Lexikorrhea occurred in 72^ of tlie patients.

10. Nearly half of the patients had dysuria, nycturia and pollakiuria.

11. More than half of the patients were constipated.

12. Approximately one-fourth of the patients attributed the onset of their symptoms to some uterine activity (menstruation, pregnancy, etc.).

13. Half of the patients had lost weight during their illness.

14. The physical examination presented no characteristic findings.

15. About one-fourth of the patients had pulmonary tuberculosis.

16. Pre-operative elevation of temperature was recorded in 62.5<i^.

IT. There was usually either an absolute or a relative leukopenia.

18. Half of the patients examined had a hemoglobin below normal limits.

19. The correct diagnosis before operation was made in only 13^ of the cases and, in more than half of these, the diagnosis was aided by the presence of ascites.

20. A radical operation was performed in 53^i! of the cases.

21. Complications during operation occuiTed in 14. .5;^ of the patients.

28. One hundred and four eases were drained. Of these, 17.3^ developed fecal fistulas. Abdominal fecal fistulee occurred


3 times more frequently among the cases drained abdominally than in those drained through the vagina.

23. In one-third of all the patients, there was suppuration of the abdominal incision.

24. No patients who were not drained, developed a fecal fistula.

25. The incidence of fecal fistulte among the cases in which the bowel had been injured was 48^, whereas among the cases in which the intestines had remained intact, the incidence was only 3.4;r. The patients with pre-operative fever developed fecal fistulfe" more than twice as frequently as those without fever.

26. Urinary fistula occurred 5 times (2.5;^).

27. The order of frequency of involvement of the pelvic organs was as follows : tubes, uterus, ovaries, cervix and vagina. Tuberculosis of these organs was found associated with tubal tuberculosis as follows: \iterus, 72.6^1^; ovaries, 33.1;*; cen'ix, 3. of/; and vagina, 0.5^.

28. In 99;* of the cases both tubes were involved.

29. In 68^ of the eases the peritoneum was involved, and in 3^ the afipendix was tuberculous.

30. In 17(^ myomata uteri were associated with the tuberculous process.

31. In only 2"^' was there an associated involvement of the urinary tract.

32. The prognosis is grave in the presence of tuberculosis elsewhere in the body, where fever exists and where the peritoneum is involved.

33. Our operative mortality was 7.6^. (This includes all the patients who died in the hospital.)

34. By means of follow-up letters, etc., 90 patients were traced and out of this number, 78 were found to be living from 2 months to 30 years after the operations. Nearly all those who are alive are in good condition.


BOOKS RECEIVED



TITLES OF PAPERS APPEARING DURING THE YEAR, 1920, ELSEWHERE THAN IN THE BULLETIN, BY THE PRESENT AND FORMER MEMBERS OF THE HOSPITAL AND MEDICAL SCHOOL STAFF

COMPILED BY THE LIBRARY

(Deleted from online version)


Vol. XXXII— No. 361


BALTIMORE, MARCH, 1921

CONTENTS

  • The Cause of So-Called Idiopathic Hydroieplialiis. i Illustrated.) By Walter E. Dandy fi"
  • X-Ray Pictures of the Bones in the Diagnosis of Syphilis in the Fetus and in Young Infants. (Illustrated.) By P. O. Shipley. J. \V. Peak.sox, A. A. Weech and C. H. Greene 75
  • Internal Migration of the Ovum. (Illustrated.) By George W. Corner 78
  • Serious Reactions to Repeated Transfusions in Pernicious Anemia. By H. JI. BowcocK S3
  • The Fate of True Solutions (Phenolsulphonephthalein) and Colloids {Trypan Blue) Injected into the Mammalian Embryo. By George B. Wisiocki
  • Proceedings of Societies.

The Johns Hopkins Hospital Medical Society .... Drainage of the Common Bile-Duct through the Cystic Duct. Cystico-choledochostomy. (Abstract.) [Dr. Mont R. Reid] ; An End-to-End Anastomosis of the Large Intestine by Abutting Closed Ends and Puncturing the Double Diaphragm witli an Instrument Introduced per Rectum. [Dr. W. S. Halsted] ; Exhibition of Specimens Obtained in End-to-End Anastomoses Performed According to the Method Described by Dr. Halsted [Dr. Emile Holman].


THE CAUSE OF SO-CALLED IDIOPATHIC HYDROCEPHALUS

By \\'ai.ti;i; E. Daxdy {From the Department uf iiuryerii. The Jolins Hopkins Hospital and CnirersHij)


Until recently all cases of hydrocephalus were considered idiopathic. We think it is now fair to assume that those cases in which an obstruction in the ventricular system can be demonstrated may be liberated from this teira incognita and may now be classified according to an established pathology; for there can no longer be any doubt concerning the cause of obstructive hydrocephalus. Any lesion which occludes the ventricular system will always produce stasis of fluid and dilatation of the ventricles proximal to the obstruction but will not change the size of the ventricles distal to it. There can be no exception to this rule. The proof of this causative i-elationship has been amply provided in recent necropsy material ' and in the experimental production of the disease at will.'- ' ' '


> Dandy, W. E.. and Blackfan. K. D : Internal Hydrocephalus — an Experimental, Clinical and Pathological Study. .1. A. M. A.. 1913, Ixi, 2216; Am. J. Dis. Child.. 1914. viii. 406.

'Dandy, W. E. : Experimental Hydrocephalus. Ann. Surg.. August, 1919, p. 129.

•Weed, L. H. : The Experimental Production of an Internal Hydrocephalus. Publication 272, Carnegie Institute of Washington, p. 425.

'Thomas, W. T. : Experimental Hydrocephalus. J. Exper. Med.. 1914, xix. 106.


The purpose of this paper is to present proof — which 1 believe is just as positive — of the cause of the remaining Ijig group of tliis disease — communimting liijdroceplialus, i. e., of that type of hydrocephalus in which all the ventricles are in communication with the subarachnoid space. In the course of intensive studies on tlie absorption of cerebrospinal fluid in hydrocephalus it was found that in the communicating type the absorption from the subarachnoid space was greatly reduced. A reduction in the amount of the absorbing spaces which are reached by the cerebrospinal fltiid was suspected as the cause and a hypothetical pathology suggested along this line of reasoning.' Later, four cases of commtmicatiug hydrocephalus were studied at necropsy and in each adhesions were found which obliterated the cisteruse; hence it was assumed that, by preventing the cerebrospinal fluid from reaching the great absorbing spaces over the cerebral hemispheres, these adhesions had caused the hydrocephalus." We realized, however, the necessity of a inore graphic demonstration of the lesion and of proof of its effects before these findings could be accepted beyond question.

= Dandy, W. E., and Blackfan, K. D. : Internal Hydrocephalus. Second paper. Am. .T. Dis. Child., 1917. xiv, 424.


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There are two ways in which an obstruction of the cisterns can be clearly shown — one after death, the other in the living patient. ( 1 ) If a colored suspension is carefully injected into the spinal canal before making an autopsy ' the color will reach but cannot pass an obstruction in the cisternifi. (2) If air is injected into the spinal canal of a living patient, the roentgenogram will show the air extending up to but not beyond the point of obstruction in the cistemEe.'- ' Unless these tests are positive, an obstruction in the cisternse or elsewhere cannot be presumed to exist nor considered to be the cause of communicating hydrocephalus. If properly applied, either test will ])rove conclusively that an obstruction either . is or is not present.

A third and equally important proof must be forthcoming before the cause of communicating hydrocephalus can be regarded as solved : it must be shown that a lesion similar to the one described in these cases of communicating hydrocephalus and similarly situated will cause hydrocephalus when exjierimentally produced in animals.

CojniuxiCATixG Hydkocephalus Experimentally Produced

In the studies presented here, all of these exactions have been met. First I have produced communicating hydrocephalus in dogs by making a barrier- of adhesions in the mesencephalic cisterna ^ (Fig. 1) . Shortly before necropsy on these animals a suspension of India ink was substituted for an equal amount of cerebrospinal fluid which had been aspirated from the cisterna magna through a puncture of the oecipito-atlantal membrane. When India ink is introduced into the spinal canal of an animal whose cerebrospinal spaces are intact, the color will find its way within two hours to every point of the subarachnoid space over both cerebral hemispheres. But in the experimental aninijil with the perimesenceplialic band of adhesions, the passage of the ink is abruptly terminated by the obstructing band and none of the color reaches the surface of either cerebral hemisphere (Figs. 3, 4) ; furthermore, as a result of the hydrocephalus which has developed, the foramina of Luschka and ilagendie have become so dilated that a retrograde flow of ink is freely permitted into all the cerebral ventricles ( Fig. 3). The entrance of ink into the furthermost recesses of the ventricles (which normally occurs only at times) shows that the color has had every opportunity to reach the cerebral sulci, but is precluded from doing so by the obstruction.

DeMOXSTRATIOX of ObsTELCTIOX IX THE SCBARACIIXOID

Space at PosT-MoRTEii Exajiixatiox

Knowing from the experiments that an obstruction in the cisterna produces communicating hydrocephalus, it then remains to prove that all or at least many eases of this disease have this as the causative lesion. The graphic color method


• Dandy, W. E. : Roentgenography ut" the brain after tlie injection of air into the spinal canal. Ann. .Surg., October, 1919, p. 397.

'Dandy, W. E.: Ventriculography following the injection of air into the cerebral ventricles. Ann. Surg., July, 1918, p. o.


should be apjjlied to all human necropsy material in which hydrocephalus is suspected or known to be present. It is important that pressure be avoided in introducing these colored solutions, for delicate adhesions, though sufficient to cause an obstruction during life, may be easily ruptured and in this way artificial results may be obtained. In animals, the color can be introduced without pressure during life and the normal circulation will convey the fluid to all the spaces which are patent. In necropsy material the results, though less perfect, will be satisfactory if the color is introduced by gravity for l."i or 50 minutes.

Despite studies in a large series of cases of hydrocephalus, we have had but one opportmiity of applying this method at a post-mortem examination in a case of hydrocephalus with comnmnication. In this instance the results were just as striking as in the experimental cases winch have Ijeen described ; the color filled the cisternoe, even the cisterna interpeduncularis. covered the cerebellar subarachnoid spaces, but failed to reach any of the sulci over either cerebral hemisphere (Figs. 17, 18, 19). On the other hand, the ink passed freely into every part of the cerebral ventricles, deeply staining their walls (Fig. 18), for both foramina of Ltischka and the foramen of ^lagendie were widely open (Fig. 19). Xo gross adhesions could be seen either in the vicinity of these openings or even along the cisternas ; nevertheless, the cerebral sulci could not lie reached by the colored solution, because the branches issuing from the eisteruaj were sealed. The character of the pathological lesion will be discussed later; the test demonstrates that an obstruction exists in the cisternae and with the additional support of the experimental evidence no doubt can exist that this obstruction is the cause of the hydrocephalus.

Why Siioi'LD ax Obstructiox ix the Cisterx.e Cause Hydrocephalus ?

Doubtless obstructions, similar to those which we are about to describe in communicating hydrocephalus, have been present in all necropsies of this disease. The adhesions may not be striking, and at times could be missed'eutirely, if one did not look for them. Indeed in some cases the lesion may t>e due to defective formation of the cerebrospinal spaces in the early embryo. These pathological findings become significant and all-important only when the anatomy of the cerebrospinal spaces and tlie manner and place of the fonnation and the absorption of cerebrospinal fluid are fully understood.

Cerebrospinal fluid circulates in a mesothelial-lined vascular system which is just as definite as the vascular systems for blood, lymph or bile. A clear conception of the gross plan of this vascular system can be obtained from the accompanying diagram by Max Brodel (Fig. .5). The cavities in the interior of the brain (the ventricular system) are concerned only with the production of cerebrospinal fluid; the spaces on the exterior of the brain (the subarachnoid spaces) are normally concerned only with the ahsorption of cerebrospinal fluid. The balance between the production and absorption of fluid is maintained by three closely grouped communicating open


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iugs — the foramina of Luschka and that of Magendie (Fig. 19). Only through these openings can fluid escape from the entire ventricular system ; consequently, closure of these openings always produces a stasis of fluid — hydrocephalus — in all the ventricles. But in communicating hydrocephalus, these conduits are open, either entirely or in part, depending upon the extent and position of the pathological lesion. This type of hydrocephalus is caused by interference with the absorption of the cerebrospinal fluid in the subaraclinoid spaces. The real absorbing area of the subarachnoid space is the great network of subarachnoid spaces over the cerebral hemisi)heres — the cerebral sulci. Here the cerebrospinal fluid is distributed over a very extensive surface of blood capillaries of the pia and passes directly through the capillary walls into the blood by osmosis. Xumerous large branches convey the fluid to these spaces from the cisterna chiasmatis and the cisterna interpeduncularis, which together serve as a distributing center for all the cerebrospinal fluid which is destined to reach the cerebral hemisphere. Since all the ventricular fluid, on leaving the ventricles, first reaches the cisterna magna (by way of the foramina of Luschka and Magendie), a relatively long passageway under the medulla, pons, and mid-brain must be traversed before this fluid can reach the cisterna interpeduncularis and the cisterna chiasmatis, whence it can be distributed to the cerebral sulci by the major branches, as described (Fig. 5). The finer anatomy and histology of these spaces have been well described by Weed.'- '

By experimental methods, which, have been mentioned in earlier publications, it has been shown that from three-fourths to four-fifths of the cerebrospinal fluid is absorbed from the subarachnoid spaces of the brain, and the remaining onequarter or one-fifth in the spinal subarachnoid space. It is doubtful if any absorption occurs in the cisternae, these channels probably serving only as large conduits to carry the fluid to the surface of the brain, much as the ureters carry the urinary secretion to the bladder. An obstruction in the eistemse under the medulla, pons or mesencephalon (that is, at any point between the foramina of Luschka and the cisterna interpeduncularis) will produce a stasis of fluid up to the point of obstruction and cause hydrocephalus just as eflleetively as would a block at the aqueduct of Sylvius or at the foramina of Luschka and Magendie. It will be remembered that through the membranous tentorium corebelli whicli separates the posterior and middle cranial cavities there is but one opening, and this is only a little larger than the brain stem (mesencephalon) which passes through it. It is evident that when adhesions close the incisura tentorii and ol)literate the mesencephalic cisterna, collateral channels for the distril)ution of cerebrospinal fluid have no possi1)le way to develop.


' Weed, L. H. : An Anatomieal Consideration of the Cerebrospinal Fluid. Anat. Record. IfllT. xii. p. 461.

" Weed, U H.: Cells of the Araehiioid. Bull. Johns Hopkins Hosp., 1920, xxxi, p. .343.


Intra Vitaji ilEXHOD of Demoxsteatixg an Obstruction IN THE Subarachnoid Space

The value of intraspinous injections of air will be apparent when it is realized that every part of the subarachnoid space can be reproduced ° in the roentgenogram, just as every part of the ventricular system can be reproduced by an intraventricular injection of air.' At times, the ventricles also can be injected from the spinal puncture and, again, the subarachnoid space may be partially or wholly injected by way of the ventricular puncture. The patient is placed in the recumbent position, with the head exactly horizontal and higher than the body. This position must be carefully maintained until the skiagram has been taken. In the normal adult, about 30 to GO c. c. of fluid can be obtained by iTimbar puncture and an equal quantity of air, which is substituted, will fill all parts of the subarachnoid space. The cerebral sulci are shown as a network of lines over the brain (Fig. 6). The presence or absence of these air-filled sulci is the crucial observation of all intraspinous injections. Normally, the sulci will always be filled. When they can be seen over the entire cerebral hemisphere, it is evident that every part of the subarachnoid space is patent. Intact subarachnoid spaces may be interpreted to mean that hydrocephalus, if present, cannot be of the communicating type ; if, therefore, hydrocephalus is present (with air-filled sulci) an obstruction must be located in the ventricular system. On the other hand, the absence of air in the cerebral sulci means that an obstruction exists in some part of the subarachnoid space ; it also indicates that hydrocephalus must exist because the cerebrospinal fluid (air) cannot reach the absorbing spaces of the cerebral hemispheres; the hydrocephalus with such pneumographic findings would be of the communicating type or possibly of an obstructive type, which, if corrected, would only be transformed into a communicating type."- '

When intact, the cisternal conduit can often be seen throughout the entire course, even through the dense petrous portion of the temporal bone; the major branches can frequently be seen passing directly from the cisterna chiasmatis and the cisterna interpeduncularis to the cerebral sulci ; and when an obstruction exists at any point along the cistei-nse, it is located definitely by the furthermost point of the air shadow. The cisterna magna is usually clearly outlined. A marked variation has been found in its size; to a certain extent, I believe its size depends upon effects of adhesions, which are so frequently present; for if the cerebellar lobes are firmly bound to the dura in the neighborhood of the foramen magnum, it is clear that the size of the cisterna magna will be reduced and that its enlargement which would otherwise naturally occur with hydrocephalus will be impossible. In obstructive hydrocephalus the size of the cisterna magna is usually reduced by the backward pressure of the superimposed dilated ventricles, the contents of whicli have no avenue of escape into the cistemte.


'Dandv, W. E.: I.oc. cit.


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Location of Occlusioxs of the Subakachnoid Space Obviously an obstruction can exist at any part of the subarachnoid tree and the results, in terms of hydrocephalus, will be dependent upon the location of the obstruction. The obstruction may be in the trunk of the tree (the cistemse) ; it may occlude all the main branches which carry fluid from the cisternae to the cerebral sulci ; it may occlude some, but not all, of these branches; or finally, more or less extensive local areas of the subarachnoid space may be obliterated. An obliteration of the cisterns; or of all the distributing branches will prevent any cerebrospinal fluid from reaching any of the cerebral sulci ; occlusion of some but not all the branches of the cisternae may or may not produce hydrocephalus according to the number of cerebral sulci which continue to receive fluid through the branches which remain intact; or a low grade of hydrocephalus may develop because part of the fluid will be handled by the patent sulci. Extensive local areas of the cerebral subarachnoid space may be destroyed without the occurrence of any hydrocephalus, because the normal subarachnoid spaces are far in excess of the normal requirement for absorption; this is demonstrated by the results of every cranial operation, following which adhesions obliterate extensive areas of subarachnoid spaces with no effect upon the balance of cerebrosjjinal fluid.

Obstruction in the Ci^;teen.?3 The most frequent location for an obstruction in communicating hydrocephalus is in the cistern*. This was first observed in the four cases which were carefully studied at necropsy and will be seen in the results which are to follow in the patients who have been studied by cerebral pneumography. One must not infer from' this statement that adhesions only in the cisternae exist in these cases, but merely that these are the adhesions which are directly responsible for the production of the hydrocephalus. As a matter of fact, there are frequently more or less extensive adhesions along the entire base of the brain, particularly over both cerebellar lobes, and even over the cerebral hemispheres. Frequently one or two of the three basal foramina (Luschka and JIagendie) may be sealed by these adhesions (Fig. 12) and at times the lumen of the third opening may be implicated. When all three openings are occluded, obstructive hydrocephalus results ; when one or more foramina are patent, the hydrocephalus is of the communicating type.

Certainly the vast majority of all cases of communicating hydrocephaliLS follow meningitis (Fig. 8) and. being a post-meningitic process, the obstruction of the cisteniiP is in keeping with the basilar involvement of most forms of meningitis. It is also worthy of note that the great majority of these cases occur in infants and young children in whom meningitis is so prevalent and in whom the delicate meninges are more susceptible to permanent injury. At times tlie meningitic process may be of prenatal origin. This is shown by the frequent occurrence of this type of hydrocephalus at birth and by the presence of the basilar adhesions as the etio


logical factor ; also by the coexistence of a meningocele which is doubtless caused by the same general process.

In more than half of our cases of comnmnicating hydrocephalus the disease has definitely arisen at some time after birth, usually following an illness which has been variously diagnosed, but which a careful history will prove to have been meningitis. Again, the hydrocephalus has almost certainly followed an acute illness, perhaps even very mild, but which on the most careful inquiry has yielded none of the signs or symptoms of meningitis. In these cases adhesions have been found, either at necropsy or at operation, denoting that this illness must have been meningitis. At other times, though quite rarely, it is even possible to find at the base of the brain and elsewhere adhesions which could have been caused only by a pre-existing meningitis, although no illness may have been observed by the parents. These facts show the importance of a careful historj- of all patients suffering from intracranial pressure; they show that characteristic full-blown signs and symptoms of meningitis are not always present; and that the post-meningitic adhesions are not necessarily in proportion to the severity of the attack of meningitis. The situation, not the extent, of the post-meningitic adhesions detennines the onset and severity of the resulting hydrocephalus. Communicating hydrocephalus can, of course, result from obstruction of the cistemEe by tumor» of the pons and mid-brain and even by tumors situated in the middle cranial fossa; instances of these relationshijis have been reported in previous papers."' '° The effects on the circulation of the cerebrospinal fluid are exactly the same whether the occlusion of the subarachnoid space is caused by tumor or by adhesions ; but because of differences in treatment, the consideration of occlusions by neoplasms will not be considered here.

In seven out of ten jiatients with communicating hydrocephalus studied by cerebral pneumography, the obstruction has been located in the pontine or mesencephalic cisterna. In each of these, the column of air ended abruptly under the pons or mid-brain and no air reached the cerebral sulci; in each, the air passed freely into the lateral ventricles, demonstrating the free communication between the ventricles and the spinal subarachnoid space ; in each, the cisterna magna was also seen, but its size varied greatly. In one instance it was scarcely visible, doubtless because adhesions between the cerebellum and the adjacent dura had obliterated this usually large chamber of fluid. In other instances the cisterna magna was greatly enlarged — even to the same degree as the fourth ventricle (Figs 9, 10) . The pontine and mesencejilialic cisteniBe showed some variation in size.

Several times, when performing cerebellar operations on patients with hydrocephalus, I have been impressed with the fact that the cisterna magna, which usually covers nearly onehalf of the posterior surface of both cerebellar lobes, was very small and at times were scarcely recoifnizable. Invariably in


'Dandy. W. E.: I.oc. cil.

^" Dandy, W. E. : Localization or Elimination of Cerebral Tumors by Ventriculography. Suifr.. Gynec. and Obst. April, 1920, p. .329.


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these cases the cerebelliuii was tightly bound to the dura by adhesions. These operative findings, together -n-ith the necropsy observations, explain the cause of the pneumograpliic variation in the size of the cisternaj.

It has, doubtless, occurred to many, as to ourselves, to ask why hydrocephalus should be internal when the fluid can pass from the ventricles to the exterior. The fact that the cereljrospinal fluid forms in the ventricles and that the fluid is dammed back to its source only partially answers this question. The full answer is now clear. When an obstruction exists in the mesencephalic or pontine cistemae, the extraventricular distribution of cerebrospinal fluid is restricted to the subarachnoid spaces in the posterior cranial fossa, and usually these spaces are reduced to less than normal size by the post-inflammatory process. The cisterna magna will be proportionately as large as the fourth ventricle when its enlargement is not precluded by adhesions; in other words the accumulation of cerebrospinal fluid and the dilatation of the fluid-containing spaces will occur up to the obstruction (the causative lesion) and the size of the various collections of fluid in these spaces will be dependent on tl;ie resistance offered.

Oc'CLisiox OF All the 3Iaix Branches of the Cisterxa

IXTERPEDIXCULARIS AND THE CiSTERXA CHIASM.iTIS

In two of our eases the occlusion was not in the cisterns but in the large branches which radiate from the cistemae interpeduncularis and chiasmatica and which carry the cerebrospinal fluid to all the surfaces of the cerebral hemispheres. Although the anatomical features of the two cases differed greatly, fundamentally they were similar in that the cisterns were patent but all the branches were sealed. In each case the clinical diagnosis of communicating hydrocephalus was established by the phenolsulphonephthalein test. In each the site of the obstruction was determined by cerebral pneumography. In one case the findings were verified by necropsy and the intraspinal color test; and in the other by operation and the clinical tests. There was nothing imusual in the history' of either case, the disease having been noticed soon after birth and having progressed with the usual rapidity vmtil a tremendously large head had resulted. In one a partial fluid balance eventually had been established, as frequently happens, and at the age of four the fontanelles had slowly closed. The other child was only eight months old and the rate of growth of the head had not diminished.

After the injection of air into the younger child, the roentgenogram showed the air to have stopped in the cisterna immediately, behind the sella turcica, i. e., at the cisterna interpeduncularis. Only a small amount of air had been injected into the spine, and this passed freely into the»lateral ventricles, liut not a trace could be found in the cerebral siiici, which normally should fill with greater ease than the ventricles. The cisterna magna and the cisterna? under the brain-stem were small. At necropsy the spinal canal was injected with India ink. The distribution of this color was exactly that of the air as shown by the roentgenogram. The ink did not extend beyond the cisterna? although it reached the region of the optic


chiasm. On the other hand, all the recesses of the cerebral ventricles, as well as the entire subarachnoid space surrounding the cerebellum, were filled with the black suspension, showing that the ink had had ample opportunity to reach the cerebral sulci, but had been prevented from doing so by an obstruction. No adhesions were evident during removal of the brain, nor could any be found later on careful inspection of the brain. In all of our other cases of communicating hydrocephalus, adhesions had been found at necropsy and one or two of the basal foramina (Luschka and JIagendie) had been included in these adhesions and their closure had resulted. But in this case the foramina of Luschka and that of Magendie were open and larger than nomial. In the accompanying photograph (Fig. 19), a wire has been inserted into the three foramina to show their position and condition. The patency or closure of each of these foramina can always be demonstrated easily and absolutely if the probe is passed from the fourth ventricle outward along the lateral recess. The personal equation cannot enter into the determination.

But in the absence of any demonstrable adhesions, and in the presence of an intact cisternal conduit, why do not the cerebral sulci fill? We know that they cannot fill, because both the air before death and the ink after death have been imable to reach them, and by the two tests, either of which should be absolute, an obstructing lesion has been located in identically the same position. There can be only one explanation for the failure of fluid to reach the cerebral sulci, namely, the absence of the main branches which carrj- the fluid from the cisterns to the cerebral hemispheres. These branches may be absent either because they have been obliterated by adhesions following meningitis or they may have failed to develop. The absence of adhesion leads me to suspect the latter to be the cause, though the proof is lacking. Weed ' has shown the cerebrospinal spaces to be a secondary splitting of the peri-encephalic mesenchyme and their development to follow closely upon the opening of the basal foramina, which result from a gradual thinning of the walls of the fourth ventricle ; prior to this time the ventricular system is closed. At times these foramina fail to develop" and hydrocephalus results, and doubtless the same agenesis, perhaps easier to understand, may account for the failure either of the cistem.-e or of its branches to develop.

It is worthy of note that in this case the cisterna is small, whereas it should be larger owing to the accumulated fluid up to the obstruction. The absence of this expected enlargement must indicate a rigid wall, which might be of inflammatory origin or it might be the congenital impediment which prevented the further development of the cistemfe in foetal life.

In the second case the pathological features at first glance will appear to show little in common ^rith the preceding case. The pathology was disclosed by operation and not by necropsy, but as there was ample opportunity to observe the entire surface of the brain, excepting most of that in the poste


" Dandy, W. E. : The Diagnosis and Treatment of Hydroceplialns resulting from tlie closure of the foramina of Luschka and Magendie. Surg.. Gynec. and Obst., Fehruarv. 1921.


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rior cranial fossa, a post-mortem examination would be of little additional value. Air was injected into a lateral ventricle and not into tlie spinal canal. As mentioned above, the pheuolsulplionephtlialein test showed a communicating hydrocephalus. At two operations both hemispheres were explored, and over neither was cerebrospinal fluid found in the cerebral sulci. A huge cyst filled the base of the cranial chamber and extending upward pushed the brain away from the floor of the skull. The cyst extended from one side of the skull to the other, and on each side it was continuous with the cistema! chiasmatica and interiiedrmcularis. In fact, on each side it was a direct extension of these cisternal. Moreover, when the cyst was opened (on either side) the brain-stem could be seen as far as the pons, owing to the tremendous size of the cistenife under tlie mid-brain and pons; and doubtless the medullary cisterna was of corresponding size. The chemical analvsis of this vast accumulation of fluid showed it to be the same as the cerebrospinal fluid in the lateral ventricles. Furthermore, the phenolsulphonephthalein test demonstrated communication between the ventricles and these extra-cerebral cysts, but only after half an hour. In other words, the communication was by a devious path and was not direct. The absence of air in the cysts after ventricular injection also eliminates any direct communication, and finally, at ojieration there was seen to be no direct communication.^

We are dealing, therefore, with a case of communicating hydrocephalus in which the obstruction is at the branches which pass from the cisterna interpeduncularis and the c. chiasmatis to the surfaces of the cerebral hemispheres (there being no fluid in the cerebral sulci) . The walls of the cisternEe, gradually yielding to the pressure of the accumulating fluid, allow the formation of the huge cysts instead of the usually restricted cisterna under the brain. No adhesions of note were found at either operation, so that the assumption of a meningitis would be R-ithout a histoiy of this affection and without any anatomical evidence of its existence. The most plausible explanation of the cause of this condition is the congenital failure of the large branches of the cisterna3 to develop. In the preceding case it is possible that the cisternee may have been obliterated rather than that the branches have failed to develop; in tliis case the cisternas are well open, in fact they are greatly distended; under the mid-brain the cisterna is as large as one's index finger.

An external hydrocephalus differs from the above picture only in that the fluid is distributed over the hemispheres instead of being confined to a localized cyst of more restricted size. In fact, in this ease the hydrocephalus was transformed into an external hydrocephalus merely by opening the cyst, but the fluid, passing over the arachnoid membrane instead of under it, poured into the subdural space instead of the subarachnoid


'- A description of the remarkable anatomical changes in this case would only add confusion if present«d here. They are therefore omitted and will appear in a subsequent publication dealing with other phases of hydrocephalus. My purpose here is to correlate all the anatomical variations of communicating hydrocephalus into a single disease with a fundamentally similar pathology and etiology.


space, where there was only a slight absorption. The pathology of this case really forms a connecting link which explains the relationship between external hydrocephalus and internal hydrocephaliis; this relationship and the general subject of external hydrocephalus will be considered in detail in a forthcoming publication.

Obstkuctiox of Some But Not All of the ^Iaix Bkaxches

OF THE CiSTEKXJS

In the accompanying ventriculogram (Fig. 14) evidence of a very early hydrocephalus will be seen. It developed in a three-year-old child under obsenation in the service of Professor Howland. She was first treated for a typical illness of acute meningococcus meningitis, from which there was an apparent recovery, though very shortly lethargy and vomiting ensued. Six weeks after the onset of the attack of acute meningitis and two weeks after apparent recovery," hydrocephalus was first suspected. At this time, the cell count in the cerebrospinal fluid was ten. The sutures of the skull were separated ; a suggestive cracked-pot sound was obtained. There was no choked disc and no other sign of intracranial pressure. Without the ventriculogram the diagnosis of hydrocephalus could never have been substantiated. With the absolute verification it is probably the earliest recorded ease of hydrocephalus. The ventriculogram was difl'erent from that of any previous case which has come under my observation. Air passed from the ventricles and finally reached the cerebral sulci, but only in a very restricted segment over the frontal lobe. Such a finding might have been assumed to be due to an imi>erfect injection of air, but one month later another ventriculogram was made and precisely the same segment of subarachnoid space and exactly the same sulci were injected. In this intenal of 30 days between the two ventriculograms, the lateral ventricle had increased in size (compare Figs. 14 and 15), though the rate of growth was considerably less than in the usual development of hydrocephalus. The phenolsulphonephthalein output from the spinal canal rose from 13 per cent to 22 per cent; the latter percentage was found at the time the first ventriculogram was made; unfortunately, no test was made when the second ventriculogi-am was obtained. It is evident, from the phenolsulphonephtlialein test, that a partial compensation has occurred, for, with 22 per cent absorption (normal 35-50 per cent), the hydrocephalus could not be full-blown. The ventriculogram was also interpreted' to mean that the filling of part of the subarachnoid spaces denoted tliat a greater amomit of cerebrospinal fluid (12 per cent more by the phenolsulphonephthalein test) than in the usual quantitative absorption in communicating hydrocephalus with an obstruction in the cisterna was being absorbed in this restricted area and that a partial compensation had developed, as it should have done.


" A pneumococcus panophthalmitis also developed, necessitating rmoval of the eye, from which the meningococcus was grown in pure

culture.


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The branches of the oisteriuv can be traced directly from the cisterna chiasmatis to the cerebral snlci of the frontal region. K'umerous perpendicular air shadows are clearly shown just above the cisterna interpeduncuJaris and rising vertically from it but ending blindly. These shadows, I believe, represent the branches of the cisternas which are obstructed and which should supply the remainder of the cerebral hemispheres with fluid. The air extends in these branches up to the point of the obstruction in each individual branch (Fig. 14 ) .

This patient has been seen at intervals for the past two years and has recovered completely. We have proof from the pneumographic records not only of the existence of a hydrocephalus, which could not have been diagnosed otherwise, of its unusual rate of development, and of its spontaneous cure, but, more important, we have the findings in the transition stages and, we think, the reason for the compensation and eventual cessation of development of the hydrocephalus. Whether at one time all the cisternal branches were occluded and some subsequently opened, producing a partially compensating hydrocephalus; whether additional spaces were reestablished after our studies were made and permitted the condition to change- from a' partially compensating hydrocephalus to a complete cure, we have not the pneumographic evidence to prove or disprove.

I do not believe that it is possible for a hydrocephalus to occur, if all or even many of the cerebral sulci can be shown to fill with air or if the phenolsulphonephthalein output after a spinal injection measures 35 per cent in two hours. From a large series of cases of hydrocephalus, there has been no exception to disprove this statement. We are, however, not yet sufficiently familiar with the roentgenographic pictures of the cerebral sulci to make many positive claims as to prognosis in these unusual types of hydrocephalus.

SuilMARY AXIi COXCLUSIOXS

(1) The cerebrospinal fluid circulates in a closed vascular system. This is just as well defined as the vascular system for blood, lymph, bile or urine.

(2) The ventricular system, in which fluid is ])roduced but not absorbed, is lined with a high cubical and columnar epithelium; the subarachnoid space, in which the cerebrospinal fluid is absorbed, is lined with low mesothelial cells. Nearly all the cerebrospinal fluid is absorbed in the cerebral sulci.

(3) Collateral circulation is almost precluded either in the ventricles or in the cisternse. An obstruction in these spaces, therefore, results in a hydrocephalus, just as closure of a ureter results in a hydronephrosis. If the obstruction is situated in any part of the ventricles (usually the aqueduct of Sylvius or the foramina of Luschka and Magendie) the hydrocephalus is of the obstructive type; if it is situated in the cisterna3 (or in the main branches of the cistemse) it is of the communicating type.

(4) That the cause of communicating hydrocephalus (the renmant of so-called idiopathic hydrocephalus) is an obstruction in the cisternge is conclusively demonstrated in three ways. (a) Experimentally communicating hydrocephalus can be pro


duced by blocking the mesonrepbalir ci.-tcnia. (b) The obstruction can be graphically demonstrated in the experimental animal or at necropsy in the human by injecting a suspension of India ink into the spinal canal ; the color stops abruptly at the obstruction, (c) In all living patients the obstruction can be clearly shown by cerebral pneumography after air has been injected into the spinal canal; the air also stops at the obstruction, and can be sharply outlined in the roentgenogram.

(5) The obstruction in the subarachnoid space is most frequently located in the mesencephalic or pontine cisterna.

(6) However, the obstruction need not necessarily be in the cisteruEB ; it may be in the large branches which carry the fluid from the cisterna; chiasmatica and interpeduncularis to the cerebral sulci. Any number of these branches may be occluded. If all the main l)ranches are obstructed, the hydrocephalus will be the same as if the occlusion were in the cisterna. If some of the branches remain unobstructed, the degree of hydrocephalus will be modified proportionately ; a complete cure may even result because of the absoi-jition which takes place in the remaining patent areas of the suliarachnoid space.

{"i) Adhesions, which follow meningitis and occlude the cisterna?, cause the vast majority of cases of communicating hydrocephalus. They also cause many cases of obstructive hydrocephalus, by blocking the foramina of Luschka and ilagendie. Adhesions give infallible proof of a preexisting meningitis. A history of meningitis may be easy, difiicult or impossible to olitain. The post-meningitic occlusions have no relation to the severity of the attack and the number of adhesions but rather to the location of the adhesions.

(8) In two cases the hydrocephalus appeared to be due to a congenital failure of the eisternie or of its branches to develop. Tumors in the pons, medulla, or mid-brain also produce partial or complete obstruction of the subarachnoid space and therefore cause communicating hydrocephalus.

(9) Pneumographic records are shown demonstrating the existence of a very early stage of communicating hydrocephalus, the cause of the hydrocephalus, the reason for its unusually tardy development, and for its spontaneous arrest.

DESCRIPTION OF PLATKS

Fig. 1. — The mesencephalic cisterna is completely blocked in a doji; by surrounding the mid-brain with a piece of gauze saturated with iodine. The lower iigure shows a section of the mid-brain with the gauze band in place. The band is between the margins of the incisura tentorii and the surface of the mid-brain. Communicating hydrocephalus follows this experimental procedui'e; the reasons for the hydrocephalus will be seen in Figs. 3 and 4.

Fig. 2. — Section of a dog's brain to show the grade of hydrocephalus which resulted from the perimesencephalic band of adhesions ( Fig. 1 ) . On the right is a section of a normal brain as a control. The hydrocephalus is of three months' development.

Fig. 3. — Drawings by Max Briidel to give a graphic demonstration of the reason for the development of communicating hydrocephalus after the formation of the perimesencephalic adhesions. India ink had been sulistituted for cerebrospinal fluid in the spinal canal two liours before the animal was sacrificed. On the right is a control


JOHNS HOPKINS HOSPITAL BULLETIN


[Xo. 3G1


animal in whieli the same qiiantitj' of ink was injected at a similar time before death. In each case the ink has had the distribution which the cerebrospinal fluid would have. In the normal (right), the ink has thoroughly and evenly covered every part of the brain's surface because all of the cerebrospinal spaces receive the cerebrospinal fluid. In the experimental animal the ink has stopped sharply at the perimesencephalio band. Xone of the ink has been able to reach the cerebral hemispheres, although the cerebellum has been as well covered as the normal. In Fig. 2 it will be seen that in the normal brain the ink has not entered the lateral ventricles, whereas in the experimental animal the ventricles have filled with ink. Since the ventricles fill with ink. there can be no question that the injection is inadequate, for the ventricles are farther forward than the obstructing band.

Fig. 4. — Dorsal view of the same brains (as Figs. 2, 3) to show the distribution of the ink on this surface. It will be seen that the ink has not extended beyond the tentorium (owing to the perimesencephalic band), whereas in the normal the entire brain is covered. Hydroceplialus results from this band because the trunk of the subarachnoid tree is occluded and cerebrospinal fluid cannot reach the spaces over the cerebral hemispheres where most of the cerebrospinal fluid absorbs.

Fig; 5. — Drawing by il. Brodel to sliow the general plan of the vascular system for cerebrospinal fluid. Fluid forms in the cerebral ventricles and is absorbed in the subarachnoid space. The paired foramina of Luschka and the median foramen of Magendie are the only openings by which the ventricular fluid can leave the ventricles and reach the subarachnoid space. Obstructions at these openings, the aqueduct of Sylvius or at the foramen of !Monro produce hydrocephalus involving the ventricles anterior to the obstruction. Obstructions in tlie subarachnoid space are just as ett'cctive in producing hydrocephalus. The sites of these obstructions and their effects will be shown in the succeeding diagrams.

Fig. 6. — Pneumogram (intraventricular injection of air) to show normal ventricle and normal subarachnoid spaces. Note that the cerebral sulci (the wavy lines) are filled over the entire surface of the brain. The cisterna' interpeduncularis and chiasmatica are shown as the distributing center from which all the cerebral sulci receive their fluid.

Fig. 7. — Diagram to show the disturbance in the circulation of cerebrospinal fluid following an obstruction at the mesencephalic or pontine cisterna. The black area represents the absorbing spaces, which cannot be reached by the cerebrospinal fluid owing to the obstruction. Hydrocephalus results because this vast area (where three-quarters to four-fifths of the cerebrospinal fluid is normally absorbed) can no longer perform its function. The mesencephalic anil pontine cisternae are the usual sites for post-meningitic obstructions in communicating hydrocephalus. A pneumogram of this type of obstruction is sliown in Fig. 9. Fig. 8 shows a patient with tliis disease and having an occlusion at this point; Fig. 10 shows the ventricular system of this patient filled with air. Figs. 9 and 10 show this obstruction demonstrated clinically by the intraspinous and intraventricular methods, respectively. Figs. 11 and 12 show the pathology of this type of hydrocephalus.

Fig. 8. — Photograph of a patient with communicating hydrocephalus following meningitis. The marked retraction of the head and neck has persisted long after the acute illness has subsided. The ventriculogram of this patient is shown in Fig. 10.

Fig. 9. — Cerebral pneumogram (retouched) of a case of communicating hydrocephalus; air has been injected into the spinal canal. The obstruction is at the mesencephalic cisterna (c/. arrow). No air has reached the cerebral sulci but the lateral ventricle has been partially filled by the retrograde flow of air through the dilated foramina of Luschka and Magendie. Compare this intra i-itam demonstration of the causative lesion with that sho^vn post mortem by the injection of ink (Figs. 17 and ISi or with the example of experimental hydro


cephalus (Figs. 2, 3, and 4)f .-1 = cisterna pontis. B :^cerel)ellar subarachnoid space. C^ cisterna magna. T = lateral ventricle.

Fig. 10. — Untouched reproduction of a ventriculogram from a casn of communicating hydrocephalus (shown in Fig. 8) ; 800 c. c. of fluid were aspirated and an equal quantity of air substituted. The entire cerebrospinal vascular system is shown in the pneumogram up to the point of obstruction, which is also sharply defined. The tremendous lateral ventricles have lost all semblance of their former shape and practically fill the huge cranial chamber. The third ventricle, the aqueduct of Sylvius, and the fourth ventricle are outlined sharply. The foramen of JIagendie can be seen; the large cisterna magna fills much of the posterior cranial fossa. The obstruction which is causing the hydrocephalus is at the anterior terminus of the shadow of the cisterna magna. The oljstruction, therefore, is in the cisterna pontis ; no air has reached the cerebral sulci. The hydrocephalus in this case followed an attack of epidemic meningitis. T = lateral ventricle. /// = third ventricle. / V = fourth ventricle. P = suprapineal recess of third ventricle. .-I . .S'. ^ aqueduct of Sylvius. 3/ = foramen of Magendie. C = cisterna magna. J = obstruction in pontine cisterna. This obstruction causes the hydrocephalus.

Fig. 11. — Inferior surface of the brain of a case of communicating hydrocephalus: the mid-brain has been divided transversely and the cerebellum and brain stem removed. Xote the large aqueduct of Sylvius B and the large tumor-like dilated third ventricle A which compresses the optic nerves and destroys the sella tursica just as a hypophyseal tumor would do. Such a protrusion of the third ventricle is not always present in hydrocephalus.

Fig. 12. — Inferior surface of the brain stem and cerebellum of the above case (Fig. 11). The foramen of Magendie is entirely closed by adhesions. The right foramen of Luschka is patent (reader's left i as indicated by the prol)e L which easily passes through it from the fourth ventricle. The left foramen of Luschka (reader's right) is sealed and protrudes as a bulging cyst. The probe which is introduced into the lateral recess of the fourth ventricle of this side meets this obstructing membrane. The dilated cystic pouch (foramen of Luschka) is surrounded by a series of arrows in order to identify it.

Fig. 13.' — Diagram showing the eff'ect on the cerebrospinal fluid circulation when some, but not all, of the branches from the cisterna; interpeduncularis and chiasmatica are occluded. The black area represents the subarachnoid space which does not receive cerebrospinal fluid. In the clear zone the circulation is intact. Figs. 14 and l.") are pneumographic records of such a type.

Fig. 14. — Photograph of roentgenogram of head after the injection of air into ventricle ( not retouched ) . This patient had an early hydrocephalus following acute cerebrospinal meningitis. Only a small number of the cerebral sulci contain air (bracket between .x and xl. The obstruction wliich caused the liydrocephalus was not in the cisterna- but in the large branches which carry the cerebrospinal fluid from the cisterme to the sulci. The arrow points to the cisternae and the dilated obstructed branches; C = cisterna magna. The shadow of the mesencephalic and pontine cisternae can be followed through the dense petrous bone. The partial filling of the cerebral sulci (x to x) explains the slow development of the hydrocephalus and its subsequent spontaneous cure. Fig. 15 is a ventriculogram of the same case 30 days later.

Fig. 15. — Pneumogram of above case (Fig. 14) 30 days later. The increase in size of the ventricle is clear and easily measurable, but it is of a moderate grade. Exactly the same sulci are injected and the same dilated cisternae interpeduncularis and chiasmatica and the same dilated obstructed branches are shown.

Fig. 16. — Diagram showing the ettect upon the <ercbrul subarachnoid space when all the main branches, which carry the fluid from the cisternae interpeduncularis and chiasmatica, are occluded. Exactly the same absorbing area is eliminated and the hydrocephalus which results is identically the same. In our cases of this type absence of these branches was regarded as probably due to a congenitally defective development of these spaces. Fig. 20 is a ventriculogram of this


THE JOHNS HOPKINS HOSPITAL BULLETIN, MARCH, 1921


PLATE VIII




THE JOHNS HOPKINS HOSPITAL BULLETIN, MARCH, 1921 Left and ngKt foramen of Monro



Oisterna chiasmat s Cisterna rnterpedunculans De6ce id ng horn of Lateral vent cle

Cisterna pontis^ / Acjueduct of Sylvius Right a.ia left foramen of LuscliKa


_teriia magna (cerebello -medulla) is)



Fig. 8.



Site of obstruction' ^ Dilated cistecna pontis


FiQ. 7.



THE JOHNS HOPKINS HOSPITAL BULLETIN, MARCH, 1921




Fio. 12.



Site of obstruction

Dilated cistema pont'o


THE JOHNS HOPKINS HOSPITAL BULLETIN, MARCH, 1921




Dilated

cisterna Interpeoluncularis

Dilated cisfenia pontis Fig. 16.


Fig. 17.


THE JOHNS HOPKINS HOSPITAL BULLETIN, MARCH, 1921



Fig. 18.



FiQ. 20.


THE JOHNS HOPKINS HOSPITAL BULLETIN, MARCH, 1921



FeUi?. ((. is... li.i.i;-;

2. Hand and for. cification of the pr wme into the area

the metac;npnls ;ii

3. Radius ;mm1 m of the area ni nii .


H ates the number of the specimen in the Embryologi -litiite.]

iidritis liiotica. RocnlffennKrain from the distal end Tlii^ IM. (inr -li-uv rM.-^n.- rali'ification.

ai- t liiiiii.iii trill- (('( \.. "Miiin to show extreme

>\ i-i..n,il .Mr I \\ Hi, II ii -iil.ii ). I.. 1,. nidation of the pr iiiihi-; . Ni'ir ihf presence of the


'] rlul.i


show


a del


fetus (CC No. 2186) showing begin I at the epiphyseo-diaphyseal junctit shadow, each resorptive area


iil.ecular (i;


ling resorption n. Resorption surrounding a


ni sypliilitir ns((,HlioTirlritis of the bones of the hand and forearm iCC Nn. 'jii4t) shnwiim a zone of rarefaction between two lines of tiiiii. X.itc the lesinii in the phalanjfes and metacarpals. 5. Human fetus (CC Nu. 2350). Luetic osteochondritis of the distal end of the femur. This bone shows an abnormally heavy calcification of the provisional area of calcification separated proximalward by a narrow line of rarefaction from the broad band of dense shadow cast by fine closely set trabeculse at the epiphyseal end of the shaft.


n. TiiiiO -di-. (W, r,,r|-) of luetic oste.-rh irin> ..| t!ir .li^i.d i-iid of the femur and

i'i..xir,iil ,ii.N ,1 iiLi, and fibula. Huin.m i, m- ii N.. !.,i:;. This is the picture "111' li iiiitr, .h.ii. l> |.irc,.des epiphyseal s-immmi-h \ w ;.l, l..ni.l of syphilitic tissue MiuiMics thr nirmiKir liroad spotty zone nt iii-m\ im..ii;iI .al.itii'ation from the distal end of the diaphysis.

7. Syphilitic periostitis of both bones of the forearm of fetus CC No. 2597. Note the longitudinal striation of the tliick periosteal shadow which is nearly in contact with the shafts of the bone.

8. Syphilis of the femur. Human fetus CC No. 2513. Showing separation of the cortex from the spongiosa.

9. Distal end of radius and ulna of Case I. This plate shows intense calcification of the provisional zone with resorption areas on the marrow side of the epiphyseal line. Both bones show syphilitic periostitis and there is separation of the cortex from the spongiosa in the ulna.

10. Radiogram of tlie distal ends of the radius and ulna of Case 11. This shows a syphilitic osteochondritis with marked areas of resorption and a mild grade of periostitis.

11. Roentgenogram of the proximal ends of the tibia and fibula of Case HI, showing syphilitic osteochondritis with over-calciflcation of the provisional calcified zone with a Trtlmmer-zone-like area behind it and a mild grade of periostitis of the tibia.


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type of obstruction. Figs. 17 and 18 show the obstruction as defined by an intraspinous injection of ink.

Fig. 17. — Base of brain of a case of communicating hydrocephalus. Ink has been injected into the spinal canal before necropsy. The black coloring extends along the cistern* to the optic chiasm. It has covered the cerebellum but none of the cereViral liemispheres, (The black shadow over part of the left temporal lobe (reader's right) is due to a post-mortem hoematoma and not to the ink.) Compare this post-mortem demonstration of the obstruction with a pneumographic demonstration (Fig. 9) during life and with the experimental lesion (Figs. 1, 2, 3, and 4).

Fig. 18 — Sagittal view of the above brain (Fig. 17). The ink is seen deeply staining tlie walls of the third and fourth ventricles and the aqueduct of Sylvius, altliough none of the color reached the surface of the cerebral hemispheres. The aqueduct of Sylvius and the foramen of Magendie are patent and enlarged, thus demonstrating that tlie hydrocephalus is of the communicating type. Compare the intraventricular distribution of ink in the experimental animal (Fig. 2).


Fig. 19. — Cerebellum and brain stem of the alx)ve case (Figs. 17 and 18) . The three wires are intended to show that tlie three foramina (Luschka and Magendie) are open. On the right side the wire had slipped out and was replaced by the photographer, who thought it had been properly reinserted. Tlie foramen is seen under the wire, the border of the foramen being indented by its pressure ; the actual foramen of Luschka can be seen in the circle of arrows; the flocculus emerges from the foramen of Luschka on each side.

Fig. 20. — Ventriculogram of a case of communicating hydrocephalus due to occlusion of the main branches of the cisterns interpeduncularis and chiasmatica. The larger two-finger-like process projecting into the ventricle is a huge cyst, which is a direct outgrowth of the cisternae interpeduneularis and chiasmatica. The elucidation of the findings was possible by a thorough inspection of the base of the brain at operation. Owing to pressure on the aqueduct of Sylvius the circulation of air from the lateral ventricles was restricted ; therefore, the cyst, the fourth ventricle and the cistern* did not immediately fill with air following the intraventricular injection.


X-RAY PICTURES OF THE BONES IN THE DIAGNOSIS OF SYPHILIS IN THE FETUS AND IN YOUNG INFANTS

By P. G. Shipley, J. W. Peabsox, A. A. Weech

AND

C. H. Gkeexe

{From the Department of Pediatrics, The Johns Hopkins University and the X-ray Department of The Johns Hopkins Hospital,

Baltimore, Md.)


For some time past it has been quite generally recognized that but little dependence could be placed on the Wassermann test during the early weeks of life as an aid to the diagnosis of syphilis. A positive Wassermann is still regarded as nearly specific but a negative serum test no longer is allowed to free the newly bom child or young infant from suspicion of luetic infection. Certainly this is true until the end of the second month of life is reached and there is a growing tendency to extend the period of capricious serum reaction to the end of the fourth month. Indeed there is so little expectation of obtaining a jwsitive complement fixation reaction from the blood of newly born children that in the obstetrical service of at least one of our large teaching hospitals ' the routine syphilological examination of blood from the cord of the newly born babies is regarded as not repaying the trouble and expenditure involved in carrying out the technique.

The diagnosis of lues in the newly bom or very young child is not by any means always easy, since clinical symptoms of the disease may be, and in fact are usually, entirely absent from the child until several weeks after birth. Moreover, a mother without a single clinical manifestation or any serological indication of spirochaetal infection may give birth to a luetic infant.

Under such conditions, when any addition to the diagnostic armamentarium against the disease in young children might be welcomed, it seems rather surprising that so little attention has been paid to the routine use of a method which has the


advantage of rapidity and ease of application — the examination of the bones by means of the X-ray.

It has long been a matter of common knowledge that the skeleton is among the tissues most frequently affected by the luetic process during intra-uterine life and as early as 1870 Wegner described three stages of osteochondritis syphilitica. Moreover, the alterations in the affected bones are easy of recognition in the X-ray picture and when present are pathognomonic.

Every .syphilitic infant does not show bone lesions on X-ray examination, but cases are not infrequent among young children in which roentgenography discloses evidences of lues when no clinical or serological data are available for diagnosticating the presence of the infection. Our experience has led us to believe that routine examination of the osseous system in newly bom children will yield valuable diagnostic data and insure recognition of the presence of a hereditary infection in a certain nimiber of children who otherwise might go on unaided for several months before some clinical symptom or the accidental discovery of a positive serum reaction would secure for them the much needed therapy.

We have had the opportunity of examining some 300 white fetuses ranging in age from the sixth month of intra-uterine life to nearly term with the object of securing as many variations as iMSsible of the normal and pathological skeletal X-ray pictures. The fetuses were of white parentage and were listed as normal in the catalofirue of the Carnegie Institute of Embrv


76


JOHNS HOPKINS HOSPITAL BULLETIN


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ology, from which collection they were taken.* Incidentally, the examination of the plates taken of these specimens furnished a striking demonstration of the ten-ible toll claimed by syphilis during intra-uterine life.

Out of the first 100 plates studied, representing the same number of white male fetuses, 15 showed advanced luetic osteochondritis, 10 had signs of less marked syphilitic involvement and 21 showed one or more bones which presented slight variations from the normal jiicture and were noted as suspicious. In other words, the skeletons of 25 per cent had marked signs of lues and 46 out of the first 100 bodies examined had well-marked or suspicious lesions.

The syphilitic lesions seen in the bones of children are roughly of two types, those seen in newly born and young infants and those which characterize syphilis of the osseous system of older children. We shall not attempt to discuss here those of the latter variety and, since those which it is necessary to recognize in infants and newly born children are essentially of the fetal type, a detailed knowledge of the lesions encountered in the fetus is most important in the routine use of the X-ray picture as a diagnostic method.

If one examines an X-ray picture of a normal fetus or newly born child, it will Ije seen at once that while the shadow cast by the diaphysis is sharply outlined, the epiphyseal cartilage is invisible, since its density is approximately equal to that of the surrounding soft parts. The cortex of the shaft, which is usually of unequal width according to the curvature of the bone, is thickest at the plane of entrance of the nutrient canal and from this point it tapers in either direction to hairline thinness at the epiphyseo-diaphyseal junction. In the central canal of the bone the marrow space is very small and one sees the spongiosa made up of sharply cut, fine, regularly ordered trabeculaj arranged in the form of a framework for the homogeneous marrow spaces about the circulatory system of the bone. The nutrient canal, through which the blood vessels enter the bone, is easily made out and can be seen to divide into two branches just beneath the cortex. The bony trabecula3 become finer and finer as the epiphyseo-diaphyseal junction is approached and end abruptly in a more or less curved, or straight, but always clear-cut line which is so sharply drawn as to appear to be ruled. They may terminate in a fine granular line running at right angles to their long axes (the calcified intracellular substance of the epiphyseal cartilage) but usually the individual trabecula may be distinguished throughout its entire length.

Syphilitic bones throw quite a different and characteristic shadow on the photographic plate after exposure to the X-ray. Usually all the bones are not affected to the same extent and some of them may have apparently escaped entirely. Those whicli are most often or most severely affected are in order of


We have here to express our gratitude to Dr. Geo. Streeter, director of the Laboratory of Embryology of tlie Carnegie Institute, for permission to use this material, and to Miss M. S. Smith of the X-raj- Department of The Johns Hopkins Hospital for the time and care spent in making excellent X-ray plates from most difficult material.


frequency the lower end of the femur, the distal and proximal ends of the tibia, the distal ends of the radius and ulna, the extremities of the metacarpals, the proximal ends of the phalanges, and the proximal ends of the ulna and radius. No liones are exempt from the syphilitic changes ; even the bodies and processes of the vertebra;, the ribs and the lx)nes of the skull do not escape.

The shadows resulting from syphilitic lesions in early life are due to vagaries in the calcification of the provisional cartilage and to the abnormal arrangement and distribution of osseous tissue. The syphilitic changes in the bones of the fetus, unless they are very severe and of long standing and the fetus is close to term, do not involve the periosteum to any demonstrable extent but are confined to the epiphyseo-diaphyseal region. At any rate in the fetal type of reaction the periosteal lesion is secondary in importance to the endochondral defect. After birth the periosteal reaction begins, possibly because of the increased demands made on this tissue by the increased muscular activity, and in young infants this may be the most marked skeletal lesion.

The beginning of the process as shown by the X-ray picture is an intensification of the shadow cast by the bone at the epiphyseal line. This line Iwcomes much broader and more homogeneous and seems to form a cap on the ends of the trabeculas of the siX)ngiosa (Fig. 1). This is significant of the lieginning of abnormally heavy calcification of the provisional calcified zone. It must be remembered that while the provisional zone of calcification in the cartilage of the normal emliryonic bone is, relatively speaking, very narrow, in many cases only one or two cells deep, in the syphilitic bone the calcified cartilage may show on section a width of from 0.5 mm. to 1.5 mm.

In other bones in which the osteochondritis is further ad\anced, it can be seen that on the marrow side of the intensified shadow of the provisional zone there is a band-like area where the shadow is less intense than in the rest of the bone (Fig. 3), giving an appearance of diminished density to the region of the epiphyseal line.

Bones may also be seen in which the dense shadow at the epiphyseal end of the bone is broken by the presence of one or more small areas of rarefaction so as to give an appearance of irregular density to the end of the bone (Fig. 3).

At other times the bone appears to end in a double line, so that two lines of heavily calcified tissue are seen, separated each from one another by a zone in which lime salts are less heavily deposited. This zone is a region which histological preparations show to contain a great deal of delicate granulation tissue. This picture becomes more and more intensified as growth goes on. The areas of dense shadow and the fine clearer baud between them grow wider and the surfaces bounding them become more and more irregular and jagged till the end of the bone has an irregular, ragged appearance (Figs. 4, 5, G). During the course of the disease the calcification of the infected areas is not only abnormally heavy but also most irregular, so that the epiphyseal border of the shadow cast by


Maecii, 1921]


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the bone has a iiotiluMj, saw-toothed or serrated a[ii)earauce (Fig. 2).

Practically all the bones are involved by the luetic process and it has been shown by Alexander," who has studied the roentgenography of osteal syphilis with great care, that luetic changes can be demonstrated in the excised ribs, in the scapula, vertebral bodies and processes and in the bones of the skull base and pelvis. About the various centers of ossification in the different liones of the lx)dy the syphilitic picture is beautifully drawn. The nucleus becomes surrounded by a very wide zone of provisional calcification and eventually becomes doubly contoured by the development of a pericentral ring of tissue which casts but little shadow\

The phalanges, metacarpals and metatarsals give characteristic pictures of luetic osteochondritis and are affected by the spirochaste with surprising regularity and to a very marked degree (Figs. 2, 3, 4). The metaeai"pal and metatarsal bones show the lesion at either end, but the phalanges, because of the manner in which they are developed, are affected only at the proximal extremities.

Periostitis when it occurs near term in the severe cases of lues may be present throughout the length of the bone or only at the extremities. It is shown in X-ray plates by a more or less wide, almost homogeneous, shadow or with longitudinal striations separated from the external surface of the cortex by a narrow clear area which bounds the bone (Fig. 7).'

One other feature of these pictures appears worth noting. It may be seen that in maiiy luetic bones the cortex is sejiarated from the spongiosa by a very naiTOw clear zone which gives the cone of spongy bone the appearance of being suspended unattached within the cortical cavity (Fig. 8). In the X-ray picture the trabeculae of the syphilitic bone appear to l)e finer than those of the normal bone.

With these facts in mind it will be seen that osteal syphilis may be easy of recognition even in the fetus and that X-ray studies, if employed as a routine, may be at times a valnalile aid in the early diagnosis of hereditary lues.

The following cases servo to illustrate the \alue of the procedure :

Case I. — JI. D., colored, female.

First seen in the out-patient department of the Harriet l.ane Home on April 19, 1918, at the age of 5 weeks with the complaint tliat she did not use the right arm well. There were no signs of syphilitic infection and nothing in the history to suggest hereditary lues. The Wassermann test was negative, but the X-ray picture (Fig. 9) of the bones of the forearm showed a slight degree of periostitis and a well marked syphilitic osteochondritis of the radius and ulna. Di-agnosis. — Syphilis, hereditary, early (epiphysitis). C.VSE II. — H. R., white female infant, aged 6 weeks. Came to the out-patient service at the Harriet Lane Home September 30, 1920, with a slightly swollen wrist-joint. There was no suggestion of any syphilitic history and examination for signs of the disease was without result. Repeated Wassermann tests were negative, but the X-ray plate of the swollen wrist (Fig. 10) showed a syphilitic osteochondritis with a very intense grade of resorption behind the epiphysis. This child was given antisyphilitic medication and the family kept under observation. It was possible to obtain blood from both the mother and father of the patient and a Wassermann reaction was done in duplicate in two difTerent laboratories on


both parents, once with serum from the father and twice witli the mother's blood. Both laboratories returned a negative report on the paternal serum. The report on the mother's seriim was twice returned by one lalwratory as positive and twice negative by the other. The child is still under treatment with diarsenol and mercury and has shown marked improvement.*

Case III. — K. P., white female child luider observation in the outpatient department of the Harriet Lane Home since June 10, 1920, aged 2 months, with a diagnosis of hypertrophic stenosis of the pylorus. Physical examination was negative except for a somewhat enlarged spleen and a slightly swollen ankle. The child's Wassermann reaction was negative three times, on the 1st and Uth of Novemljer, and on the 2d of Decemlier, 1920. The mother's Wassermann was negative on the Ilth of November. The X-ray picture of the swollen leg (Fig. 11) showed syphilitic osteochondritis of both proximal and distal ends of the tibia and fibula. Since November 2d the child has improved under treatment with mercury and diarsenol.

Two other conditions which are encountered in children may give X-ray pictures which closely resemble, and in some cases are identical with, the pictures described above. Scurvy and rickets, when the latter disease is healing under the influence of cod-liver oil therapy, may be diflficult or impossible to differentiate by roentgenographic means from osteal syphilis of the fetal type. Fortunately, however, in the early weeks of life neither of these conditions need be seriously considered in diagnosticating hereditary lues, .since there is no good evidence to show that fetal rickets ever occurs and it is agreed that scorbutus is rare before the sixth moutli of life has l^een reached.

In passing it is interesting to note that lues of the fetus and newly born child apparently, even in advanced cases, interferes very little, if any at all, with skeletal growth since the fetuses which we have studied were in all respects, as far as careful anthropometry could determine, of normal growth for the age which they had reached.

It is our purpose shortly to publish a series of studies in an attempt to correlate the jiathology of the syphilitic bone with the shadow cast by it on exposure to the X-ray.

BIBLIOGRAPHY

1. Williams, J. W. : The value of the Wassermann reaction in obstetrics based upon the study of 4.i47 consecutive cases. Johns Hopkins Hospital Bull., 1920, XXXI. Sr-,6.

2. Alexander. Bela: Die ostealen Vcrilnderungcn Ix"! kongcnitalen Syphilis, Leipzig, 191.5.


.Since this case was inider observation the father of the patient has been found to have an aortic aneurysm and is at present tuider treatment in the out-]iatient department of The .lohns Hopkins Hospital.


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INTERNAL MIGRATION OF THE OVUM


Bv George W. Counek


{Fi-om the f!talio)i for Ej-perimeiital Evolution of tlie Carnetjie Iiii

J-ahunitorij of Tlie Johnt

111 contemplating the passage of fertilized ova from the Graafian follicle to their resting-place in the uterus, observers have often been struck bj" the fact that au egg discharged from a given ovary may pass through the opposite tube, or when the uterus is bicornate, maj"^ actually find lodgement in the opposite cavity. Long tubular bicornate uteri like those of swine offer ready demonstration of migration of the ovum, for it is a very frequent observation indeed (about once in three cases) that one horn of a pregnant uterus contains more embr3-os, the other less, than the number of corpora lutea


titiifiiiii. Coll! SpriiHi Uurhor. Lonii Island, and the Analomif-nl Hopkins Uniiersitii i

and Winekler (1!)05), in each of wliii-h one ovary and the opposite tube were removed, but nevertheless the patients subsequently became pregnant.

The frequency of migration of the ovum in tiie human subject is not known, but may be crudely estimated by various means. Mayrhofer (1876) considered that migration must occur at least once in 10 ovulations. The present writer (Corner, 1915) found from a study of \'i8 pregnancies in swine that in this sj^ecies one or more ova migrate in at least one-third of all cases. An exact statement cannot be made



Fig. 1. — Ovaries and uterus of pregnant sow in which migiation ha^ oreiiiied Se\en coipora lutea In left ovary, two in right ovary; four fetuses in left cornu fi\e in light cornu One fourth natural size.


in the corresponding ovary. To cite one example of hundreds available, it was found in a certain sow (Fig. 1) that the left ovary contained seven recent corpora lutea, the right ovarv' two; the left uterine cornu four fetuses and the right five. Three of the embryos in the left uterine cornu had originated, therefore, in the right ovary. Like conditions have long been known in other animals with similar \iteri.

Li the human uterus, with its single cavity, migration of the ovum will not be detected except under peculiar conditions, hut numerous clear cases have been described. In many tubal pregnancies the corpus luteum has been found in the ovary opposite to the pregnant tube; for an especially convincing case of this type the reader is referred to one reported by Williams (1917). Migration has also been seen in cases of pregnancy in bicornate uteri, and offers at least a plausible explanation of cases such as those reported liy Kelly (1906)


because the data are obscured by non-development of one or more embryos in four-fifths of the litters.

It is obvious, as first pointed out by Kussmaul (1859), that there are two possible pathways of migration. Either the ova pass from the ovary into the abdominal cavity and thence directly into the opposite tube (external migration, fig. 2.) or they travel by way of the homolateral tube into the uterus and thence to the place of implantation in the contralateral uterine cornu or Fallopian tulie (internal migration. Fig. 3). External migration is not possible in those mammals in which the distal portion of the tube forms a closed pouch or ovarian capsule about the ovary, as in the rat (Fig. 4) and guineapig ; but no such anatomical bar exists in man, rabbit or cat, in which the tubal extremities open freely into the abdominal cavity. In these animals it is conceived that the possibility of external migration is further enhanced by the action of the


March, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


79



Fig. 2. — Diagram illustrating external migration of the huipan ovum. Four-fifths natural size.



Fig. 3. — Diagram illustrating hypothetical internal migration of the human ovum. Four-fifths natural size.


TUBE AND OVARY WITHIN PERITONEAL 5AC



ciliated lining and possibly by peristaltic movements of the Fallopian tubes, which produce currents in the films of abdoininal fluid between the pelvic organs, by which ova may



^^^^^^^...J^


Fig. 5. — Illustrating form of the Fallopian tube of the sow, theoretically permitting migration of the ovum by either route. Two-thirds natural size.


be drawn into the open ostia. Experimental evidence of external migration has been given by Leopold (1880), who excised one tube and the opposite ovary in rabbits, and found the animals still capable of bearing young.


Fig. 4. — Illustrating closed ovarian capsule of Fallopian tulje in the rat, which makes external migration of the ovum impossible. X 7.



Fig 6 — Diagiam constructed fiom the verbal description of Andrews case of supposed internal migration of the human ovum (see text).

With the rarest exceptions, all convincing human cases of migration of the ovum are capable of explanation by the external route. No conclusive evidence, clinical or experimental, has been found to show that internal migration occurs, and thus it has remained merely a hypothetical possibility. Andrews (1913-13), however, has recently reported a case (Fig. 6) which seems to fall into this class, since there was an interstitial pregnancy in tlio right side which could be excised


so


JOHNS HOPKINS HOSPITAL BULLETIN


[Xo. 3G1


withiiut ujieiiing the uterine cavity, witli a normally implanted twin embiyu in tlie uterine cavity, in a woman whose right tube and ovary were entirely absent.

Undoubtedly, however, much of the supposed evidence for migration from clinical cases has been uncritical or incomplete, so that Burckhard (1904) did not hesitate even to deny the occurrence of fliigration by either route, except in a few human • cases in which there is a previous abnormal aiTaugement of the pelvic organs. Under this exception he admits some of the cases of tubal pregnancy in the contralateral tube, as described above. In those human and experimental cases in which previous excision of a tube is part of the mise-enscene, ' he feels that the possibility of subsequently recurring patency of the stump has not been sufficiently considered ; and in the study of animals with bicornate uteri and large litters, he believes errors have arisen in consequence of the failure of some of the corpora lutea to develop or to persist, or, on the other hand, because no allowance was made for the possible persistence of corpora lutea from previous ovulations. Although these objections are not all tenable, they riiust at least be considered in future attempts to demonstrate one or the other kind of migration of the ovum.

With respect to the pig, the present writer has direct information as to the possible causes of error suggested by Burckhard. As before pointed out (Corner 1915), there is no likelihood of confusing corpora lutea of different ovulations, owing to their rapid retrogression; while failure of corpora lutea to develop or to persist during pregnancy has never been observed in a rather large experience. Polyovular follicles undoubtedly occur and may perhaps even attain full development and discharge of their ova, but they are rare, and no experienced student of the ovary could belie\-e them sufficiently numerous to explain away a frequency of migration amounting to one-third or more of all pregnancies. Therefore, as will be confirmed by additional evidence to be given below, in the pregnant sow the number of corpora lutea found in the ovaries probably represents with perfect accuracy the number of eggs which were discharged into the Fallopian tubes at the ovulation wliicli gave rise to the pregnancy.

The Evidexce for Intekxal Migkatiox In the writers previous brief discussion of migration of the ovum in swine, to which reference has already been made, it was assumed that the cases were of the external variety, merely because this hypothesis had been proven more likely with regard to the human cases. Kiipfer (1920) who has studied seven cases of migration in swine, makes the contrary assumption as to the route. In this guess he is correct, for the statement can now be made that after all, in the pig, external migration has not been demonstrated, biit that migration of fertilized ova by the internal route is a frequent plienomcnon of physiological significance.

The evidence wdiich not only demonstrated internal migration, but also suggests some of the factors which regulate the process, has been extracted from data gathered (for another


purpose) during a detailed examination of the ovaries and uteri of 54.5 sows. The work was done during a stay at tlie Station for Experimental Evolution of the Carnegie Institution of Washington, at Cold Spring Harbor, Long Island, and the -writer is most grateful to the Director, Dr. C. B. Davenport, for the opportunities afforded. Further thanks are due to ilessrs. Joseph Stern and Company, meat packers, of Xew

TABLK I

Showikg Xu.mbkrs of Corpora Lutea in Ovaries, and of Ova in

Fallopian Tubes, in 26 Consecutive Cases of

Recent Ovulation in Swine


Serial number


Corpora

lutea in left ovary


Corpora

lutea in

right ovary


Ova in

left tube


Ova in right tube


Total corpora

lutea


Total found


Ova not found


1


3



3



3


3




3


.5


3


5


S


8



3


7


4


7


4


11


11



4


3


6


3


5


9


8


1


5


4


5


4


.5


9


9



6


5


2


5


2


7


7



7


5


4



3


9


8


1


S


6


3


6


3


9


9



9


2


6


2


6


8


8



10


4


3


4


3


7


7



11


7


n


7



12


12



)'2


4


6


4


6


10


10



13


5


3


4


2


8


6


2


14


4


2


4


2


6


6



15


11



11



11


11



1(!


6


2


6


2


8


8



17


5


3


5


3


8


8



18


S


1


7


1


9


8


1


19


5


6


5


6


11


11



20


4


3


4


3


7


7



21


s


2


7


2


10


n


1


22


4



4


5


9


9



23


4


4


4


4


8


8



24


4


3


4


3


7


7



>25


.5


3


4


3


8


7


1


20


.5


3


5


3


i ^


,8



Totals


131


SO


127


S6


220


213


"


York City, for material, and tv 'S\v. Clyde E. Keeler for assistance.

Twenty-six consecutive sows were selected, by the appearance of the ovaries, as having ovulated within the past three day? : the ova were therefore en route through the Fallopian tube-;, and were actually recovered therefrom, by a method previously described (Comer and Amsbaugh, lliK). By using great care in tlie ]irocedure, and washing nut caili tube as often as


March, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


81


five times when necessary, it was found possible to collect from a given sow, with almost mathematical certainty, all the ova expected on the basis of the corpus luteum count. In all 26 sows examined, there was a total of 220 corpora lutea, against which 213 ova were regained from the oviducts, or 96 per cent of those expected (Table I).


Showing Distribution oi- Embr\'os in Uterus, When Equal xttmbers of ova were dischabged from each ovary


Serial number


Corpora

left ovary


Corpora

lutea in right ovary


Embryos in left cor.nu


Embryos in right


Result


27


4


4


4


4



28


6


6


6


6



29


4


4


4


4



30


3


3


3


3



31


4


4


4


4



32


.5


5


5


5



33


5 .


5


5


5



34


4


4


4


4



35


4


4


4


4


No migration.


36


3


3


3


3



37


3


3


3


3



38


5


5


5


5



39


3


3


3


3



40


4


4


4


4



41


4


4


4


4



42


3


3


3


3



43


3


3


3


3



44


3


3


4


2



45


3


3


4


2


Migration of one


41)


4


4


5


3


ovum in each case.


47


7


7


8


6



The reader will have noticed that not only practically all the discharged ova are readily discoverable, but also that the eggs in a single tube are always accounted for by the discharged follicles (corpora lutea) in the corresponding ovary. In these 26 consecutive cases, then, there was no case of external migration.

l^ext a similar table was made by counting the corpora lutea and the embryos of nearly 500 pregnant sows which were passing through the same abattoir. In these animals, in spite of the fact already mentioned, that a large early embryonic mortality obscures and lowers the apparent proportion of migration, still (as was found some years ago) about one-third of the sows show migration of one or more ova. If distributed, for the sake of comparison with the first series, into groups of 26, no such group contains less than five cases in which migration occui-s.


These two facts, that migration in general is verj- common, but external migration rare or non-existent, together prove the occurrence of internal migration of the fertilized o^nim of the sow.

DETERiiixixc Factoks axd Pkobable Utility of Ixtkkn-ai.

lllGKATIOX OF the OvCJI

We may now venture the hypothesis that the phenomenon , of internal migration has a practical utility in the pig; it is important that the individual embryos of the large litters shall each find a fair share of space in the uterine cavity. As

TABLE III

Showing Distribution of Eiibryos in Uterus, When the Total

Number of Ova Discharged was Uneven, One Ovary

ExcEEniNG the Other by One 0\t:ji


Serial number


Corpora


Corpora


Embryos


Embrvos



lutea in left ovary


lutea in righi ovary


in left


in right


liesult


48


5


4


5


4



49


4


3


4


3



50


3


4


3


4



ol


4


3


4


3



52


4


5


4


5



53


5


6


5


6



54


5


4


5


4


Xo migration.


55


4


5


4


5



56


3


4


3


4



57


4


3


4


3



5S


3


4


3


4



59


.4


3


4


3



60


3


2


3


2



61


3


4


3


4



62


6


3


5


6



63


5


6


6


5



64


4


5


5


4



65


3


4


4


3


iligration of one


67


3


4


4


3



6S


5


4


4




69


3


4


4


3



70


3


4


4


3



71


2


3


4


1


Migration beyond balance.


shown by the exanii)les in Table I, the right and left ovaries often discharge very unequal numbers of ova, which might well lead, were it not for migration, to the overcrowding of embryos in one cornu.

This suggestion was tested by analysis of the records of the l>reaiiant uteri, frmn tlie whole series only those cases. ll:> in


82


JOHNS HOPKINS HOSPITAL BULLETIN


[Xo. 361


number, being chosen, in wliich all the corpora were represented by normally implanted embryos, thus avoiding the obscuring effect of early embryonic degeneration. If migration is by rule and not by chance, then in these cases we should find : (1) that when the ovaries discharge equal numbers of ova. the number of embryos in each chamber remains equal; (2) liowever unequal the output of the two ovaries, the number of embryos in the uterine comua should tend to approach equality. It will also be clear that cases which deviate from these expectations should be commonly those in which the litters are small, and further that they will be damaging to the hypothesis in proportion to the number of ova which in any one case migrate in the adverse direction.

I. In 21 cases the ovaries discharged equal numbers of eggs. By hypothesis there should have been no migration. Eesult: no migration in 17 cases, but in four cases there was migration of one ovum in each (Table II).

II. In 24 cases the total number of eggs discharged was uneven, one ovary exceeding the other by one egg. In this circumstance, by our hypothesis it is a toss-up whether or not one ovum shall migrate, as the balance cannot be perfectly restored. Eesult: no migration in 14 cases; migration of one ovum in 9 cases; migration beyond balance in one case : migration toward excess side, no case (Table III).

III. In 68 cases, the output of one ovary exceeded that of the other by two or more eggs. By hypothesis there should have been migration toward the lesser side in all cases. Eesult : in 21 cases perfect balance was obtained by migration; in 20 more, the total number of eggs being uneven, balance was restored to ±i. In 3 cases, in all of which the discrepancy between the ovaries was great, perfect balance was not quite attained in the uterus (Cases 113-115). In 9 cases migration did not stop at an even balance ; in 7 of these one ovum too many went over, in 2 cases two ova migrated beyond the balance, in no case, however, forcing more than seven embrj-os into tlie uterine chamber. In 14 cases there was no migration at all, but in all these the original imbalance was small in degree, so that the need of migration was slight. In one case there was migration of one ovum toward the excess side (Case 139, Table IV).

To sum up, the hypothetical expectation was fulfilled in 84 of 113 cases, with 29 deviations, all of which were trivial in degree; hence the supposition that the process of internal migration is tmder physiological regulation for useful ends seems to be justified.

The anatomical mechanism of internal migration is now open to conjecture and experiment, but there can be but little doubt that the embryos are shifted by the peristaltic action of the uterine musculature. Some such action must be postulated in any case to account for the regular spacing of the implanted embryos within the uterus ; and the only novelty in the present contribution is the notion that both comua act as one continuous tube, which must be readily capable of peristalsis in either direction. It may well be also that the peculiar form of the ungulate blastodermic vesicle, which reaches the length of 30 or more centimeters "before implantation, may render it espe


TABLE IV

Showing Distributio:^ of EireRTOs in Uterus, Whex the Octptjt

OF the Ovaries was Unequal. One of the Ovaries

Exceeding the Other by Two or More Ova


Serial


Corpora


Corpora


Embryos


Embryos



number


lutea in


lutea in


in left


in right


Result


left ovary


right ovary


cornu


cornu



72


4


6


5


5



73


5


7


6


6



74


6


4


5


.5



75


4


6


5


.">



76


8



4


4



77

5


3


4


4



7S


6


4


5


5



79


2


4


3


3



80


6


4


5


.3



81

82 S3


8 2


1

2

6

3 5 4


3

4


Migration to exact balance.


84


1


3


2


2



85


4


2


3


3



86


1


5


3


3



87


8



4


4



88


5


1


3


3



89


4


2


3


3



90


6


2


4


4



91


3


1


2


2



92


3


1


3


3



93


5


2


4


3



94


4


1

2


3



95


3



5


4



96


7


2


4


5



97



3


4


5



98


4


7


5


6



99


6


1


4


3



100


5



3


2



101


2


5


3


4


Total number of


102


1


8 *


5


4


ova uneven;


103


3


6


4


5


balance restored


104


2


7


5


4


to± 4.


105


1


4


3


. 2



106


4


1


3


2



107


4


1


3


2



108


4


1


2


3



109


2


5


3


4



110


8


5


7


6



111


8


1


4


5



112


5


2


3


4



113


11



8


3


Balance not fuUv


114


7



5


2


restored.


115


1


9


4


6



116


2


8


6


4



117


6



2


4



118


4


7


7


4



119


9


3


5


7


Migration l>eyonil


120 121


6

7


2

4


3 4


5

7


balance.


122


2


6


5


3



123


4



1


3



124


5


3


3


5



125


5


3


5


3



126


6


4


6


. 4



127


5


3


5


3



128


5


3


5


3



129


2


4


2


4



130


6


4


U


4



131 132


4 4


6 6


4 4


6 6


Xo migration.


133


2


5


2


1 ^



134


4


2


4


2



135


3


1


3


1



136


3


5


3


5



137


1


4


1


4



138


5


3


5


3


Migration toward


139


6


7


5


' 8


excess side.


March, 19-21]


JOHNS HOPKINS HOSPITAL BULLETIN


83


daily suitable for transportation by the uterus. It will be of much interest to learn whether migration of the pig's ovum can be demonstrated before the tenth day, while it is still minute and spherical.

If the forgoing discussion has any bearing upon the clinical side of the question, it is that internal migration of the human ovum is still to be regarded as occasionally possible, more especially perhaps in cases of multiple gestation. Twin embryos were present in the case of Andrews, previously mentioned, which is up to the present the most satisfactory case among those interpreted as examples of this form of migration in the human.

RKFEREXCES

Andrews, H. R. : 1912-13. A case of simultaneous intra-uterine and extra-uterine pregnancy, witli probalile " internal wandering " of the ovum. Proe. Roy, Soc. Med. London. Oljstet. and Gyn. Sect., 52-53.

Burckhard, G. : 190-1. 1st eine innere und iiussere Ueberwanderung des Eies moglieh? Ztsch. f. Geb. u. Gyn., LIV, 470-484.


Corner, G. W.: 1915. The corpus luteum of pregnancy, as it is in swine. Publication No. 222 (Contributions to Embryology, No. 5) of the Carnegie Institution of Washington.

Corner, G. W., and Amsba ugh. A. E. : 1917. ffistrus and ovulation in swine. Anat. Rec, XII, 287.

Kelly. H. A.: 1906. Operative Gynecohigy. (2d Edition) vol. 2, p. 185.

KUpfer, M.: 1920. Beitrage zur Morphologic der Weiblichen Geschlechtsorgane bei den Siiugetieren. Viertcljahrschrift der Xaturforsch. Gesellsch., in Zurich, LXV, 377-433.

Kussmaul, A.: 1859. Von dem Mangel, der Verkummerung und Verdoppelung der Gebilrmutter und der Uel^erwanderung des Eies. Wiirzburg (quoted by Williams, 1917).

Leopold, G.: 1880. Die LTeljerwanderuiig der Eier. Arcli. f. Gvn., XVI, 22-44.

Mayrhofer. C: 1876. Die gelben Kiirper und die Ueberwanderung des Eies. Wiener Med, Wclinschr.

Williams, J. Whitridge: 1917. Obstetrics, Chapter 3.

Winckler: 1905. Ein Fall von Ueberwanderung des Menschlicheu Eies. Verb, deutsch. pathol. Gesellsch., Jena, VIII, 177.


SERIOUS REACTIONS TO REPEATED TRANSFUSIONS IN PERNICIOUS ANEMIA

By Harold il. Bowcock, Atlanta, Ga., Foniwrhj Assistant liesident riiijsician. The Johns Hopkins Hospital


Since the introduction of blood transfusion as a therapeutic procedure in the treatment of pernicious anemia, numerous reports have appeared upon the various phases of reactions after transfusion. Three cases arc here reported, in which after a large number of transfusions, there occurred extremely severe reactions following the transfusion of apparently compatible blood. Cases I and II of this series have been briefly referred to by Sydenstricker, Mason and Bivers,' who concluded that transfusion is a self-limited process in pernicious anemia. In two of the cases the severity of the reaction seems to have been largely responsible for the death of the patient. It was considered inadvisable and dangerous to continue this form of therapy in the other patient, who died a ^^hort time after discharge from the hospital.

Blood matching of recipient vs. donor was carried out in every instance, and the donor chosen only in complete absence of microscopic agglutination or hemolysis of the donor's cells by the recipient's serum, or the recipient's cells by the donor's serum. The matching was carried out according to the method described by Sydenstricker and others.' A small amount of Vilood is drawn into a Wright pipette or test-tube and centrifuged to obtain the serum. A cell suspension is made by mixing two drops of blood in 5 c. c. of normal salt solution, which may contain 0.125 per cent sodium citrate. Coverslips ar€ passed through 9.5 per cent alcohol and polished. One drop of serum and one drop of cell suspension are placed on the coverslip by means of capillary tubes, and mixed with a glass rod. The preparation is then inverted on a hollow ground slide, sealed with oil. and examined. In several instances earlv


in the series of transfusions the incubation period was only 30 minutes. It was noted in Transfusion V of Case I that agglutination did not occur at the end of 30 minutes, but did occur at the end of 45 minutes. Consequently, later nmtchings were incubated for one hour or longer. In every instance in which the donor had given blood for an earlier transfusion he was rematched against the blood of the recipient before being used again, for it has been shown by McClure and Dmin = that a donor may be found compatible for one transfusion, Init may be incompatible for a subseqitent transfusion and this can be demonstrated by blood matching.

The early transfusions of the series were carried out by the Lmdemann syringe-cannula method." In the later transl'usions the citrate method described by Lewisolm * was used.

This series of eases is reported chiefly to show the inadequacy of the present method of determining the compatibility of blood for transfusion, particularly in those cases in which the recipient has been the sul)ject of a largo number of earlier transfusions.

CASE I First Admission J. B. Female, ael. 43, white, married, occupation — housewife. Medical X'o. 34717. Di-a gnosis: Pernicious anemia. Transfusion of blood. Reaction following blood transfusion. Admitted: September 10, 1915.

The com plaint was weakness, sliortness of breath and increasing pallor.

Tlic fniiiilfi liistori/ was negative.


84


JOHNS HOPKINS HOSPITAL BULLETIN


[Xo. 3G1


Past History. — The patient liad scarlet fever at 6. She had had two miscarriages. During tlie past two years her periods had been more profuse than normal. There had been diarrhea at times.

Present Illness. — For over a year the patient liad been troubled wiLli burning on urination, a scalded and burning sensation in her mouth, and a chronic cough. For the past ten months she had suffered from lightheadedness, and for the past two months roaring in her ears. She had noticed a yellow coloration of the skin, numbness and tingling in her fingers and toes, palpitation and dyspnoea on exertion, oedema of her feet recently, and dimness of vision at times.

The physical examination showed a general pallor with sallowness of the complexion and an icteric tint to the sclerotics and skin, striking pallor of the mucous membranes, slight diffuse enlargement of the thyroid, bleeding from the gums, and retinal hemorrhages. The relative cardiac dulness measured 14 cm. by 3.5 cm., and there was a blowing systolic murmur at the apex. The liver extended one finger's breadth below the costal margin on inspiration, and the spleen was palpable at the costal margin. There was slight pitting oedema of the ankles. The blood pressure was 140/95. The patient showed an almost constant elevation of temperature from 100° to 102° F.

Laboratory.— Kb. (Sahli) =27%. R. B. C. = 1,136,000. W. B. C. = 3,560. The stained smear showed a typical picture as demonstrated in the charts. Gastric analysis showed a hydrochloric acid deficit of 8%, and a combined acid of 2%. The Wa. R. was negative. The urine showed a trace of albumin and a few W. B. C.

TRANSFUSIONS

I. Eight hundred cubic centimeters of matched whole blood given during 30 minutes by the Lindemann method. Upon returning to the ward the patient experienced a generalized itching sensation over her body; the skin was somewhat flushed and an urticarial eruption developed. She vomited once. There was slight temperature elevation. Donor, H. E. B., husband.

II. Nine hundred cubic centimeters of matched whole blood given during 30 minutes. Lindemann method. No reaction. Donor, J. A. D.

III. Nine hundred cubic centimeters of matched whole blood. Lindemann method. Upon returning to the ward the patient complained of itching all over and vomited once. No other reaction. Donor, H. W. D.

IV. Nine hundred cubic centimeters of matched whole blood. Lindemann method. No reaction. Donor, M. E. B.

v. The donor's and recipient's blood had been incubated and read at the end of 30 minutes for matching; there was no agglutination or hemolysis. Twenty cubic centimeters of blood were withdrawn from the donor and injected into the vein of the recipient; the latter had been feeling perfectly well. Almost instantly the patient's face became flushed and she complained of feeling badly and aching all over, and especially of pain in her arras and back. Her respirations became more rapid and there was slight cyanosis; she complained of a choking sensation and coughed several times. No more blood was injected. The symptoms became slowly more marked and the patient attempted to vomit several times. Transfusion was abandoned. Upon returning to the ward the patient had a severe chill lasting 40 minutes and a transient temperature elevation to 102° F. The pulse was weak and variable. Urine voided five hours later gave a positive test for Hb. The blood of the recipient and of the donor were rematched; at the end of 30 minutes the preparations were negative, but at the end of 45 minutes, in thick preparations, there was marked agglutination of the recipient's red blood cells by the serum of the donor. Thin preparations were negative at the end of one hour. Four hours following this reaction the patient felt perfectly well. Donor C. W. D.

VI. Nine hundred cubic centimeters of matched whole blood. Lindemann method. No reaction. Donor, husband.

X-30-15. The patient was discliarged. Hb = 62%. R. B. C. = 4,000,000.


Second Admission

Medical No. .35134. Diagnosis : Pernicious anemia. Transfusion of blood. Admitted: December 6, 1915. The comp/aiiif was weakness.

During the previous three weeks the patient had been troubled with palpitation and pounding in her ears, dyspnoea on exertion and edema of the ankles at night. She entered the hospital for an examination of her blood.

The physical examination was as upon the previous admission. Iji addition, there were fresh retinal hemorrhages. Her temperature langed from 99.8° to 100.6° F. up to the time of the first transfusion, after which it remained normal. Blood: Hb. (Sahli) =29%. R. B. C. = 1,148.000. W. B. C. = 4.000. Resistance of R. B. C. to hypotonic salt solution (fragility test) : Hemolysis began at 0.40% and was complete at 0.25%. The urine showed a very faint trace of alli\imin. and a ])ositive test for urobilin.

TR.VNSI-'USIONS

VII. Seven hundred and eighty-eight cubic centimeters of matched whole blood. Lindemann method. The patient became restless, but suffered no reaction. Donor. .T. A. D., brother.

\'ni. Nine hundred and two cubic centimeters of matched whol? blood. Lindemann method. The patient complained that her eyelids felt swollen, and of slight itching in the palms of her hands. No other reaction. Donor, C. W. D.

IX. Eight hundred cubic centimeters of matched wliole blood. Lindemann method. No reaction. Donor, husband.

XII-21-15. The patient was transferred to the Surgical Department f(U- splenectomy. Hb. = 60%. R. B. C. = 3,432.000.


SiROiCAL Admission


Admitted


Surgical No. 3S909. Diagnosis: Pernicious am December 21, 1915,

Xn-21-15. Splenectomy was performed. There was a slight oozing of blood from the operative wound which ceased with a transfusion of 280 cubic centimeters of blood.

TRANSFUSIONS

X. Two hundred and eighty-six cubic centimeters of matched whole blood. Lindemann method. No reaction. Donors. A. D.. brother, and B., husband.

XL Five hundred and twenty culjic centimeters of matched whole blood. Lindemann method. No immediate reaction. L'pon returning to the ward the patient complained of itching of her back whicli showed an urticarial eruption. Her pulse went to 140 per minute and her respirations to 40. There was a chill, lasting about 30 minutes, and the patient became quite cyanotic. There was a transient elevation of temperature to 101.5°. The reaction lasted one hour. Donor. S. I. L.

XII. Five hundred and fifty cubic centimeters of matched whole blood. Lindemann method. No reaction. Donor, not stated.

XIII. Six hundred and sixty cubic centimeters of matched whole blood. Lindemann method. No reaction. Donor, husband. '

XIV. Two hundred and seventy cubic centimeters of matched whole blood. Lindemann method. No reaction. Donor, \V.

11-15-16. There was an uneventful recovery from splenectomy. The patient was discharged. Hb. = 82%.

Third .Admis.sion

Medical No. 36344. Diagnosis: Pernicious anemia. Transfusion of blood. Admitted: August 2, 1916.

The patient had been in fair condition while at home; she hail rested a great deal and spent half of each day in bed. She had recently been growing gradually weaker, and there had been edema of the ankles when she was up out of bed.


March, 1931]


JOHNS HOPKINS HOSPITAL BULLETIN


85


The physical examination was the same as upon previous admissions. In addition, there was slight edema of the ankles, and a splenectomy scar in the left abdomen. There was a constant elevation of temperature ranging from 100° to lOi". Hb. = 24%. R. B. C. = 1,238.000. \V. B. C. — 9,250. The urine showed a faint trace of albumin and a positive guaiac test for hemoglobin.

TR.\X.S1USI0.\S

X\'. Tliree hundred and fifty cubic centimeters of matched whole blood. Citrate method. The blood was given slowly during one hour. Twenty minutes after the procedure, the patient had a severe shaking chill, the temperature rising rapidly to 106° F., and falling graduallv. There was no hemoglobinuria on repeated examinations. This transfusion was held very badh' and the hemoglobin and red blood cell count continued to drop. Donor, B., husband.

XVI. Five hundred and fifty culiic centimeters of matched whole blood. Citrate method. During this operation a great deal of trouble was experienced from the blood clotting in the needle; the clotting seemed to take place immediately upon contact between the donor's and the recipient's blood. This difficulty was overcome by adding twenty-five cubic centimeters of sodium citrate. There was an immediate severe i-eaction with a shaking chill lasting about twenty minutes, an elevation of temperature to 106.6° F. and nausea. The temperature fell gradually to its former level. There was a marked hemoglobinuria \yhich persisted until the time of death. There had lieen no untoward symptoms after the injection of the first twenty cubic centimeters of blood. Donor, D., brother.

VIlI-14-16;. The patient had grown progressively weaker, and showed no improvement in the blood picture. Inasmuch as better results had been obtained on previous admissions with tlie Lindemann method of transfusion, it was decided to make use of this procedure.


XVII. Seven hundred cubic centimeters of matched whole blood. Lindemann method. Twenty cubic centimeters of blood were given and after a wait of ten minutes there had been no reaction. The remainder of the blood was given in alwut forty minutes. The patient had no reaction while on the table, but on the way to the ward she developed a severe shaking chill, lasting about thirty minutes, with an elevation of temperature to 104° F. This was accompanied by marked cyanosis, without any demonstrable signs of cardiac dilatation, dyspncea, pain in the back, and marked general discomfort. Subjectively, this was the severest reaction which the patient had had. There was marked hemoglobinuria ; the urine was almost black. Seven hours later the patient was a little more com fortable but still in a critical condition with a temperature of 103.6° F. and a pulse of 160, weak in quality. Donor, T. A. L.

VIII-15-16|. The patient had been irrational all day with a temperature of 102.4° F. and a pulse of 130, of poor quality. Strophanthin. Murphy drip per rectum, and suljcutaneous infusion of normal salt solution produced no improvement ; she had to be catheterized, and 300 cubic centimeters of black urine were obtained, showing a strongly positive guaiac reaction, but no casts or red blood cells.

VIII-17-16. There was still a marked hemoglobinuria in catheterized specimens of urine. The patient died at 6.4.') a. m.

M.\CROSCOPIC ilATCHI.XGS WITH V.\RIOUS DiLUTIO.XS OF DO.XOR'S .\XD

Recipient's R. B. C. and Sera


Recipient

DOH ~


J 1/4 1/4 1/4 1/4 1/4 1/4 1/4 I No agglutinati(

B., U. B.C.— 50% 1/4 1/8 1/16 1/32 1/64 1/128 1/256 ( or hcmol.vsis.


Recipient's serum 1/4 1/4 1/4 1/4 1/4 1/4 1/4 I No agglutination

Donor D., R. B.C.-50% 1/4 1/8 1/16 1/32 1/64 1/128 1/256 i or heinoI.vsis.

Recipient's serum 1/4 1/S 1/16 i/32 1/64 1/128 ) No agglutination

Donor B.. R. B.C.— 107o 1/4 1/4 1/4 1/4 1/4 1/4 \ or hemolysis.

Recipient's serum 1/4 1/S I/I6 1/32 1/64 1/12S ( No agglutination

Donor D., R. B.C. -10% 1/4 1/4 1'4 1/4 1 '4 1/4 \ or hemolysis.




CASE


I Date


Hb.


R. B. C.


d si


S



a a

a.'



S




.1 <


a,


i

.a 3 o

k

is


•a . JO


1


"Si


3 i"o


Transfusions


I,X-I0-I5


27%


1,136,000


3,560


66.0


.5


.5


27.5


3.0


1,0


1.5


4

-1



n


+


+






I.\-24-15


20


680,000 9-25-15 800 c.c.


I -\ -20-15


35


1,664,000


2,160






9-30-15 OUOc.c.


X- 9-15


55


2,240,000


3,280


52.5




42.0


3.5



1.5






1.0






10- 9-.5 900 c. c.


X-15-15


50


3.360,000



....





10-16-15 900 c. c.


X-18-15


55


4,170,000 10-23-15 20 c. c.


X-24-15


52


2,672,000 10-30-15 900 c, c.


X-31-15


6!


4,000,000



70.0


1.6


.4


20.0


3.6


1.6


2.8

XII- 6-15 XII-14-I5


29 42


1,148,000 2,450,000


4,000 3,100


56.5


.5



41.0


1.5


.6



+


+


-1

-t



+





Second admission. 12-10-15 788 c. c. 12-14-15 602 c. c.


XI 1-17-15


52


2,968,000


3,280






12-18-15 800 c. c.


XII-19-15

XII-22-15


60

48


3,432,000 3,000,000


7,000





....


....




"




12-21-15 286 c. c. Splenectomy. 12-30-15 520 c. e.


I- 7-16


60


3,024,000


4.760


33.0





54.5


7.0


3.0


2.5





-f


7






1-22-16 550 c. c.


11-11-16 II-I5-16


74 82


3,208,000


6,080


53,5


2


.5


23.5


13.5


4.0 ••


1.0


..





2-12-16 660 c.c. 2-13-16 270 c.c.



VIIl -2-16


21


1,238,000


9,250






" Third admission. 8- 3-16 350 c. c.


VIII- 4-16


311


1,560,000



43.5


1.0


.5


52.5


.5


.5


1.5


+ + +


+ + +


+


+


57 VIII- 7-16 VIII-12-16


28 26


1,112 000 1,544,000






8- i>-16 550 c. c






VIIl-Io-16 VIII-16-16


25


1,048,000


10,400 19,400


60.0



"' S-15-16 700 c. c.






' 86


JOHNS HOPKINS HOSPITAL BULLETIN


[Xo. 361


Analysis. — This patient (Case I) liad three admissions to the hospital during a period of 11 months, and received a little more than 10 J liters of blood in 17 transfusions. Eight times during this series she experienced reactions of varying degrees of severity, showing a marked hemoglobinuria on three occasions. Transfusion V gave one of the most severe reactions accompanied by hemoglobinuria, although only 20 c. c. of blood were injected. The same donor seems to have been used for the eighth transfusion, which was followed by no reaction except pruritus and discomfort about the eyelids. The patient's husband acted as donor six times, giving a total of 3,620 c. c. of blood, with one mild reaction, after Transfusion I, shown by urticaria and pruritus, and with one severe reaction, after Transfusion XV, shown by a severe shaking chill and an elevation of temperature to 106° F., but no hemoglobinuria; on four occasions his blood produced no reaction of any sort. Splenectomy gave no jx-rmanent benefit. After the reactions to Transfusions XV and XVI macroscopic niatchings of the recipient's serum against the donor's cells were carried out with varjing dilutions of serum and cell suspension ; they were all negative for agglutination or hemolysis.

CASE II First Admission

H. A. P. Male. Act. G2. White, widowed; occupation — oiler of maehinerj'. Medical Xo. 3533."). Diagnosis: Peniicioiis aneniia. Admitted: January 3, 1916.

The complaint was weakness and lack of Ijlood.

Family History. — One brother had died of cancer of the rectum; one sister had died of tuberculosis. Otherwise, negative.

Past Histoiy. — The patient's general health had been good. He had had recurrent attacks of malaria from 10 to 50 years of age; had always worked hard. 11 to 13 hours daily, exposed to high temperatures. Otherwise negative.

Present Illness, — The symptoms were of one year's duration. He had first noticed frequency of urination ; later, weakness in his knees, and then the entire body, which had become progressively worse. The weakness was accompanied by shortness of breath. During the three weeks before admission there had been precordial pain on exertion, and he had become too weak to work. He had suffered from anorexia and constipation and had vomited on one occasion. There was early loss of se.xual power. He had lost 37 pounds in weight since the onset of his illness.

The physical examination revealed dyspncea on slight exertion, a lemon tint of the skin, a flabby musculature, and evidence of loss of weight, but with a still thick layer of subcutaneous fat. The right pupil was larger than the left. There was marked oral sepsis, and the tongue showed papillary atrophy. A faint systolic murmur was heard at the apex of the heart. The blood pressure was 118/60. There was slight edema of the ankles. The fundi showed numerous retinal hemorrhages. There was a constant elevation of temperature ranging from 99° to 101° F.

Laboratory. — Blood: Hemoglobin (Sahli) = 26%. E,. B. C. = 936,000. W. B. C. = 5.440. Gastric analysis showed no free acid. The urine showed albumin and granular casts. The Wa. R. was negative.

TRANSFUSIONS

X. Two hundred cubic centimeters of whole blood. Lindemann method. The patient had a severe chill with signs of collapse and an elevation of temperature to 102.8° F. There was no hemoglohinuria. Donor, E. M. P.


II. Three hundred cubic centimeters of matched whole blood. Lindemann method. Xo reaction. Donor, A. P.

III. Six hundred and eighty-two cubic centimeters of matched whole blood. Lindemann method. Xo reaction except an elevation of temperature to 101° F. Donor, L. P.

yV. Six hundred and forty cubic centimeters of matched whole blood. Lindemann method. Xo reaction. Donor, C. X. P.

V. Six hundred and thirty-eight cubic centimeters of matched whole blood. Lindemann method. The patient felt chilly after the transfusion, but there was no rise in temperature. Two urticarial wheals developed, and the patient vomited once. Xo other reaction. Donor, H.

VI. Six hiuidred and sixty cubic centimeters of matched whole blood. Lindemann method. The patient felt chilly and his temperature rose to 101.6° F. Xo other reaction. Donor, W. B. P.

11-816. Kb. = 657c. R. B. C. = 4.680.000. W. B. C. = 1,40(1. 11-12-16. Transferred to the Surgical Clinic for splenectomy. Surgical Xo. 39006. 11-12-16. Splenectomy was i)erforme(l.

VII. Four hundred and forty cubic centimeters of matched whole blood. Lindemann method. Xo reaction. Donor, Y.

VIII. Three hundred and fifty cubic centimeters of matched whole blood. Lindemann method. Xo reaction,. Donor, E. P.

11-28-16. Hb. = 807o. R- B. C. = 3,170,000. W. B. C. = 7,200.

11-29-16. The patient was transferred to the Medical Service. There was an uneventftU recovery from the operation.

Medical Xo. 3.5677. IX. Five hundred cubic centimeters of matched whole blood. Lindemann method. Several hours later the patient complained of a slight chill and his temperature rose to 102° F. Many large urticarial wheals appeared over the entire body, but there were no other symptoms and no hemoglobinuria. Donor, W. E. K.

X. Four hundred and fifty cubic centimeters of matched whole blood. Lindemann method. X'o reaction. Donor, P.

XI. Four hundred and fifty cubic centimeters of matched whole blood. Lindemann method. Xo reaction. Donor, brother, who had given blood once previously.

IV19-16. The patient was discharged. Hb. = 817c. R. B. C.= 3,170.000. \V. B. C. = 2.S00.

Skcond Admission

Medical Xo. 36290. Di-at/nosis: Pernicious anemia; combined sclerosis. Admitted, 6-22-1916.

After leaving the hospital the patient gained 27 pounds in weight. There had been shortness of breath on exertion, palpitation, and roaring in the ears, difficulty in holding his urine if the bladder was full, frequency, and nycturia, 3 to 4 times a night. He had tiecome very ataxic and had to use a cane in walking, and there was marked parasthesia of the feet and legs, extending as high as the umbilicus at times, and slight parasthesia of the hands and forearms.

The physical examination was the same as upon previous admission. In addition, there was weakness of the leg muscles, marked ataxia, a positive Romberg, loss of muscle sense in the toes, and the knee-kicks and ankle-jerks could not be obtained.

HI). = 26%. R. B. C. = 1.136.000. W. B. C. = 7,240.

TRANSFUSIONS

XII. Five hundred cubic centimeters of matched whole blood. Citrate method. Xo reaction. Donor, L. C. P.

XIII. Five hundred cubic centimeters of matched whole blood. Citrate method. Xo reaction. Donor, C. P.

XIV. Three hundred and fifty cubic centimeters of matched whole blood. Citrate method. There was an immediate reaction with a severe shaking chill lasting 15 minutes, and a transient rise of temperature to 104° F. Xausea and vomiting occurred, and a wheezing respiration. There was no hemoglobinuria. Donor. J. P. Five hours later the patient felt fine.

XV. Four hundred cubic centin)etcrs of matched whole blood. Citrate method. Xo reaction. Donor. P. This donor had been used twice previously.


March, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


87


XVI. Five hundred and fifty cubic centimeters of matched whole blood. Citrate method. There was a slight chill and an elevation of temperature to 101° F., but no other symptoms. Donor, H.

XVII. Five hundred and fifty cubic centimeters of matched whole blood. Citrate method. No reaction. Donor, P.

VIII-9-16. The patient was discharged.

Hb. = 60%. R. B. C. = 3.500.000. \V. B. C. = .3,460.

Third Admission

Medical No. 36839. Diagnosis: Pernicious anemia; combined sclerosis. Admitted: November 11, 1916.

Complaint the same as upon previous admission. Tliere were no new complaints, but the patient felt somewhat weaker.

The physical examination was the same as upon the previous admission and in addition there was slight ataxia of the hands.

Hb. = 24%. R. B. C. = 1.296,000. W. B. C. = 9,600.

TRANSFUSIONS

XVIII. One hundred and fifty cubic centimeters of matched whole blood. Citrate method. There was no reaction except a slight rise in temperature. Donor, son.

XIX. One hundred and twenty cubic centimeters of matched whole blood. Citrate method. There was a very severe reaction with profuse sweating, nausea, and vomiting, and an elevation of temperature to 101.8° F. The patient became very dull and irritable, and his pulse became rapid and of poor quality. His condition was critical for several hours. There was no hemoglobinuria. Donor, son.

XX. One hundred and fifty cubic centimeters of matched whole blood. Citrate method. There was a sharp reaction 45 minutes later


with a chill, nausea, and vomiting, and an elevation of temperature to 101.8° F. There was no hemoglobinuria. Donor, brother.

XII-6-16. Further transfusion was abandoned as being too dangerous. The patient was discharged.

Hb. = 18%. R. B. C. = 1,141,000.

XII-18-16. The patient died at home.

Analys-is. — This patient (Case II) had three admissions to the hospital in a period of two years, and received a total of a little more than eight and one-half liters of blood in 20 transfusions. He suffered nine reactions of varying degrees of severity. On no occasion was hemoglobinuria demonstrable. During the third admission the patient's son acted as the donor for small transfusions on two occasions ; from the first transfusion there was practically no reaction, while after the second reaction the recipient's condition was critical. Donor, W. B. P., was used three times ; the tise of his blood was followed once by chilly sensations and a slight elevation of temperature, and twice it produced absolutely no reaction. Splenectomy produced no pennanent improvement in the patient's condition.

CASE III First Adxussion

D. W. Female, aet. 45, white, single, occupation — none. Medical No. 38864. Admitted: July 21, 1917. Dtajrnosts; Pernicious anemia, oral sepsis, rectal polyp.

The complaint was anemia.

The family history was negative.


CASE II


I

3-16


I

20-16


I

22-16


I

25-16


I

30-16


II

7-16


11

8-16


II

U-16


II

21-16


II

28-16


III

7-16


IV

2-16


IV


19-16


VI


22-16


VI


-29-16


VII


- 5-16


VII


- 7-16


VII


-16-16


VIII


- 3-16


VIII


- 9-16


XI


-12-16


XI


-24-16


XII


- 4-16


1,448,000 2,352,000 2,416,000 3,040,000 4,680,000 2,376,000 2,726,000 3,170,000 3,824,000 3,000,000 3,128,000 1,136,000 1,450,000 2,152,000 2,480,000 3,240,000 2,636,000 3,500,000 1,296,000 1,420,000 1,040,000


1,400 4,800 1,300 7,200 6,200 3,160 2,840 7,240 1,760 3,520


4,120 3,444

5,nso


72.8 2.4 54.4


26.6


4.6


12.4


2.8


48.8


9.2


60.0


3.6


67.0


8.0


56.0


2.0


34.0


3.0


4.0


38.0


7.0


63.0


8.0


29.0


-H-h-t •n


-n-n-f-1 -1-4-f -H -l--f -H-l-t-h-t-l-(--|--K-t


-H+ +




+++



+ +



+



+





1

•f


+++


-H-f-l

+


-1

++


-t--)

+


+


+


+


Transfusions




1-11-16 200 c. c. 1-21-16 300 c. c. 1-24-16 682 c. C. 1-26-16 640 c. c. 2- 2-16 638 c. c. 2- 7-16 660 c. c.



2-12-16 Splenectomy



2-19-16 440 c. c.



. . 1 2-26-16 350 c. c.




3- 6-16 500 c. c.



..


3-13-16 450 c,c.


Very few.


. . 4- 5-16 450 c. c.


Very few.


. . 1 Second admission.


Decr'd.


.. 1 6-28-16 500 c. c.



.. 7- 4-16 500 c. c.



7- 6-16 350 c. c.


Decr-d.


7-15-16 403 c.c.



7-22-16 550 c. c.



8- 5-16 560 c. c.



Third admission.


Many.


11-14-16 150 c. c.



., 11-15-16 120 c. c.




12- 3-16 150 c. c.


JOHNS HOPKINS HOSPITAL BULLETIN


[Xo. 361


Past History. — Her general liealth had been good. There had been intermittent attacks of malaria for several years which finally cleared up with treatment. There had been slight bleeding from hemorrhoids, and she had had nycturia, sometimes once a night. She had had an acute attack of cystitis several years previously, which had cleared up with treatment. Otherwise negative.

Present Illness. — In February, 1917. the patient noticed gradually increasing weakness, and later suffered with pounding of her heart accompanied by asthenia. She had had occasional attacks of vomiting, prodxictive of a large quantity of green fluid; later these vomiting attacks had become very frequent. In April the patient was told that she had anemia and that her hemoglobin was iO'y'r. There had been no diarrhea, but the stools had been more fluid than norrnal. The patient noticed that her face was pale and that she had a lemo.i yellow tint to the skin of her body.

Phiisical Examination. — The general appearance was typical of a severe grade of pernicious anemia. There was an icteric tint to the skin and conjunctivae. The general nutrition was excellent. There was a number of suspicious teeth and slight gingivitis. There was a soft systolic murmur at the cardiac apex.

During the first two weeks the patient ran an irregular temperature, reaching 100.5° F. almost every day, after which it remained normal with a few exceptions.

Lahoiatorij.—Rh. (Sahli)= 10%. R. B. C. = 9S0.000. W. B. C. = 3,640. The stained smears showed a typical picture as shown by the chart. The urine showed a trace of albumin and some hyaline casts. The B. P. was 145/82. Her blood group was Group IV. An orthopcpdic consultant reported slight pronation of the left foot, apparently the result of disuse. A proctoscopic examination revealed several large external hemorrhoids and a pedunculated polyp, which was removed. Following a dental examination five teeth were extracted and the sockets curetted. A gastro-intestinal series of X-rays were made with a normal report. The Wa. R. was negative.

TR.\XSFUSIONS

I. Four hundred and twenty-five cubic centimeters of matched whole blood. Lindemann method. There was a slight chill, and an elevation of temperature to 103.8° F. The patient was restless and nauseated. Donor, F.

II. Five hundred cubic centimeters of matched whole blood. Citrate method. A chill occurred during the operation, and elevation of temperature to 102° F. Donor, Ct.

III. Five hundred cubic centimeters of matched whole blood. Citrate method. There was no reaction except slight discomfort. Donor, CI.

IV. Five hundred cubic centimeters of matched whole blood. Citrate method. There was a rather marked reaction with an elevation of temperature to 102° F., and the patient was generally uncomfortable. Donor, not stated.

V. Four hundred cubic centimeters of matched whole blood. Citrate method. Xo reaction. Donor, H. The urine showed a positive test for urobilin after this transfusion.

VI. Four hundred cubic centimeters of matched whole blood. Citrate method. Xo reaction. Donor. H. (same as for previous transfusion ) .

XII-20-17. Discharged.

Kb. = 70%. R. B. C. = 3.460,000.

, Second Admission

Medical No. 39120. Admitted .January 4, 191S. Difir/nosis : Pernicious anemia.

The patient returned to continue the treatment. Slie was in excellent condition. Hb. = 70%. R. B. C. = 3,460.000.

TR.\NSFUSIONS

VII. One thousand one hundred and fifty cubic centimeters of matched whole blood. Citrate method. X^o reaction. Donors. Cs.


and CI. (The bloods of the donors were matched against each other, as well as against the blood of the patient.)

VIII. One thousand cubic centimeters of matched whole blood. Citrate method. Xo reaction. Donors. A and Cr.

11-16-18. Discharged.

Hb. = 71%. R. B. C. = 3..-)00.00(). W. B. C. = 6.100.

Third Admission

Medical Xo. 39836. Admitted ilay 18. lOIS. Diagnosis: Pernicious anemia.

Present Illness. — Since leaving the hospital, the patient had led a fairly active life. She had felt very well until one month before admission, when she began to notice that the least effort was tiring. There was slight vertigo on turning her head.

Hb. = 74%. R. B. C. — 3,000,000.

The physical examination was the same as upon previous admissions, but in addition there was slight edema of the ankles.

A gastric analysis showed a hydrochloric acid deficit of 7% and a total acidity of 5%.

TR.iNSKrSION

IX. Seven hundred cubic centimeters of matched whole blood. Citrate method. X^o reaction. Donor, Cs.

VI-19-18. The patient was discharged. Hb. = ,8.-,%. R. B. C. = 2,700,000. W. B. C. = 5,160.

Fourth Admission

Medical Xo. 40847. Admitted Xovember 14, 1918. Diagnosis: Pernicious anemia. Oral sepsis. Fascicular myelitis.

The complaint was of numbness in both legs.

Present Illness. — Alxput the first of August, 1918, the patient noticed numbness in the toes of her left foot, present night and dajr This sensation later extended up the right foot and the calves of the legs, and the lower part of the abdomen did not feel natural. About two weeks after the onset of this complaint, the patient voided more frequently than usual and experienced some difficulty in holding her urine.

The physical examination was the same as upon previous admissions. In addition, the knee-kicks and ankle-jerks were hyperactive and the sense of touch was somewhat impaired over the lower extremities.

Hb. = 75%. R. B. C. = 3,056,000. W. B. C. = 11.800. The urine gave a negative test for urobilin. Following a dental consultation, one tooth was extracted, the socket curetted, and the gingivitis was treated.

transfusions

XI. Four hundred and fifty cubic centimeters of matched whole blood. Citrate method. Xo reaction. Donor. HI.

XII. Five hundred cubic centimeters of matched whole blood. Citrate method. Xo reaction. Donor, Hs.

XI-26-18. Discharged. Vitally staining R. B. C. = 0.8%. Hb. = 100%. R. B. C. = 4,008,000.. W. B. C. = 7,700.

Fifth Admlssio.n

Medical Xo. 42333. Admitted June 5, 1919. Diagnosis: Pernicious anemia. Achylia gastrica. Combined sclerosis.

From the time of discharge until six weeks before admission the patient remained in good condition. She maintained a hemoglobin of 90% or higher. About six weeks ago she began to feel weak and her Hb. was 80%. One week ago the hemoglobin examination was 70% and the R. B. C. count below three millions. There has been no improvement in the condition of her legs, the n\imbness extending a short distance alx)ve the knees.

The physical exa.minatioyi was the same as upon previous admissions.


Maech, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


89


Hb. = 45%. R. B. C. = l.SoO.OOO. \V. B. C. staining R. B. C. = 0a%.


') 1.000. Vitally


TB.\NSKUSIONS

XIII. Five hundied cubic centimeters of matched whole blood. Citrate method. During the transfusion an urticarial wheal was noted on the patient's left arm. About one hour later the patient became restless, vomited, and there was an elevation of temperature fo 104° F. A specimen of urine voided seven hours later gave a positive test for Hb. Xo red l)lood cells were seen in the specimen. The temperature remained elevated on the following day, and she did not void, but had to lj<? catheterized. On the following day (second), the patient was still quite drowsy. The skin and sclera;

were more icteric, and numerous small petechiae had appeared over the body. The urine showed no abnormal blood pigments. There developed marked herpes labialis, stomatitis and glossitis. Donor, L. E. W. Group IV.

VI-13-19. The patient was still mentally confused.

XIV. Four hundred and fifty cubic centimeters of matched whole blood. Citrate method. The patient began to feel chilly and to shake toward the end of the procedure, and the last 100 cubic centimeters of blood were not run in. The temperature rose to 101.4° F., but was down on the following morning. Donor, H. F. Group IV. Several other Group IV donors were tested at the same time. There was no agglutination with any of them, but in all except the donov used, there was hemolysis of the donor's cells by the patient's serum. This fact is interesting in view of the statement by Moss ° that the serum of any one group will not agglutinate or hemolyze the corpuscles of other members of the same group, but will agglutinate and may hemolyze the corpuscles of any other group except those of Group IV.

VIII-28-19. The patient was discluirged. HI). = S.'if/r. K. B. C. = 2,400.000. \V. B. C. = 10,000.

Sixth Admission

Medical Xo. 430U5. Admitted March 5, 1920. Diagnosis: Pernicious anemia. Combined sclerosis. Chronic cystitis. Achylia gastrica. Stokes-Adams syndrome. Oliesity. The patient had felt fairly well since her last admission. She had had considerable difficulty in walking and onh^ did so with support or the aid of a cane. She stood with a broad base and there was some tendency to swaying. This condition had Ijeen growing gradually w^orse. She had had electrical treatment with " violet rays " along her spine without improvement. She complained of a marked feeling of discomfort in both lower extremities, and there had been incontinence of urine at times. The last time the hemoglobin determination was made at her home it was reported as 80%.

The physical examination was the same as upon previous admissions. In addition, the knee-kicks and ankle-jerks were strongly hyperactive, and there was a sustained ankle clonus on the left, and a fairly well sustained clonus on tlie right. There was a patellar clonus on Ijotli sides. Plantar stimulation gave dorsal flexion on both sides. Muscle sense and appreciation of sharp and dull were impaired in both legs. Appreciation of hot and cold were somewhat diminished over both legs, as high as the knees. Appreciation for tovich was diminished over the left leg and tlie left fo<3t. The blood pressure was 126/70.

Lnftorafori/.— Hb. = 46%. R. B. C. = 1 ,4.'?0.000. W. B. C. = 13,0.")0. Vital staining R. B. C. = 0.2%. The urine showed a faint trace of albumin, some liyaline and granular casts, and many W. B. C. in clumps. The iirine gave a positive test for urobilin.

For ten days after admission the patient was kept on an experimental fat-free diet without any improvement in the blood picture.

TRANSFUSIONS

XV. Five hundred and fifty cubic centimeters of matched 'and grouped whole blood. Citrate method. Tlie blood was run in very


slowly. After receiving about 17.5 cubic centimeters of blood, the patient's respirations became somewhat sighing in character and then slightly dyspnoeie. The transfusion was discontinued. The patient began to shake violently, but did not feel chilly. An hour later the temperature had risen to 104.6° F. She vomited and became somewhat irrational. She went to sleep at 8 P. M. and could not be roused during the night. On the following day the temperature remained elevated. The sclene and skin were quite yellow. The patient was in a very low mental stat« ; she seemed to be able to fix her attention, but did not respond to questions. She had not voided sixteen hours after the transfusion, and was catheterized for 3.50 cubic centimeters of reddish orange colored urine, containing many hyaline and granular casts and a few R. B. O. The urine gave a strongly positive t^st for hemoglobin with benzidine. Donor. Co. The blood of both the patient and the donor were regrouped; they were both Group IV. In rematching, on first trial there was a i)erfect match; on second trial, the recipient's serum vs. the donor's cells gave no agglutination or hemolysis; the donor's serum vs. recipient's cells gave no agglutination, but did give very slight hemolysis as shown by the presence of a few " shadows " under high power examination of the specimen. All inculjations W'ere carried on for at least one hour, usually longer.

III-2I-20. The patient could be roused with difficulty and would respond to questions. There were marked herpes labialis and herpes zoster.

III-28-30. The patient bad involuntary stools and involuntary voiding at times, but usually had to be catheterized. There was twitching of the upper extremities, and the stream of talk was occasionally incoherent and irrelevant. The pulse grew weak, but responded to strophanthin.

IV-2-20, The blood urea nitrogen was 74 mgm. per 100 cubic centimeters. The carbon dioxide of the plasma was 44.7 vol. %. The patient showed a constant temperature elevation as high as 102.8° F., and continued to require catheterization. CVstitis had become very marked and the urine showed a large amount of ropy pus in the specimen bottle. A urine culture showed a marked growth of B. coli. She began to have seizures, manifested by the loss of consciousness, and lasting from one to ten minutes. There was fixation of the eyes, twitching of the facial muscles, and coarse jerky movements of the hands and arms. Sometimes they Ijegan with hiccup, wretching, and vomiting of a light brown fluid. There was occasionally a very slow lateral nystagmus. During these attacks, the respiration became rapid and labored and there was foaming at the mouth. The radial pulse rate in these seizures was one half of the rate before or after the attack, and corresponded with the rate counted at the cardiac apex. For a period of a week the patient had numerous such seizures during the day and night, at the end of which time they ceased.

IV-4-20. Carbon dioxide of the alveolar air was 24 vol. %„ A blood culture gave no growth.

XVI. As the patient had had such extremely severe reactions in previous transfusions, it was decided to attempt a transfusion of the serum of Group I, which contains no isoliemolysins or isoagglutinins. A Group I donor was obtained and .500 cubic centimeters of blood was withdrawn in the usual inetliod, and allowed to clot over night in the ice-box; the following day 235 cubic centimeters of the supernatant serum was pipetted olT; centrifugalised at high speed to remove all cellular elements and inactivated at 56° C. for one hour. The serum was then diluted with 100 cubic centimeters of normal salt solution to render it less viscous. The diluted serum was injected intravenously in the usual ftietliod, by gravity. There was no reaction of an}- sort. Donor, 0., Group I.

IV-18-20. The patient gradually became rational. The two small infected hypodermic areas which had followed the injection of strophanthin a week previously showed improvement. An early bedsore on the right buttock showed no improvement. There was


90


JOHNS HOPKINS HOSPITAL BULLETIN


[Xo. OGl


complete paralysis of both lower extremities, and complete loss of muscle sense, and of all sensations as high as the umbilicus.

IV-25-20. The patient's condition Ijecame very unsatisfactory. Her respirations became rapid and shallow with periods of hyperpnoea, and the pulse rapid, feeble and irregular. The temperature ranged from 101° (R) to 104.4° (R). The psyche was in a twilight state. There was a myocardial death at 8.10 P. M., with a temperature of 105° F. at death.

Analysis. — The patient in Case III had six admissions to the hospital in a little less than three years and during this period received about eight and one-half liters of blood in 15 transfusions, and 235 c. c. of blood serum in one transfusion. She suffered six reactions of varying degrees of severity, showing hemoglobinuria on two occasions. From the time at which she first came under observation until the development of a marked cystitis, and later, the transfusion of serum, the blood picture showed very little regenerative activity. Whether the evidences of bone-marrow stimulation, shown by the blood picture from April 2, 1920 until the time of death, resulted from the cystitis and hypodermic infections, or from the transfusion of Group I serum, it is impossible to say. However, the picture shows greater bone-marrow activity following the administration of blood serum. It is rather interesting that the hemoglobin and E. B. C. determinations showed a progressive improvement until the time of death. The acidosis shovai


by this case has been described by Barekey and Kahn " as one of the findings in pernicious anemia.

In endeavoring to explain these very severe reactions the first question which naturally presents itself, is: Were the donors' bloods really compatible with those of the recipients' ? In all of the matchings carried out before transfusion the bloods apparently were compatible. In Case I, "Transfusion Y, the incubation of the preparations was carried on for only 30 minutes; hence we may reasonably assume that up to this time 30 minutes had been the tisual incubation period in the routine blood matchings. Thereafter the preparations were allowed to incubate for one hour or longer. In Cases I and II tlie matchings were performed by the bacteriological laboratory ; and in Case III all tests for compatibility were examined liy at least two persons before being pronounced acceptable. In no instance were donors used when examination had shown either agglutination or hemolysis.

The blood groups of Cases I and II are not known. Case III was repeatedly found to belong to Group IV and only Group IV donors were used for transfusion of whole blood. This fact lends additional interest to the severity of the reactions experienced by Case III, as it has been stated by Drinker and Brittingham,' and reaffirmed by Lee ' that the members of


Date


Hb.


R. B. C.


d



S


0.'


s


s


i^


s


o

<


2

0.


a.


i

x; O


|6

So


1


><

g

i


^


1^


Transfusions


VtI-21-17


10


980.000


3,640



-t--t--|

-H--I

+


-1





Few.



7-23-17 425 c. u.



VII-27-17


27


1,448,000


4,200






7-30-17 600 c-. u.



VIII- 8-17


38


1,688,000


5,009 8- 9-17 500 L-. c.



VIII-19-17


41


1,808,000


2,400






•• 8-21-17 500 c.L-.



XI-26-17


68


2,248,000


7,480


56.0


6.0


.0


35.0


5.0


2.0


.0


-f-f


-i-t Few.



12- 4-17 400 c. c.



XI 1-16-1 7


70


2,860,000


6,200


49.0


6.0


1.0


38.0


6.0


.0


.0


4--f


f-h

Few.



12-18-17 400 c. c.



XiI-20-17


70


3,460,000






Second admissiou



1-10-18


74


3,520,000


6,200


64.0


5.0


.0


26.0


5.0


.0


.0


-!--(

+






' +


....


Few.



1-21-lS 1150 c. c.



II- 2-lS


67


2,680,000


5,SO0


63.0


4.0


.0


25.0


7.0


1.0


.0





2- 5-18 1000 c.c.



11-16-18


71


3,500,000


6,100






Third admission.



V-18-1S


70


2,736,000


4,600 •



4

-1


5-27-18 700 c. c.



y-29-18


82


2,720,000


4,800



-1

+




-f






6- 6-18 500 c. c.



VI-18-18


85


2,700,000


5,160






Fourth admission



XI-H-18


75


3,056,000


11,800


53.2


2.8


.0


41.2


2.8


.0


.0


-1

+ -1

-1-4

Normal.



11-16-18 450 c. c.



XI-19-1S


80


3,528,000


6,800


62.0


4.0


.4 1 32.0


.8


.8


.0


+


+


Decr'il.



11-21-18 500 c. c.



X 1-26-1 8


100


4.008,000


7,700


53.2


2.4


.8


?


3.6


.0


.0





Normal.


0.8


Fifth admission.



VI- 5-19


45


1,856,000


5,100


55.2


8.0


.0


36.4


.4


.0


.0


-^-^-^


+



-1

1.0


-H


Decr'd.


0.1


6- 7-19 500 c. c.



VI-15-19


43


1,472,000


4,700


37.6


6.0


.4


52.0


2.4


.0


1.6


-n

+-I


Ver.v few.



6-16-19 450 c.c.



VI 11-28-19


83


2,400,000


10.000






Sixth admissiou.



III- 5-20


43


1,470,000


^4,800


59.0


4.0


.0


36.0


1.0


.0


.0


-n-t

-l--f-l



+



-h-H


Very few.


0.2


3-19-20 175 c.c.



III-20-20


27


990,000


5,500


78.0


.0


.0


22.0


.0


.0


.0


-H-f-f


-n-t



-1





None seen



Cystitis devolopei


.


IV- 2-20


26 20


770,000 790,000


17,650 15,500


90.0 83.0


.0 1.0


.0 .0


10.0 15.0


.0 .0


.0 1.0


.0 .0


+ + + -I t--f-H

++-t+++





+


3




Decr'd. Decr'd.





IV- 7-20


4- 7-20 23.i c. c. Gr. I serum.


oi


IV- 9-20


20


710,000


15,350


80.0


4.0


.0


11.0


3.0


2.0


.0


+-1--H

+++



+ + +


19




Few.




IV-24-20


46


1,430,000


13,050


83.0


.0


.0


13.5


2.0


.5


1.0


-n

++ ....



Few.




Maucii, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


91


Gvdup IV are universal donors, and may give blood for use with recipients of any other group. Lee states that donor and recipient need not be in the same blood group if the serum of the recipient does not agglutinate or hemolyze the E. B. C. of the donor, because the blood of the donor will make up only one-fifth to one-twelfth of the total blood volume of the recipient, and the donors serum is thus diluted; moreover, the recipient's cells are protected by his own serum. Drinker and Brittingham have suggested that in vitro reactions are occasionally unreliable and Sydenstricker and others' state that it is safer to give recipients of other groups the washed Ii*. B. C. of Group IV, than to attempt to use the whole blood. Case III proves conclusively that there are instances in which Group IV blood cannot be used with impunity, even in a member of the same group.

In an attempt to exi)lain the mechanism of the reactions it is obvious that the reactions must have been due to either: (1) imperfect techuic: (2) unavoidable factors in the procedure of transfusion: {')) or some undemonstrablc incompatibility of the blood used.

There seems to be no reason for questioning the technic, as a imiform technic has been employed throughout the series, and a very large number of other cases have been transfiised in the same manner without suffering serious reactions. Of necessity the Lindemann transfusions were always performed in the same manner. With the citrate method the apparatus offers one factor for discussion, since it has been shown by Stokes and Busman ° that a certain type of new rubber tubing is responsible for some of the reactions to arsphenamin ; they suggest that this may be a contributory factor to reactions with other intravenous methods. However, it is kuovni that during the sixth admission of Case III the same apparatus, without change, had lieen iised repeatedly on other cases without any reaction.

In an exhaustive study on the causes of reactions to citrate transfusions, DTinker and Brittingham ' discuss factors which seem to be unavoidaljle in the present state of knowledge about transfusion. They conclude that reactions are due to: (1) Changes in the blood platelets, a part of the process of coagulation, (2) direct action of sodium citrate on E. B. C, rendering them more fragile and promoting hemolysis; (3) very rare gross incompatibilities which escape in v^itro detection.

Coagulation has l)een considered a factor of importance by Novy and De Kruif," who have shown experimentally with animals that blood becomes highly toxic in the precoagulation stage, and that the effects produced are those of anaphylatoxin, ])roducing the same picture as anaphylactic shock. However this factor enters into eveiy transfusion and as a rule we do not see severe reactions as a result of it.

In citrate transfusion the action of .sodium citrate in rendering the red blood cells more fragile and thus promoting hemolysis may be a contributon- factor. On the other hand the degree of hemolysis cannot Ije great, as Drinker and Brittingham do not mention having observed hemoglobinuria in any of tlieir cases, while in the series under consideration, hemoglobinuria occurred four times, excluding transfusion V in Case I,


in which the blood was later shown to have been incompatible. Moreover, it is far from proven that hemoglobin is as toxic as it is generally considered to be. Sellards and Minot," in a study of the relationship between experimental hemoglobinuria and blood destruction in man, produced hemoglobinuria by the intravenous injection of the hemoglobin obtained from 4 c. c. to 33 c. c. of laked human E. B. C. They state : '"' One of the striking features of these injections is the absence of subjective symptoms after these comparatively large injections of hemoglobin. One normal patient received 28 c. c. of laked cells mthout any subjective symptoms and showed a slight hemoglobinuria. Another normal individual received 33 c. c. of laked cells. An hour after the injection a short mild chill developed which lasted about ten minutes, but it was not accompanied by nausea or headache. The patient became entirely comfortable after this chill, but during the first half of the night he did not sleep on account of flushing and a succession of hot and cold sensations. There was an intense hemoglobinuria and this discomfort continued for several hours after the active excretion of hemoglobin in the urine had ceased. The donor of cells for hemoglobin in this case was a member of Group IV." Twelve other cases showed varying degrees of hemoglobinuria without any subjective symptoms. They suggest that there are other factors in addition to the setting free of hemoglobin which play a role in the production of symptoms in those cases having some hemolysis following a transfusion. Likewise, Bayliss '^ has concluded from experimental injections of hemoglobin in cats that hemoglobin is non-toxic; he also found the stroma of the red blood cells to be non-toxic. In summarizing his results, he states, " It appears that the serious results of the transfusion of incompatible blood are not to be ascribed to the hemolysis as such, but are rather an aspect of the action of foreign serum protein analogous to that responsible for anaphylactic shock." Furthermore, Minot and Lee report three instances of reactions identical with those imder consideration, but they do not state how many previous transfusions the patients had received. In one case they believe that the procedure hastened the patient's death, while in two cases it did not do so. They state, " In the case in which death was hastened the patient received in 12 days three transfusions of about -100 c. c. each. Following the first two there was no reaction, while following the third, from the same donor as was iised for the first, the patient complained at once, particularly of headache; shortly vomiting occurred, the patient became toxic, the temperature rose, and inarked jaundice developed, and he died in about 18 hours. No hemoglobinuria occurred. Another sick patient, shortly following a transfusion from a donor whom she had previously received blood from without ill effects, developed a similar severe reaction. The reaction consisted of a chill, temperature 102. .T° F. : gastric symptoms and rapidly marked jaundice developed. Very slight hemoglobinuria occurred. Death occurred two weeks later. A similar, much less severe reaction occurred in a third very sick patient who died five days after the fourth transfusion in three weeks. The isoagglutination tests in these three cases showed no agglutination


92


JOHNS HOPKINS HOSPITAL BULLETIN


[Xo. 3(51


or hemolysis and we verilied them after the reactions in the first two cases; The donors and patients belonged to the same isoagglutination groups. Though these reactions may be of some sort of an isohemoh-tic nature, they are not of the known type. It would seem that they may have been due to the development by previous transfusions of some unknown and unrecognized antibody to the donor's blood." They further suggest that the reaction may have been due to a lowered tolerance to blood pigments which had accumulated during the blood destruction incident to the disease, and from the destroyed blood of previous transfusions, and that the subsequent introduction of more pigment had been sufBcient to produce signs of toxicity.

The latter explanation does not seem so attractive as the former, since their argument is substantiated by the fact tliat the case which died had received the hemoglobin from 17 c. c. of laked E. B. C. in a previous experimental intravenous injection and had reacted with " marked toxic symptoms and an intense hemoglobinuria," whereas following the transfusion the reaction was more severe and there was no hemoglobinuria. The statements of Novy and De Kruif, Sellards and Minot, Bayliss, and Minot and Lee thus have some bearing on the question of undemonstrable incompatibilities of blood producing severe reactions in transfusion. The manifestations of the reactions in the three cases under consideration are particularly suggestive of an anaphylactic reaction, as the picture resembles the immediate reaction occurring in " serum sickness" with dyspnoea, cyanosis and particularly urticaria. All three cases showed urticarial eruptions duriag the series of transfusions, and Case I, after one transfusion complained of puffiness about the eyes, although no cedema of the skin was noted. On another occasion the pains in the arms may have been joint pains. The tenability of the belief that the reaction is anaphylactic is further strengthened by the inability to demonstrate any incompatibility of the blood used, for the blood undoubtedly was incompatible in every instance in which a severe reaction occurred. This assumption would account for the absence of agglutination or hemolysis in tlie blood matchings, and we might expect to find a precipitin reaction between the incompatible bloods. It was considered desirable to study Case III from this viewpoint, but the opportunity did not present itself, as it would be necessary to have the donor's and recipient's blood before and after a transfusion in which a severe reaction had occurred.

A. study of the foregoing cases emphasizes the importance of a few practical considerations, some of which have been stated before. The most significant fact is that there are certain cases of pernicious angmia in which it becomes increasingly difficult with successive transfusions to find compatible donors, and in which severe reactions will occur, no matter how carefully blood matching is carried out. In the present state of our knowledge of means for determining the compatibility of blood, transfusion is a self-limited process, and until more suitable methods are devised for blood matching no attempt should be made to transfuse these cases. The inadvisability of further attempts at transfusion should be indicated by the


discovery that the patient reacts badly, particularly with hemoglobinuria, although no discrepancy is demonstrable upon rcmatching donor and recipient. As a matter of conjecturi'. it may be found by precipitation methods witli the use of m hemolytic series that suitable donors are available for these cases, as precipitation tests are much more delicate than agglutination tests and might reveal a lesser degree of incompatibility. Furthermore, blood matchings should be carried out with the most extreme care and no preparation should be passed upon favorably in which the field does not show a perfectly uniform distribution. The period of incubation, except in emergencies, should be at least two hours, for Walter Baetjer " has seen some instances in which the bloods were slow agglutinators and produced no definite change in the preparation in one hotir. The preparations should be examined for uniform distribution immediately after being set up. Whenever possible, the preparation should be allowed to incubate over night and be read on the following day. Whenever a recipient begins to show signs of reaction the transfusion should be discontinued at once ; any remaining Idood could be injected at the end of one or two hours if a severe reaction had not occurred. Pemberton'° reports three deaths in which transfusion was completed after the beginning of a reaction. The development of an urticarial wheal during the course of a transfusion should be the sign for immediate cessation of the operation, and it seems doubtfid whether the remainder of the blood should be used later.

Coxci.usioxs

1. In certain patients sufl'ering from pernicious anemia, who have been transfused repeatedly, transfusion becomes selflimited because of the inadequacy of methods for selecting suitable donors.

2. This difficulty having once been discovered, no attcnijit should be made to transfuse these patients.

3. The severe reaction is probably due to an anajiliylactic manifestation, and not to hemolysis per se.

4. Blood matching should be carried out with the greatest care; whenever possible, tlie incubation period should be at least two hours, or longer.

5. Blood serum free from cellular elements may jiroduee bone-marrow stimulation.

6. Members of Group IV cannot be regarded absolutely as universal donors.


BIBLIOGRAPHY

1. Sydenstricker, V. P. W.. JIason. V. R.. and Rivers, T Transfusion of Blood liy the Citrate iletliod. Jour. Am. Med. 1917, LXVIII. 1677.

2. McGlure, R. D., and Dunn, G. K.. : Transfusion of Blood, tory, Metliods, Dangers, Preliminary Tests, Present Status. Jolins Hopkins Hosp., 1917. XXVTTI.

3. Lindemann, E.: Simple syringe transfusion. Am. JoinChild, 1913. VI, 2S.

4. Lewisohn, R : A New and Greatly Simplified Method of Transfusion. Med. Record, Prel. Report, 1915, LXXXVII, 141


yi.:

Ass..


HisBull.


. Dis. Blood


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5. Moss, W. L. : Studies on Isoagglutinins and Isohemolysins. Bull. Johns Hopkins Hospital, 1910, XXI, 63.

6. Barsky, J., and Kalin. M. : A study of the Chemistry of Perni cious Anemia. Proe. Soc. Exp. Biol, and Med., 1918-19. XVI, .31.

7. Drinker, C. K., and Brittiiighan, H. H.: The Cause of Reactions Following Transfusion of Citnitfd Blood. Arch. Int. :Med.. 191'J. XXIII, 133.

S. Lee, R. I.: A simple and Rapid Method for the Selection of Suitable Donors for Transfusion by the Determination of Blood Groups. Brit. Med. Jour., 1917, U. 684.

9. Stokes, J. H., and Bushman. Ci. J.: Tubintj as a Cause of Reactions to Intravenous Injection, Especially of Arsphenamin. Prel. Report. Jour. Am. Med. Ass., LXIV. 1013.


10. Novy, F. G., and De Kruif, P. H.: Anaphylaxis and Anapliylato.xiii. Jour. Am. Med. Ass., 1917, LXVIII, I. 524.

11. Sellards, A. W., and Minot, G. R.: Injection of Hemoglobin in Man and its Relation to Blood Destruction, with Especial Reference to the Anemias. Jour. Med. Research, 1916. XXIX, 469.

12. Bayliss, \V. M. : Is Heniolysed Blood Toxic? Brit. Jour. Exp. Path., 1920 (Feb.), I.

13. Minot, G. R., and Lee, R. I.: Treatment of Pernicious Anemia, especially by Transfusion and Splenectomy. Boston Med. and Surg. Jour., 1917, CLXXVII. 761.

14. Statement of Dr. Walter Baetjer.

1."). Pemberton. .1. de J.: Blood Transfusion. Surg.. Gyn. and Obst.. 1919. XXVIIT, 262.


THE FATE OF TRUE SOLUTIONS (PHENOLSULPHONEPHTHALEIN)

AND COLLOIDS (TRYPAN BLUE) INJECTED INTO THE

MAMMALIAN EMBRYO

By George B. Wislocki

{From the Lnhoralorij nf Surgii-al Resenrch. Hintard Medical Hchool. mid the Ileparfiiient of Aiiatoinii of The Jolins Hojih-ins ' Medical fichool)


Savoij, in 185T, was the first investigator to inject a substance into a living fetus and observe its appearance in the mother. He injected acetate of strychnine into two out of four fetiises in a dog. Nine minutes after the injection the mother exltibited tetany and died 28 minutes later. The two injected fetuses were dead; the uninjected fetuses were alive and showed no symptoms of tetany. He also injected two fetuses in a cat; 10 minutes later the mother showed signs of tetany and died in IT minutes. The injected fetuses, although showing tetany, survived the mother; two uninjected fetuses showed no tetanic symptoms. He then injected si.x fetuses in a rabbit. The mother died in 18 minutes; the fetuses, which all showed signs of tetany, survived the mother for a short period. In another experiment, after strychnine had been injected into four fetuses in a dog, the animal showed tetanic spasms after 30 minutes. Savory noted that in nearly all his experiments the fetuses were less susceptible to strychnine than the mother.

Savory's interesting ol)servations were confirmed by Gusserow (in 1878) who injected a series of 24 pregnant rabbits, 7 dogs, and .5 eats with strychnine. His results were very similar to Savory's. He noted that the more advanced the gestation, the more rapidly stryclmine passed from fetus to mother. Strychnine convulsions appeared in the mother in from 11 to 36 minutes after the injections, and usually resulted in death in from 30 to 45 minutes." Gusserow concluded, from Savory's experiments and from his own. that substances can pass from fetus to mother.

Preyer (in 188.5) observed the passage of several other substances from fetus to mother. He injected 0.2 c. c. of a 12 per cent solution of hydrocyanic acid into a mature fetal I guinea-pig; two minutes later the mother had convulsions, became dyspnceic and died after four minutes. The injected


fetus was dead; and uninjected one was still alive at the time of death of the mother. In another similar experiment the mother exhibited convulsions one and one-half minutes after the injection of 0.2 c. c. of a 12 per cent solution of hydrocyanic acid. Preyer also experimented with nicotine. This drug, when injected into several gniinea-pig fetuses, produced clonic convulsions in the fetuses in one and a quarter minutes, but in the mother only mild symptoms of poisoning, which did not result in death.

In another experiment a quantity of curarine, sufficient to kill an adult guinea-pig in 15 minutes, was injected into a guinea-pig fetus. The mother became -completely paralysed and died in 80 minutes. The injected fetus, as well as two uninjected ones, showed no symptoms of poisoning. Several other experiments with curarine gave similar results.

Lannois and Brian (in 1898) investigated the passage of several other substances from fetus to mother. They injected sodium salicylate into guinea-pig and rabbit fetuses, and in three instances foimd the drug excreted in the urine of the mother at the end of one hour. \Vith potassium iodide three trials were negative, but in one instance they were able to detect the substance in the maternal Ijlood stream at the end of an hour. With methylene blue they succeeded in recovering the substance from the maternal urine in five out of six attempts. At the end of two hours only chromogen was obtained from the urine, but in from six to seven hours the unchanged dye-stuff was finally excreted. They too obsei-ved that the passage of substances from fetus to mother was most rapid near term.

Baron and Castaigne (in 1898) found that potassium iodide, injected into guinea-pig fetuses, appeared in the maternal urine in 40 minutes. When injected early in pregnancy they noted the passage of the same drug in 30 minutes. Methylene


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blue injected underneath the scalp of a human fetus during labor appeared in the maternal urine in one-half hour. They found that the substances do not appear in tlie urine if the fetuses are dead.

Guiuard and Hochwelker (18?9) observed the passage of rosauilin from fetus to mother in four instances, the shortest interval required for the drag to reach the maternal urine being 25 minutes. They found that death of the fetus invariably suspends the fetal-maternal passage of a substance. They injected strichnine aud aconite repeatedly into dead fetuses without any effect upon the mother.

Charrin (1898) injected diphtheria toxin into fetuses and observed symptoms of intoxication from it in the mother.

Kreidl and Mandl (1903) injected atropine, adrenalin, pilocar[3ine, physostigmine, and phloridzin into a number of rabbit, cat, dog, goat and monkey fetuses. Atropine (1 c. c. of a 1 per cent solution) caused dilatation of the pupils in the mother, commencing 10 minutes after the drag had been injected into the fetuses. Pilocarpine (several cubic centimeters of a 1 per cent solution) caused extreme salivation in the mother vvithiu 10 minutes after its injection. The passage of physostigmine was demonstrated by injecting it into the fetuses of an animal which had been previously curariuized. On the injection of physostigmine the sciatic nerve resumed its irritability toward electric stimuli. Finally, phloridziu was shown to cause melituria in the mother within three hours follovtdng the injection of several cubic centimeters of a 5 per cent solution into the fetuses. Adrenalin was the only drug from which an effect on the mother could not be demonstrated. Numerous experiments with adrenalin led to the conclusion that it decomposes and loses its pharmacological activity before it traverses the placenta. Kreidl and Mandl mentioned no differences of time required by the drugs to pass from fetus to mother in the various species of animals employed by them.

In addition to the observations upon the fetal-maternal passage of substances which have been injected directly into the fetuses, several experimenters have investigated the possibility of substances passing from the amniotic fluid into the maternal bloodstream. Thus Gusserow (1858) injected strychnine into the amniotic sacs of a series of rabbit, cat, and dog fetuses. In three of these experiments the mother showed symptoms of strychnine poisoning in 15 to 20 minutes. In seven others strychnine poisoning failed to develop in the mother. Preyer (1885), analyzing Gusserow's work, came to the conclusion that the three positive experiments afforded excellent proof of the passage of substances from the amniotic fluid into the maternal blood stream. In the seven negative experiments he was able to point to some technical eiTor, the use of chloroform, or the death of the fetus, as an explanation for the failure of the strychnine to produce poisoning in the motlier. Bar (1881) undertook two similar experiments. He injected 20 drops of a strychnine solution into the amniotic sac of a rabbit fetus. After 20 minutes the mother had convulsions. He introduced a similar amount into the amniotic sac of a fetus of another animal ; in 20 minutes the mother had severe convulsions.


Toerngren (1888) injected iodide of pota.ssium in doses of one or two grams into the amniotic sacs of rabljits. The substance later appeared in the urine of the mother. The time required was at least 45 minutes, and passage occurred whether the fetuses were at term or in the middle of development.

In addition to the question of transmission of substances injected into the fetus through the placenta, the possibility of excretion by the Wolffian body and the metauephros during fetal life have been investigated experimentally. Thus, Wiener (1881) injected sodium indigo sulphonate through the uterine wall into the subcutaneous tissue of several dog fetuses. In 25 minutes the substance appeared in the convoluted tubules of the kidneys, and a few minutes later in the fetal bladders. The substance similarly injected into rabbit fetuses appeared in 20 minutes in the convoluted tubules, and subsequently in the fetal bladders. The glomeruli remained uncolored. Wiener also injected diluted glycerine subcutaneously into rabbit fetuses, whereupon hemoglobinuria resulted in one and a lialf hours. He also injected a solution of potassium ferrocyanide into the amniotic sac of a rabbit and after two and a half hours detected it in the fetal urine.

Bar (1881) repeated Wiener's experiments, using potassium ferrocyanide. At the end of 40 minutes several drops of urine in the bladder gave the Prussian blue reaction.

Bakounine (1895) injected indigo carmine into the omphalomesenteric vessels or the aorta of developing chicks, and observed the excretion of the coloring matter by the tubules of the Wolffian body. The glomeruli never exhibited the dye.

Eecently Firket (1920) has reported the results of injef^ting a solution of sodium ferrocyanide and iron ammonium citrate into the umbilical vein of cat fetuses. On sacrificing the mothers at intervals varying from 15 minutes to several hours and examining the fetuses, Prussian blue was observed in the convoluted tubules, urine, and allantoic fluid.

Mention must also be made of the experiments of Krukeuberg (1885) on rabbits. After the injection of potassium iodide into the maternal blood stream he found traces of the substance in the fetal kidneys.

In the present experiments the fate of phenolsulphonephthalein and trypan blue injected into fetuses was investigated. Phenolsulphonephthalein was selected becaiise it is a crystalloid, diffuses readily and is non-toxic. Trypan blue was used because its forms a colloidal solution, is relatively non-toxic and its behavior in the adult organism is well understood.

PHENOLSULrHONEPHTHALEI X

Phenolsiilphonephthalein was injected into a series of cat and guinea-pig fetuses by the follo\dng technique : The pregnant animal was anesthetized with ether, a laparotomy performed, the bladder exposed, the urethra ligated, and a bent glass cannula tied into the bladder. The cannula was allowed to drain into a beaker containing a 1 per cent solution of sodiiun hydroxide. The uterus was next exposed and a fetus palpated. A syringe containing sterile phenolsulphonephthalein solution and bearino; a Id-sauge needle was inserted


March, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


95


through a nick in the uterine wall, through the fetal membranes into the peritoneal cavity of the fetus. One cubic centimeter of phenoJsulphonephthalein was injected into the peritoneal cavity of the fetus and the syringe withdrawn. The uterus was carefully replaced in its normal position and the laparotomy opening closed. Tlie animal was kept under light ansesthesia. The interval elapsing between the time of injection and the first appearance of the dye in the maternal urine was noted ; as soon as this occurred the animal was sacrificed. The fetuses were removed from the uterus, and the bladder content of the injected fetus was tested for phenolsulphonephthalein. The urine of the adjacent fetuses and fluid contained in their membranes were also tested for the presence of the dye. The results of these experiments are presented in Table I.

It will be seen that phenolsulphonephthalein, when injected into the peritoneal cavity of the fetus, is absorbed by the fetal blood-stream and conveyed to the placenta, through which it slowly diffuses into the maternal circulation. The time required for the drug to appear in the mother is quite variable for individuals of the same species. Xo difference is observed between the cat and guinea-pig in the time required for the passage of the dye from fetus to mother. Further, it is seen that phenolsulphonephthalein is readily excreted by the fetal kidneys, for it was found in the fetal bladder in every instance in which suiScient urine could be collected to test for its


presence. Xone of the drug could be detected in the urine or amuit)tic fluid of the adjacent uninjected fetuses.

Tkypax Blue

Trypan blue (1 c. c. of a 0.5 per cent solution) was injected into the peritoneal cavities of cat and guinea-pig fetuses by a similar technique. Table II shows the results of these experiments.

It wiU be observed that trypan blue could not be detected in the maternal urine during the period of 5 hours while the animals were under obsen-ation. At the termination of the experiment the dye in every instance was found in the fetal kidneys. No trypan blue was observed in the iminjected fetuses.

In a second set of experiments trypan blue was injected into the peritoneal cavities of the fetuses imder aseptic precautions. After closing the abdomen of the pregnant animal it was allowed to recover from anffisthesia. The animals were finally sacrificed at intervals of 24, 48 and 72 hours, respectively. In none of these cases was tr\'pan blue found at any time in the maternal urine.

In every instance in which the mother was allowed to survive 24 hours or longer, the fetus which had received an injection of trypan blue was found vitally stained. In the gross the staining was quite striking. The placenta and fetal mem


TABLE I


Animal


Crownrump length of injected fetus


Substance and quantity injected


Where injected


Time of appearance in maternal urine


Urine of injected fetus


Urine and

amniotic fluid

of uninjected

fetuses


Condition of

injected fetus at time 01 removal from uterus


Guinea-pig 1. . .


95 mm.


1 c.


c.


phenolsulplionephthalein.


Intra peritoneally.


1 hr. 45 minutes.


Positive.


Negative.


Living.


Guinea-pig 2. . .


112 mm.


1 c.


e.


phenolsulphonephthalein.


Intraperitoneally.


55 minutes.


Undetermined.


Negative.


Living.


Guinea-pig 3. . .


67 ram.


1 c.


c.


phenolsulphonephtlialein.


Intrapcritoneally.


1 hr.


Positive.


Negative.


Living.


Guinea-pig 4. . .


118 mm.


1 c.


c.


plienolsulphonephthalein.


Intraperitoneally.


40 minutes.


Positive.


Negative.


Living.


Guinea-pig 5. . .


106 mm.


1 c.


c.


phenolsulphonephtlialein.


Intraperitoneally.


55 minutes.


Positive.


Negative.


Living.


Cat 1



1 c.



plienolsulplioneplithalein. phenolsulplionephtlialein. phenolsulphonephtlialein. phenolsulphoneplitlialein. phenolsulphonephthalein.


Intraperitoneally. Intraperitoneally. Intraperitoneally. Intraperitoneally. Intraperitoneally.


1 hr.


Positive.



I ivin"


Cat 2


116 mm.


1 c.






Livi .


Cat 3



1 e.





Negative. Negative. Negative.


Living.


Cat 4


115 mm. 87 mm.


1 c.

1 0.


c. c.


45 minutes. 1 hr. 35 minutes.


Positive. Positive.


Cats


Living.



.\nimal


rump length of injected

fetus


Substance and quantity injected


Where injected

(


Time of appearance in maternal urine


Urine of injected fetus


Urine and

amniotic fluid

of uninjected

fetuses


Condition of

injected fetus at time of removal from uterus


Guinea-pig 1. . . Guinea-pig 2. . . Cat 1


92 mm. 122 mm. ;

75 mm. 32 mm.


1 c.c. 0.5% trypan blue. 1 c.c. 0.5% trypan blue. 1 c.c. 0.5% trypan blue. 1 c.c. 0.5% trypan blue.


Intraperitoneally. Intraperitoneally. Intraperitoneally. Intraperitoneally.


None in 5 hours. None in 5 hours. None in 5 hours. None in 5 hours.


Positive. Positive. Positive. Positive.


Negative. Negative. Negative. Negative.


Living. Living. Living.


Cat 2



°


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[Xo. 361


branes of the injected fetus were dark blue, while the uterine musculature and decidua in the region of the injected fetus were unstained. No staining of the placentse or membranes of the neighboring uniujected fetuses was observed. On rupturing the membranes of the injected fetus the amniotic fluid was observed to be quite l)lue. In the cat fetuses an additional blue coloration was noted in the allantoic fluid. The umbilical cord, as well as the fetus itself, appeared deep blue. On gross sagittal section of the fetus its tissues were observed to be uniformly blue with the exception of the brain and cord, which were unstained.

A detailed description of the microscopic appearances of these vitally stained fetuses will be reserved for a future paper, but the main features of the staining will lie here briefly outlined. Trypan blue occurs in many of the tissues of the fetus in the form of characteristic cytoplasmic granules. It occurs most abundantly in the liver and kidneys. The Kupffer cells of the liver contain numerous tiny, brilliant bhie granules within their cytoplasm. The epithelial cells of the convoluted tubules of the kidneys are heavily laden with blue pigment. Trypan blue has not been deposited elsewhere than in the convoluted tubules, for the glomeruli and collecting tubules are unstained. So-called clasmatocytes, pigmented with trypan blue, occur throughout the loose connective tissue of the fetus. The cells constituting the delicate stroma of the umbilical cord and fetal membranes contain minute granules of dye within their cytoplasm. The amniotic epithelium coutains similar cytoplasmic granules. In the placenta the dye occurs in the form of tiny granules in the cytoplasm of the cells which form the delicate stroma supporting the fetal vessels. It is also observed in the endothelial cells of the placental capillaries. Dye is not seen in the chorionic epithelium or in any of the maternal elements of the placenta.

The liver and kidneys of the mother were examined microscopically for trypan lilue, but no trace of the dye could be discovered.

SniilAEY

1. Phenolsulphonephthaleiii, which rp])rescnts an easilv diffusible, non-toxic dye, is absorbed from the peritoneal cavitv of the fetus. It passes slowly from the fetal blood stream through the placenta into the maternal blood stream and is excreted by the maternal kidneys. It is also excreted by the fetal kidneys, since it is found in the fetal urine. This observation demonstrates that the fetal kidneys are capable of excretion, but sheds no light on the extent to which they act as a pathway of excretion before l)irth. ISTo difference was noted between the eat and the guinea-pig as to the time of transmission of the dye by the placenta, but a marked difference in the time required was observed in individuals of the same species.

2. Trypan "hlue, a less diffusible, non-toxic colloidal dye, is also absorbed from the peritoneal cavity of the fetus. It is not excreted in the maternal urine, and microscopic examination shows that it is not transmitted by the placenta to the maternal organism. It is excreted bv the fetal kidnevs. The


observations' with trypan blue show that the placenta is incapable of transmitting an inert foreign colloid from fetus to mother, and hence it is prot)able that the placenta does not transmit the colloidal products of fetal excretion unless they are first converted into simpler, readily diffusible, substances. •3. The fetus becomes vitally stained after injections of trypan blue into the fetal peritoneal cavity. The dye is stored in the endothelial cells of the liver, and also accumulates in the ephithelial cells of the renal convoluted tubules. The dye is aljsorbed by clasmatocytes which occur throughout the fetus and in the placenta and fetal membranes.

REFERENCES

Bakounine, S.: Sur I'aetivite spcretriee des epitheliums de Wolff et des epitheliums reiiaux dans les premiers jours de developpement embryonnaire. Arch, ital, Biol.. 189.5, XXIII, 3.50-3.54.

Bar, P.: Recherches pour servir a I'histoire de rhydramnios. Paris, 1881.

Baron. P., and Castaigne, J.: Contribution a I'etude de la pathogenie de I'eclampsie puerpei-ale; etude experimentale du passage des substanies toxiques du foetus a la miTe. Arch, de nied. exper. et d'anat. path., 1898, X, 693-711.

Charrin, A.: Transmission des toxins du fcetus a la mere. Arch, de Physiol. 1898. X, 703-705.

FirUet, J.: Etude histo-physiologique de I'eliniination de certains sels par le rein embryonnaire. Comptes rendus Soc. biol., 1920, LXXXIII, 1-230-1231.

Guinard, L., and Hochwelker, H.: Experiences sur les conditions du passage des substances solubles du foetus a la mere. Arch. d. physiol. et path, gen., 1899, I, 4.56-462.

Gusserow, A.: Zur Lehre vom Stoffaustavisch zwischen Mutter und Frucht. Arch. f. Gyn., 1878. XIII, 56-72.

Kreidl, A., and Mandl, L. : Experimentelle Beitriige zur Physiologie des Stoffaustausches zwischen Fiitus und Mutter. Zentralbl. f. Physiol., 1903, XVII. 281-290.

Krukenl)erg, G. : Zur Frage der fotalen Nierensekretion und der Fruchtwasserbildung. Arch. f. Gyn., 1885, XXVI, 258.

Lannois, M., and Briau, E.: Passage de substances du foetus a la more. Lyon medical. 1898, LXXXVII, 323-329.

Preyer, W. : Specielle Physiologie des Embryo. Leipzig, 1885.

Savory, W. S.: An experimental inquiry into the effect upon the mother of poisoning the fetus. 1857.

Toerngren. A.: Sur les rapports entre le sang maternel et de liquide amniotique. Biol, forenings forhandl. Stockholm, 1888, I, 66-68. Recherches sur I'echange de substances entre le liquide amniotique et le sang maternel. Paris, 1889.

Wiener, M. : Zur Physiologie der fotalen Niere. Breslauer iirztliche Zeitschr., 1881, Sep. 24, Xr. 18.



Mabch, 1921



PROCEEDINGS OF SOCIETIES



THE DANGERS TO LIFE OF SEVERE INVOLVEMENT OF THE

THORAX IN RICKETS


By Edwards A. Park and John Howland


The thora.\ is affected like all other parts of the skeleton in the course of severe and prolonged rickets, and frequently becomes the seat of most e.xtensive deformities. A mild degree of involvement of the thorax in the rachitic process is itself of little or no importance. More severe involvements, however, constitute a veritable menace to life itself. The object of this paper is to call attention to a little recognized but very definite symptom-complex which is accompanied by characteristic autopsy findings. The symptoms and pathological changes in question are the direct result of the diseased condition of the thorax. We also wish to discuss the mechanism by which these symptoms and pathological changes are produced and life is threatened.

The material, which fonns the basis for our study, consists of 32 children between the ages of 8 months and 4^ years. All the children exhibited well-marked rachitic deformities of the thorax. In the case of six of them, however, the rachitis had not progressed far enough to produce great weakening of the thoracic wall and in four there had occurred healing or at least thickening of the ribs to an extent suiBcient to make the deformed thorax rigid. Excluding these ten cases, which served only for the study of the deformities of the thorax, there remain 22 cases. These 23 cases form the actual basis for this report. In all of them there were present not only


the characteristic deformities of the thorax but also the essential element, great weakening of the thoracic wall, and in all there were the characteristic train of symptoms and X-ray changes in the lungs, to be enumerated later. The youngest of the 22 children was but 8 months old. Only one child (aged 3;^ years) was more than 2| years of age. The average age was 16 months. Thirteen were boys, nine girls. It so happened that all were colored. Although rachitis reaches grades of development in the black race in America rarely encountered in the white race, nevertheless, the condition described occurs as well in white as in black children. We have seen well-marked examples in white children in both this country and France. It is important to note that all 22 children were greatly under weight. One weighed 64 per cent under the normal standard for the age. Their average weight was 46 per cent under the average weights for healthy children of corresponding ages. All 22 children also were undersized. The body length averaged 88 per cent of the average for the corresponding ages. It is interesting to observe that the circumference of the chest was proportionately less than the length of the body. It was 83 per cent of the average for healthy children of corresponding ages. The circumference of the head averaged 96 per cent of the average of the standard measurements for the corresponding ages.


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All 22 children also showed clinical evidence of rickets in parts of the skeleton other than the thorax. The deformities of the head and extremities were not particularly striking in all instances, however, and not in proportion to the deformities of the tliorax. The majority had multiple fractures of the extremities, in a number of them not recognized until examined with the X-ray. A rhinitis with mucous discharge and resulting stenosis of the nasal passages was present in the majority of the children. In some, undoubtedly, it played a part in the causation of the inspiratory collapse of the thorax and hence in the development of the respiratory condition.

When viewed from in front, the deformed thorax appears smaller than it actually is, in part because of its peculiar shape, presently to be described, in part because of its situation between the disproportionately large rachitic head and distended abdomen. Eoughly the deformed thorax may be likened to a blunt wedge, the sternum and adjacent portions of the costal cartilages corresponding to the narrow end of the wedge. The peculiarity in its shape is due to the fact that the anterolateral portions have sunk inwards with the production of broad hollows, the deepest parts of which correspond to the sites of the costochondral junctions (Figs. 1 and 2). At the end of expiration, these depressions extend in a general way from the midaxillary line behind to within 2-3 cm. of the sternum, sometimes including, sometimes failing to include the nipple, and from the third or fourth rib above to the ninth below, where the thorax usually begins to flare outward over the abdomen. The upper part of the depression, which is narrow, is usually covered by the peetoralis major muscle. The deepest part lies at the sixth or seventh costochondral junction. The depression on the right side is in most cases larger and deeper than the one on the left, probably because the heart furnishes support to the thoracic wall on the left side. In the less severe forms tliere may be no depression on the left side but only flattening of the normal arch. The posterior angles of those ribs entering into the formation of the depression are much more bent than normal. Together they form a rounded ridge-like elevation 3^ em. broad, which projects laterally and sharply separates the back from the antero-lateral surface of the chest. Anteriorly this ridge slopes downward into the floor of the depression and forms its posterior boundary.

If the child can be made to sit up, it is at once apparent that the clavicles are exceedingly prominent. They are much bowed and stand out unusually far from the base of the neck. In a considerable number of cases they are the seat of fracture. The manubrium is prominent and appears to be elevated, as indeed does the whole thorax. In consequence of the high position of the thorax, the neck in front seems unusually short (Fig. 3). The sternum is thrust forward and is not infrequently curved or bent. Its inclination downwards and forwards is often much exaggerated. The prominence of the sternum, which might be compared to the inverted hull of a boat, is due to the fact that the ends of the ribs on the two sides of the chest are closer together than normal as tho


result of tlie collapse of the thoracic wall at the sides. A great increase in the arch of the costal cartilages is thereby p»roduced. Occasionally on one or on. both sides the costal cartilages are so greatly arched that those parts of them immediately adjacent to the sternum bow forward in front of the sternum and convert the latter into the floor of a groove. The manubrio-gladiolar junction often forms an obtuse angle pointing downward. In several of our cases the gladiolus was so inclined forward that it formed an angle of about 10° with the vertical, and in one instance an angle estimated at 25°. The xiphoid often points slightly backwards. The costal margins composed of the conjoined cartilages of the lower ribs ajid the ribs themselves usually flare outwards. On account of the hollows at the sides and the flaring of the lower margins the thorax when removed from the body bears a resemblance to a corset.

As already indicated, the thorax is not symmetrically deformed; indeed it is often markedly asymmetrical. The lateral depressions are never the same on the two sides. The broader the depression, the narrower the anterior surface of tlm thorax on that side and the sharper and more prominent the ridge made by the posterior arches of the ribs behind; the deeper the depression, the greater the flare of the costal arch below. The sternum itself often deviates from the median line and slopes toward one side or the other. The costal arch is always higher on one side than on the other and the flaring on the two sides unequal. If the child has sat, the vertebral column always exhibits lordosis in the interscapular region with kyphosis below and often well marked scoliosis. The back is rarely flat. If one of the lateral depressions is particularly wide and deep, the ribs involved pass backward and outward from the vertebral column instead of outwai'd, causing the back on that side to project posteriorly, lloreover, the deeper the lateral depression in front, the narrower the back on that side behind (Fig. 4).

When fractures of the ribs are present, the distortion of the thorax may be greatly increased and the resulting deformities much more difficult to analj'ze. When the fractures are situated a short distance behind the costochondral junctions, small pits 1-1.5 cm. in depth are often formed. When the fractures are near the posterior angles of the ribs, these angles lose their rounded character. Since one rib derives support from another, often several ribs become fractured in series and, inasmuch as the points of fracture usually occur in line with each other, the resulting deformities appear as sharp ridges running obliquely down the side of the chest with a depression in front of them. It is of course impossible to do more than indicate the bizzare forms which the thorax may assume under the influence of the rachitic process with its resultant fractures.

When inspiration takes place in the deformed thorax just described, almost every deformity which has been mentioned becomes intensified. The depressions at the sides lengthen, broaden and deepen. The floor is carried backward and inward toward the vertebral column, in severe cases from 1-1.5 cm. and even 2 cm. As the lateral depression en


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larges, the posterior angles of the ribs involved narrow, and the whole posterior costal arch undergoes a displacement backwards. The prominence formed by the sternum and costal cartilages narrows as if squeezed together at its base. The manubrium moves slightly fonvards and upwards. The lower end of the gladiolus remains stationary or is drawn backward; in some cases it moves slightly forwards as in older children with chicken-breast. Often the sternum describes see-saw movements with respiration, or with each inspiration the middle part of the sternum bows forward beyond its upper and lower ends. In general, it may be said that every hollow, every eminence, ever}' peculiar curvature or inequality present during expiration becomes increased during inspiration.

The moment that the inspiratory effort is complete, the whole thorax snaps back into the expiratory position as if released from a spring.

If measurements of the circumference of the tiiorax are tnken, it will be found that the circumference at the level of the nipple either increases to the extent of only 1 or 2 mm. during inspiration or is not increased at all or undergoes an actual loss (Fig. 5). In realitj-, however, it is impossible to obtain correct measurements of the variations in the circumference of the thorax during inspiration, because the tape bridges over the hollows of the sides. It is difficult to detect, anywhere in the diseased thorax, movements of the ribs occurring during inspiration which would bring about an actual increase in intrathoracic volume save the feeble upward and forward movements of the upper part of the thorax indicated by the slight movements in those directions of the manubrium. The evidence of the loss of intrathoracic space during inspiration in the collapse of the thoracic frame at the sides is so apparent as to leave little doubt that, the movement of the ribs alone considered, the net result of any given inspiration must be actual loss. Since the child remains alive, however, there must be some mechanism available through which the capacity of the thorax is increased with eacli, inspiration. That mechanism must lie in the diaphragm. We shall return presently to the discussion of the diaphragmatic function.

The deformities and unusual movements of the thorax just described are brought about because the bony thorax has lost its rigidity. This loss of rigidity is the direct result of the failure of calcium deposition and, very probably, also, of resorptive processes in the bones themselves set in Operation by the disease. The ribs, nonnally composed largely of inorganic material, firm and unyielding, become composed chiefly of organic material and are soft and yielding, The shafts of the ribs of some of the children, who have died, offered about the same resistance to bending as if they had been composed of pasteboard. In these severe cases fractures are almost regularly present. In one ease we counted twenty. These further greatly impair the rigidity. The most extreme weakening at any portion of the costochondral arch develops at the costochondral junctions. .

Under normal conditions the cartilage and shaft of the rili meet as do two accurately matched beams. The opposed ends


of cartilages and ribs are slightly uneven and are to a certain extent mortised into each other. The union between cartilage and shaft is made firmer by the columns of calcified intercellular substance wliieh,- forming in the tenninal zone of cartilage, extend like so many nails into tlie substance of the shaft. The normal costochondral junction is so strong that, when an attempt is made to break it, it is the shaft of the rib which buckles under the strain. In rickets a zone composed of osteoid tissue (bone tissue devoid of its normal content of calcium), connective tissue, blood vessels and degenerated and undegenerated cartilage in the form of bands and islands, gradually forms between the cartilage and shaft. This heterogeneous mass of tissue, known as the transitional zone or metaphysis, has no rigidity and is capable of offering about the same degree of resistance to any deforming force as connective tissue. As a result of forces acting upon the thorax, the weak metaphysis begins to yield almost as soon as it begins to form. The costal cartilages, wholly unaffected by the disease, retain their normal elasticity and, when forced inward during inspiration, tend always to spring back into their normal positions. The diseased ribs, however, never having possessed an elasticity at all comparable to that of the cartilage, lose the greater part of what was formerly theirs. As the result of the continuously repeated strain, to which they are subjected by inspiration, they become bent further and further inwards until finally their extremities lie internal to the cartilage. In the most severe forms of rachitic involvement of the thorax the costochondral junctions become so deformed that the end of the cartilage is no longer joined to the end of the shaft but to the outer side of the end of the shaft (Fig. 6). When the costochondral junctions have become affected to this extent, all rigidity has long since disappeared ; indeed the shaft and cartilage have become so loosely attached to each other that a considerable degree of motion can readily take place between them. In this state the costochondral junction really constitutes a false joint.

The forces that operate to produce deformity in the thorax are the negative pressure in the thoracic cavity existing during inspiration, the elasticity of the lungs, the pull of the diaphragm and of the various voluntary muscles passing to the thorax from the abdomen and neck. To this list of forces might be added two of less importance, gravity and intraabdominal pressure. With the exception of gravity, the forces mentioned are applied either solely or in by far their greater part during inspiration. The normally curved, strong, resilient thorax of the healthy child withstands them completely. When the negative pressure within the normal thorax reaches extreme heights during inspiration as in laryngeal stenosis, it is always the costal cartilages of the lower ribs and the lower part of the sternum which yield and are sucked backwards. The ribs and costochondral junctions unaffected by disease are capable of withstanding great strain. The diseased ribs and costochondral junctions which form the wall of the rachitic thorax cannot do so. The forces brought to bear upon them gradually cause the shafts of the ribs to sink inwards anteriorly, carrying the cartilages with them. The


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muscles of the neck attached to the first and second ribs and clavicles pull these bones upwards. The abdominal muscles draw the lowermost ribs downwards. Intra-abdominal pressure, if in excess of the normal, forces the lower aperture of the thorax outward. The weakened thorax has become the prey of every force exerted upon it.

Eeference has already been made to the fact that the circumference of the thorax is diminished, remains stationarv-, or is increased verj- slightly during inspiration. Although it is impossible to determine the point, it is highly probable that as the result of thoracic respiration alone an actual loss of intrathoracic space would occur during inspiration. It is the action of the diaphragm that makes life possible. But the diaphragm can act to advantage only when its points of attachment remain firm. In the weakened thorax of rickets the diapliragm expends part of its energy in drawing its own points of attachment inward. In so doing it diminishes the extent of its descent and impairs by just so much its power to increase intrathoracic space. This is not all. Owing to the deformity of the thorax, the diaphragm must tend to remain even in expiration in a state of partial inspiratory contraction. When inspiration takes place, it miist commence its contraction from a position of partial contraction and is able, therefore, to accomplish only the last part of the work which, as a muscle in a state of normal relaxation at the outset, it would be capable of accomiDlishing. It is quite possible also that the contractile power of the diaphragm is impaired as a result of the rickets itself.

The changes just described in the thoracic wall must inevitably lead to changes in the thoracic contents. When the thorax is opened, attention is immediately attracted to two striking conditions (Fig. 7), the knuckle-like enlargements at the costochondral junctions which project a considerable distance into the thoracic cavity, and the grooves, one on the external surface of each limg not far from the anterior border, running in a direction from above downward, outwards and backwards. If the lungs are pulled forward into their anatomical positions, the grooves on the surface of the lungs come to lie directly opposite the lines of the deformed costochondral junctions, and the relationship between the two is clearly shown by the presence of depressions in the grooves exactly corresponding to the costochondral prominences themselves. In reality the depressions are moulds of the prominences. When the lungs are removed from the thorax, it is seen that they are far too small for the size of the child. The right lung is usually proportionately smaller than the left. It can then be seen that the grooves divide the external surface of each lung in such a way that roughly one quarter lies in front and three-quarters behind. That part of the lung in front of the groove is for the most part emphysematous, while that part lying behind it is generally dark bluish in color and of a finn consistency. Obviously it is atelectatic. It is not entirely atelectatic, however, for interspersed with the collapsed pulmonary tissue is tissue in a state of emphysema. In some cases the greater part of one lobe is atelectatic. On section through the lung, it can be seen that the floor of the groove


is composed of atelectatic tissue and that the thickness of the limg at the groove has been reduced to 2-3 mm. Further, the part lying in front of the groove, though chiefly of emphysematous tissue, contains scattered areas of atelectasis, while behind the grooves atelectasis so predominates over emphysema that the greater part of the lower lobe appears to be collapsed (Fig. 8). Areas of lobular pneumonia are almost always present. They are not large and frequently cannot be recognized on gross examination. The cut surface almost invariably exudes serum, showing the presence of edema. No pleurisy is present. In some cases, however, adhesions are found between the visceral pleura and the sharp points at the summits of the knuckle-like enlargements of the costochondral junctions (Fig. 6). These points are formed by the projection of the pointed shafts of the ribs through the rachitic metaphyses. The adhesions are produced by the irritation of the sharp bony points against the pleural surface. On microscopic examination of the lungs atelectasis is the predominating and essential condition in the more solid parts. Evidences of inflammation can usually be found, but large areas of the lungs are not the seat of pnemnonic consolidation.

As a result of the deformity, the thorax becomes divided into two communicating chambers (Figs. 9 and 10), an anterior one bounded in front by the sternum and abnormally arched costal cartilages and at the sides by the projecting walls of deformed costochondral jtmctions, and a posterior one bounded by the rest of the thorax. In the anterior chamber the heart is imprisoned. The apex of the heart always lies against the barrier of the costochondral junctions on the left, usually at the level of the fourth or fifth rib. The distended right auricle, forming the right border of the heart, reaches to within a short distance of the costochondral junctions on tlie right side.

On removal of the heart and exposure of its cavities, that of the left ventricle appears to be normal in size and to have normally developed internal musculature, but that of the right ventricle often appears dilated and hypertrophied (Fig. 11). The latter stands open and is half again as large as the cavity of the left ventricle. The columnae earneffi are thick and flattened out against the ventricular well. Though the weight of the body is considerably less tlian the average for the age, the weight of the heart may equal or even exceed the average for the age. The wall of the left ventricle is of normal thickness ; the wall of the right ventricle is frequently much thickened. Hypertrophy of the heart is, therefore, present, and the part giving evidence of it is tlie right ventricle. In one of our cases there was hypertrophy of the left ventricle as well. Upon the surface of the liver can invariably be seen the imprints of the 7th, 8th and Oth costal cartilages impressed through the diaphragm. The intestines are usually distended.

A number of months of progressive rickets must elapse for the costochondral junctions and shafts to become so weakened that the characteristic clinical condition develops. The clinical picture in well marked cases is as follows : The child lies on the back with arms at the sides and legs semiflexed and rotated outward ( Fig. 1 ) . The external rotation of the legs.


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due to the laxity of the muscles and ligaments and probably also to curvatures in the bones themselves, is so extreme that, though flexed, the knees lie in contact with the bed. The child lies remarkably still, never attempting to change the position of the body and only occasionally turning the head or shifting slightly the extremities. The head shows the marks of rickets, as do the extremities, and the forehead is frequently covered with sweat. The large head appears as if placed directly on the thorax. The chin rests against the upper part of the chest and a deep fold in the soft parts alone indicates the neck. The expression is anxious. The mucous membranes may be slightly cyanotic. The dyspnea is extreme; the respirations are from 60 to 100 a minute — and in one case 150. They are accompanied by dilatation of the nostrils and an expiratory grunt. A cough occurs from time to time, usually singly, separated from succeeding coughs by one or more respirations. Sometimes, however, the cough comes in short paroxysms which seem to distress and terrify. The respirations are shallow. With each inspiration the thorax contracts. When the child coughs its collapse is doubled. As the thorax sinks in with each inspiration, the abdomen expands. Indeed the appearance suggests that the contents of the thorax are being rhythmically squeezed into the abdomen rather than that the lungs are being inflated and the normal process of respiration is taking place.

On account of the almost continuous movement of the thorax, especially marked and jerky in the region of the eostochondral junctions, the determination of the location of the apical impulse of the heart is exceedingly difficult. It may be impossible to locate it. Usually it can be seen in the fourth or fifth spaces or in both about 1 cm. beyond the nipple line, often in or just beyond one of the depressions at the costochondral junctions. In some cases the apex impulse is strong and visible over rather a wide area and can be felt ' as well as seen. There may be marked epigastric pulsation, or pulsation over the entire left side of the precordium. It is impossible to determine the location of the left border of the heart by means of percussion on account of the proximity of the enlarged costochondral junctions and impossible to determine the right border by that means with any degree of accuracy, not only on account of the changes in curvature and the abnormal character and asymmetry of the thoracic wall already described, but on account of the abnormal conditions in the lungs themselves. If, however, the costochondral junctions on the two sides lie close together, it may be assumed that the right border of the heart is close to the wall formed by the costochondral junctions of the right side, that


' \Mierever on tlie chest wall the apex impulse of the heart may appear to be, however, there can never lie any doubt in regard to the situation of the apex of the heart itself. The heart is always imprisoned in the space bounded in front by the sternum and cartilages and at the sides by the wall of costochondral enlargements which project into the cavity of the thorax. Beyond the barrier of the costochondral junctions the apex of the heart never passes. Any impulse whicli the heart can communicate to the chest wall by means of its apex is caused by the impingement of the apex against one of the costochondral junctions in the barrier.


is, the heart occupies the entire space between them. The action of the heart is very rapid. Unless cardiac disease unrelated to the rickets is present, the sounds are clear. We have never observed an accentuation of the pulmonic second sound which could be regarded as pathological.

In the examination of the Itmgs it is diffitult to obtain accurate information concerning pathological conditions by means of percussion on account of the abnormal physical conditions in the thorax itself. Changes in percu.s.sion resonance are always present and easily demonstrated, but are not necessarily produced by changes in the lungs. Usually an impairment of the percussion note can be found in some portion of the chest, but in our experience it is never great. In not one of our cases was there well marked dulness. The breath sounds also are subject to great variation in different parts of the chest. In the lateral depressions they are often of an exaggerated vesicular character. Invariably in some parts of the thorax the breath sounds are greatly diminished and may be scarcely audible. The respiratory murmur may be higher pitched than normal, expiration may seem prolonged but loud bronchial breathing is never present. Eales can always be heard. They may be abundant or few, fine or moist, but are never evenly distributed throughout the lungs. They are most apt to be numerous over the bases of the lungs. The liver edge can be felt, usually 4 cm. or more below the costal margin. The spleen is often jDalpable.

The X-ray findings in the chest are characteristic (Figs. 13 and 13). The ribs look extraordinarily slender and have a porous appearance. They are bent and have lost their normal inclination and parallel arrangemeWt. Fractures, even though present, are not evident. In cases of long standing rickets, in which the thorax has finally acquired rigidity, the ribs may appear greatly thickened. If scoliosis of the vertebral column is present, it is of course v'isible. The heart seems disproportionately large for the size of the thorax, often appearing enormous in comparison with the latter. On both sides of the heart are longitudinal slmdows with indefinite margins 1-1.0 can. mde (in X-ray plates of ordinary magnification). They extend downwards, at the same time curving slightly outwards, from a point at about the level of the second or third thoracic vertebra to the shadow of the liver and diaphragm below. The one on the right side begins near the shadow of the vertebral column above and is separated by a slight interval from the right border of the heart below. The one on the left side merges as it descends with the shadow of the heart or skirts the left border of the latter. The two longitudinal shadows are produced by the atelectatic lung beneath the costochondral junctions. If the costochondral junctions themselves cast shadows, as they do when healing has commenced, these also share in the formation of the longitudinal shadows. Elsewhere the lungs have an irregularly hazy appearance, due to the existence of scattered areas of atelectasis and also in some cases to scattered areas of an inflammatory nature. The lungs external to the longitudinal shadows never appear clear and never show the large dense clearly outlined shadows of complete consolidation. The


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X-ray findings in the thorax in these cases, though quite typical, are often erroneously considered to indicate tuberculosisj

The clinical picture just described greatly resembles that of pneumonia and is usually considered such. Yet the temperature is rarely greatly elevated, and is not infrequently normal (Fig. 14). In one of our cases the temperature was normal for the first seven days in the hospital. It began to rise only two days before death, reaching at that time 101° F. During the nine days of observation the respirations were never less than 60 and averaged between SO and 100 to the minute. The leucocyte count also is low. In the 23 cases the leucocyte count varied between 4000 and 18,000 and averaged 11,000. In some of the severest cases the leucocyte count did not exceed 8000, Another fact of importance is that the symptoms remain but slightly modified after the evidences of infection have disappeared. The clinical picture just presented is caused by the loss of the rigidity of the respiratory frame, the result of the rickets. The infection is subsidiary; it furnishes the extra burden which the enfe.ebled thorax cannot bear.^

The sequence in the development of the condition seems to be as follows : The rachitic thorax loses its rigidity, yielding during inspiration simultaneously at costochondral junctions and shafts. As the rigidity of the. thorax becomes diminished, the depressions at the sides, which at first were present only during inspiration, persist during expiration. As the bones progressively lose their elasticity, the djTiamic deformity gradually becomes static as well. Thoracic respiration is at first slightly, later profoundly, affected. Coincident with the impairment of thoracic respiration diaphragmatic respiration is enfeebled. The efficiency of each inspiration, therefore, is diminished. A compensation is attempted in an increased frequency of respiration and in an increased force. Biit the greater the force applied, the greater the collapse produced. Nature's efforts in large part defeat themselves. The diaphragm pulls its attachments yet further inward, and the accessory muscles draw the bones to which they are fastened out of position without moving or giving stability to the thorax as a whole. Owing to the progressive reduction in the size of the thorax and its loss of power to expand, the lung begins to become atelectatic. One of the parts early affected is that pressed upon by the costochondral junctions. As the pathological process progresses, the atelectasis increases ; the pressure in the pulmonary circulation rises ; and hypertrophy of the right heart follows. If the rigidity of the ribs becomes still further impaired, a point is reached at which the disabled respiratory machine is just sufficient to perform its work. If now a slight additional burden is put upon it in the form of an infection, it becomes insufficient. Xature resorts to the only expedient possible ; the fi'equency of respiration becomes enormously increased; the clinical condition above described ensues.

The course in such cases as we have been discussing is subject to great variation. In one group of chiklren the rcspira


' See legend explaining Fi]


tory symj)toms and distress became progressively worse until death intervened. In another group the condition remained essentially unchanged over a long period. From time to time the temperature would rise to 103° or 103° F. without apparent cause or any increase in the number of white blood cells. It would remain elevated for a day or two, and then fall to normal again. With the rise in temperature, the respiration would become more rapid and the respiratory distress more acute. Death often seemed to impend, but with the fall in temperature the condition of the child would again ameliorate. This state of affairs, characterized by alternating exacerbation and decline of symptoms, has continued for weeks. Such children after spending several weeks in the hospital improve sufficiently to leave, but in a short time are readmitted in the same dangerous condition as before.

If a child does not die, he may gradually improve, even though the rickets continues and lime salts are not deposited in the bones. The shafts of the ribs and the costochondral junctions ultimately may acquire sufficient strength to withstand the forces exerted upon them. Given time, osteoid tissue is produced in such quantity both in the cancellous tissue, under the periosteum and in the metaphysis itself as to supply the requisite rigidity. Even though the costochondral junctions remain weak, respiration will take place in a normal or approximately normal manner provided the shafts of the ribs acquire sufficient strength. Ultimately a rigidity may be furnished the ribs through an overproduction of inferior material. It is due to this fact that we do not often see cases, such as have been described, in children older than 3^ years. Extreme deformities of the thorax are common enough in children 3 and 4 years of age, but the deformed thoraces will almost always be found to be rigid, and the bones of such children, not only the ribs but also the bones of the extremities, will be seen to be enormously thickened when studied by means of the X-ray. The children of our series whose thoraces were the weakest were children from 8 months to 1^ years old. For the com pr eh ens-ion of the condition it is necessartj to realize that deformity and normal thoracic function are compatible, in other words, that the element of danger is not the deformity hut the loss of rigidity of the thoracic wall.

With the aid of cod-liver oil calcium salts can be deposited in the rachitic metaphyses and shafts and a true healing of the disease accomplished. In spite of this, however, the deformities will persist for months or years. But gradually, we cannot say how rapidly, the deformities of the thorax are outgrown. In adults and in older children malformations of the thorax, such as we have described, are never seen. Changes iu the extremities such as bow-legs and knock-knees are common enough in adult life. It is rare, however, to find a rachitic adult showing more than slight evidence of previous thoracic deformity. The pigeon-breast of older children and adults is usually a late development for which continued obstruction in the upper respiratory tract rather than rickets is responsible.

In regard to the mortality we cannot say a great deal. Out of a series of 23 well marked cases studied in the hospital, we


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know that 11 have died." It is probable that others of the 22 children discharged have died outside the institution as the result of the rachitic involvement of the thorax. The mortality in the severely affected cases is undoubtedly exceedingly high.

Eickets is often looked upon as a disease that in itself does not threaten life. It does threaten life, however, and may be the direct cause of death when it deprives the thorax of its rigidity. It increases the danger to life from all respiratory infections, e. g., tuberculosis, pneumonia, at that moment when it causes the thorax to yield during inspiration.

Treatment must be prophylactic. Such extreme rachitic changes as we have described should never develop. To bring rickets to a sudden termination is in the present state of our knowledge out of the question. To offer mechanical support to the yielding ribs through orthopedic devices seems impracticable. At present the only course is to administer cod-liver oil iu moderate doses, to avoid infection and those things which give rise to abdominal distention.

Before concluding this paper, we wish to point out that we have found in the rats rendered rachitic by means of faulty diets* a condition identical with that Just described in children, the subjects of the most severe rachitis. In the course of severe rickets in the rat, growth becomes greatly inliibited. The weight falls far behind the weight of the healthy animal and finally remains stationary. Growth in length is also much retarded. Multiple fractures of the ribs develop. As a result of the weakening effects of the disease upon the bones, the shafts of the ribs and the costochondral Junctions lose their rigidity. The thorax collapses at the sides and the costochondral Junctions become deformed and displaced well into the interior of the thorax. The costal cartilages Join the shaft often at right angles and are attached not to the ends but to the outer sides of the shafts near the end. The deformed costochon(Jral Junctions of the rachitic rat are the deformed I ostochondral Junctions of the rachitic child in miniature. The sternum and adjacent portions of the cartilage are thrust forward and the sternum acquires an abnormal forward inrlination as it descends, exactly as in the human being. As tlie result of the displacement of the costochondral junctions ) II ward, the thoracic cavity becomes divided into the two chamliers already described (Fig. 15). The heart is imprisoned in the anterior chamber, which it completely fills. The lungs are partially collapsed and show bands of atelectasis in those parts subjected to the pressure of the costochondral junctions, and scattered areas of atelectasis elsewhere.

With each inspiration the whole lateral wall of the thorax >inks forward. Eespirations are enonnously increased. In •me rat, the subject of advanced rachitis of the thorax, the respirations numbered 220 to the minute. If the faulty diet is continued a sufficiently long time, the animals die. Whether they die, however, as the result of the loss of rigidity of the thorax or from other causes, we have not tried to determine.


' One of the 22 cases is a child just admitted to the hospital. The outcome is uncertain.

'Jour. Biol. Chem., 1921, XLV. .3.33.


DESCRIPTION OF PLATES

Fig. 1. — H. B., aged 17 months. The depression at the side of the thorax is well marked, as is also the rounded ridge created by the posterior angles of those ribs forming the floor of the depression. The rounded elevation formed by the posterior angles of the ribs is the posterior boundary of the depression, and sharply separates the back from the antero-lateral surface of the deformed thorax. The forward inclination of the sternum and the recession of the ensiform cartilage are well shown. The picture of the child is quite typical. Though the legs are flexed, the knees are in contact with the surface of the table.

Fig. 2. — Photograph of E. D.. aged 3i years. The collapse of the sides of the thorax is extreme. The left side is more sunken than the right as the result of fractures of the ribs.

Fig. 3. — Photograph of S W., aged 3J years. The deformity of the thorax is typical. The photograph is reproduced to show the high position of the thorax. The manubrium immediately underlies the chin. The neck is marked by a fold. The deformity of the vertebral column is characteristic of rickets. In reality, the child no longer belongs to our series of cases, because the ribs and costochondral junctions had acquired sufficient rigidity through an overproduction of osteoid completely to withstand the forces exerted upon them. The bones of the extremities had become enormously thickened.

Fig. 4. — R. W., aged 28 months. The depressions at the sides of the thorax, when marked, narrow the back. At the level of the scapulse there is lordosis, but below in the region of the lower dorsal and upper lumbar vertebra; a well marked rachitic kyphosis. The abdomen is large. The child is obliged to support the body with the hands in order to sit. In the most severe cases the child is too weak to sit.

Fig. 5. — Tracings from chest and abdomen of J. R., aged 16 months, to show that the circumference of the thorax may actually undergo a decrease during inspiration. Thin pneumatic bags were placed, one around the middle of the chest so as to cross the lateral depressions, the other around the abdomen. Both bags were covered with thin bands of canvas, filled with air and connected with tambours.

Tracing 1 records the movements of the thorax. Inspiration begins at a and ends at h. The tracing shows that a progressive diminution in the size of the thorax, measured in the horizontal plane, occurs during inspiration. The sharp rise in the tracing marked x was produced as the result of the sudden recoil of the thorax occurring immediately after the inspiratory efl'ort was finished. The thorax seems to snap from the inspiratory to the expiratory position at the end of inspiration like a suddenly released spring.

Tracing 2 shows the increase in the circumference of the abdomen during inspiration, a marks the beginning of inspiration, b its termination.

The loss of rigidity of the thorax was so great that the slight pressure from the inflation of the pneumatic bags was enough to cause asphyxia and cessation of breathing. The child was resuscitated with great difliculty and the attempt to obtain further tracings abandoned.

It is appreciated that the records obtained by the method described do not give exact measurements of the variations in the size of the thorax during respiration. They show definitely, however, that in severe rickets the thorax may undergo a marked decrease in size at the level of the lateral depressions while inspiration is taking place.

The tracings were obtained through the kindness of Dr. Harold L. Higgins.

Fig. 6. — A section taken in the horizontal plane through the enlargement formed by the junction of the cartilages and rib from the thorax of A. H,, aged 14 months. The section was stained with hematoxylin and eosin.

a — shaft.

b — undifTerentiated cartilage.

<• — cartilage of the proliferative zone.


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d — the transitional zone or metapliysis lying between the proliferative zone of cartilage and the shaft. In this zone tongues and bands of cartilage (like the rest of the cartilage appearing black) are interspersed with composites of tissue made up of connective tissue, blood vessels ending in large tufts, degenerated cartilage in the various stages of metaplasia into osteoid, and osteoid itself.

e — connective tissue and osteoid filling in the crevice between the cartilage and transitional zone on the one hand and the outer surface of the shaft on the other.

/ — a piece of the visceral pleura which adhered to the pointed end of the shaft protruding through the costochondral enlargements. The visceral pleura rubs again.st the sharp point of the shaft and finally becomes attached. Although the section shows the tag of visceral pleura, it misses the protruding end of the shaft which lay in another plane than the plane of the section. The cartilage and shaft meet at right angles. The cartilage is joined to the shaft on its outer side.

Fig. 7. — The thorax of W. M., aged 1 6 months, opened at autopsy. The costal cartilages have been cut through near the costochondral junctions and removed together with the sterniun,.

a — enlarged costochondral junctions; the cut ends of the cartilages are visible. The cartilages meet the shafts in some instances at right angles. The bulbous character of the enlargements of the costochondral junctions and the knuckle-like projections which they make into the interior of the thorax are well shown. The sharp ends of the shafts of the ribs can be seen protruding through the inner side of the enlargements and forming their summits.

b — grooves on the external surfaces of the lung produced by the pressure of the enlarged costochondral junctions. The thoracic wall has been retracted so that the grooves are exposed to view.

c — emphysematous lung in front of the grooves. As a result of the partial compression of the bronchi by the enlarged costochondral junctions the discharge of air from those portions of the lung internal to the grooves is interfered with. A condition of emphysema is therefore produced.

d — a large part of the left lung is atelectatic.

Fig. 8. — A section taken through the lung of A. H., aged 14 months, to show the combination of atelectasis and emphysema.

a — atelectatic lung underlying the enlarged costochondral junctions.

6 — atelecta,tic lung bordering on the vertebral column.

c — pulmonary tissue in a state of emphysema.

" The left lung is apparently diminished in volume. A vertical groove traverses the lateral aspect of the upper lobe in such a way as to separate the anterior quarter from the posterior three-quarters. The groove is formed by atelectatic tissue. In front of the groove the lung is downy and yellow, in a state of emphysema. Behind the groove the lung is pink, showing areas of emphysema and some atelectasis. The groove traverses also the lingula, separating the tip which forms a rounded inflated mass l)y a neck of atelectatic tissue from the portion behind. The paravertebral parts of both lower and upper lobes are in a state of atelectasis. The surface is depressed and dark blue and the interlobular tissue is visible. Scattered elsewhere through the lower lolie arc liluish depressed areas of atelectasis."

" The right lung is also reduced in bulk. The groove marked by the atelectasis is even more conspicuous. Where it crosses the middle lobe it is 2 em. in width and the floor thereof 2 mm. in thickness. That part of the middle lobe which lies in front of it is distended to its utmost capacity and is downy and white. Tlie grooving of the upper lobe is very pronounced. Fully one-half of this lung appears collapsed. All that part in the paravertebral groove and by far the greater part of the rest of the lower lobe is atelectatic. The apex and that part of the lower lobe which lies in front of the groove above mentioned are extremely distended, ^'iewing the lung from the inner side and below, it is seen that the atelectasis occupies large areas, tending to be most marked in the region of the hilus — but extending to the periphery." [Quotation from autopsy protocol.]


Fig. 9. — Views of the normal thorax; a — cut across at the level of the sixth rib and viewed from l)elow; 6 — ^viewed from in front.

Fig. 10. — Views of the deformed thorax in rickets.

a — a not very severely deformed thorax cut across through the sixth rib and cartilage, viewed from below. Note the asymmetry. The projections inward of the deformed costochondral junctions divide the thorax into two chambers. In the anterior one the heart is contained. As usual the recession inward of the thoracic wall is greater on the right side than on the left, and the arch of the ribs and cartilages correspondingly increased. Attention should be called to the fact that the thorax is in the position in which the deformities are least marked. If the drawing had Ijeen made from the thorax in the position of inspiration instead of e.'cpiration, the degree of deformity would have been increased almost two-fold. The costochondral junctions would have been 1 cm. or more nearer the vertebral column; the anterior chamber would have been correspondingly narrowed and the arching of the ribs increased.

b — The thorax of the same child, viewed from in front. The malformation is more marked on the right side than on the left. The enlargement of the costochondral junctions is very slight externally but well marked on the inner surface of the thorax. Owing to the collapse of the thoracic wall inwards and backwards toward the vertebral column, the costal margins have been drawn upwards and backwards over the surface of the liver, so that a much larger part of the latter is uncovered than under normal conditions.

c — the junction of cartilage and shaft of the rib viewed from in front. The cartilage has been twisted about probably as the result of the rotatory movements to which the shaft of the rib is subject, so that it no longer lies in line with the shaft even in the horizontal plane. The enlargement is much greater on the inner than on the outer side.

d — junction of cartilage and shaft seen from below. The projection of the sharp end of the shaft through the enlargement formed by the abnormal junction of cartilage and shaft is well shown. The projecting point of the rib forms the summit of the enlargement.

Fig. 11. — Photograph of the heart of A. H., aged 14 months.

a — left ventricle;

b — right ventricle. Note the hypertrophy of the internal musculature of the right ventricle.

Right chamber shows great hypertrophy and is dilated. Its wall measures 3 to 5 mm. in thickness. The wall of the left ventricle close to the aortic ring measures 1 cm. The internal musculature of the left ventricle seems normal. The internal musculature of the; right ventricle is hypertrophied. Valves normal. \Veight of heart 85 gm." [Quotation from autopsy protocol.] (Body weight not recorded. )

Fig. 12. — X-ray photograph of chest of C. H., aged 10 months. The ribs appear extremely slender and porous. They do not show the normal inclination and parallel arrangement. Some of them are greatly bent. On either side of the shadow cast by the heart are the longitudinally directed shadows cast by the strips of atelectatic lung underneath the enlarged costochondral jimctions. The longitudinal shadow on the right side is separated from the shadow of the right border of the heart by a just perceptible int^rvaL The shadow on the left side skirts the left border of the heart above and merges with it below. Evidently the heart extends from one row of costochondral junctions to the other. The lungs beyond the longitudinal shadows have a hazy appearance. The evidences of rickets in the humeri and scapula; are well marked. The X-ray photograph is typical.

Fig. 13. — The X-ray photograph of thorax of V. F., aged 17 months. The heart shadow is well defined and large in comparison to the size of the thorax. On the right side of the heart shadow and on the left side are shadows caused by the deformed chest wall. The sides of the chest have sunken to such an extent that the portions of the thoracic wall forming the anterior parts of the depressions lie in the antero-posterior plane, that is, parallel to the Roentgen rays in


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THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL, 1921




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JOHNS HOPKINS HOSPITAL BULLETIN


109


stead of perpendicular to them. The shadow on the right side completely outlines the anterior margin of the depression. The shadowon the right side east by the atelectatic lung underneath the enlarged costochondral junctions is merged with the shadow cast by the deformed chest wall while on the left side the shadow is continuous with the shadow cast by the latter. The heart must touch the row of costochondral junctions on the left side and extend almost to the row on the right. The ribs have a porous appearance and are abnormally bent. Scoliosis of the vertebral column is present.

The X-ray photograph in this case, showing so plainly the deformity of the chest wall, is unusual. It is reproduced for that reason.

Fig. 14. — Temperature chart of V. F., aged 17 months. Throughout tlie period of observation in the hospital the respirations


during waking or sleep were never less than 60 to the minute. The thorax was greatly deformed and weakened. With each inspiration the collapse of the sides was extreme. The physical signs in the lungs were characteristic. There was no evidence of a pneumonic process either on physical examination or on examination with the X-ray. The respirations became more and more labored. Death seemed to occur from exhaustion.

Fig. 15. — A segment of the thorax of a rachitic rat viewed from below. Note that the costochondral junctions form marked prominences internally and divide the thorax into two chambers. In the anterior chamber the heart is, so to speak, imprisoned, exactly as in the case of the human subject. Note the abnormal curvature of the shafts of the ribs, and the asymmetry.


DIPHTHERIA BACILLUS CARRIERS

A REPORT OF CONDITIONS FOUND IN AN ORPHAN ASYLUM

By W. L. ]\Ioss, C. G. Guthrie and J. Geliex

(From tlic Division of Clinical Pafhologi/ of the Medical Clinic, The Johns Hopkins University and Hospital)


Dtiring an investigation of dii^litheria bacillus carriers in the winter and' spring of 1912 * throat cultures were taken from 800 children attending one of the public schools of Baltimore. From the carriers disclosed by the examination of these cultures, 50 were selected at random for further study. Throat cultures were taken from this group of 50 carriers at inten'als of two weeks for ten weeks and a fortnight later cultures were taken from the entire 800 children. There were thus seven observations on 50 of the children and 2 on the remaining 750 over a period of three months. At the time of each of these seven observations, the condition of the throat was noted and the temperature was taken at each examination except the first. An attempt was made to isolate diphtheria bacilli from each of the positive cultures encountered, and the strains isolated were then tested tinctorially, culturally and for virulence. Some weeks after the last series of cultures, a systematic effort was made to determine the relation of the carriers found to the community at large. The detailed results of this investigation may be found on reference to the paper cited above but are summarized briefly here.

1. The first examination in February, 1912, revealed 85 carriers among the 800 children, or 10.62 per cent. Ee-examination of the same 800 children three months later showed 69 carriers, or 8.62 per cent. It was a striking fact, however, that only 10 of the children gave positive cultures at both examinations. The number of children yielding positive cultures at either one or the other examination was 144, or 18 per cent.

2. Definite statements could not be made with regard to the actual duration of the carrier state in the 50 carriers selected for rei^eated study, but our findings indicated a progressive diminution in the number of positive cultures found

Guthrie, C. G., Gelien, J., and Moss, \V. L. : Diphtheria Bacillus Carriers: Second Communication, Johns Hopkins Hosp. Bull., 1920, XXXI, 388.


at the successive examinations and at tlie last examination only six showed diphtheria organisms.

3. The diphtheria bacilli found in the throats of these carriers were typical Klebs-Loeffler organisms, but many of the straiHfe were non-virulent. The non-virulent strains apparentlylliftej-ed from the virulent ones only in their ability to produce toxin. Since the other members of the diphtheria group encountered in the throat were readily distinguished from B. diphihericE, they caused very little difficulty in diagnosis and were considered of no pathogenic importance.

4. Virulence tests showed that only about 11 or 12 per cent of the carriers which we studied harbored virulent organisms and that of the total positive cultures obtained only about 10 or 11 per cent were virulent.

5. Xo convincing proof of a change in virulence of the organisms in the throat was obtained.

6. To quote directly concerning the relation existing between the presence of diphtheria bacilli and pathological throat conditions other than clinical diphtheria : " Our general impression upon this point is that the mere presence of diphtheria bacilli in the throats of carriers is not responsible for any objective pathological condition whatever, and does not cause an elevation of temperature. On the other hand, persons with pathological throat conditions other than clinical diphtheria, particularly those with diseased tonsils, seem to furnisli a somewhat more favorable field for the lodgment and growth of the diphtheria bacillus than that-aft'orded by persons with normal throats."

7. Regarding the relation of the 160 carriers investigated by us to the occurrence of clinical diphtheria either in themselves or in their associates :

(a) Only 11 gave a history of having had diphtheria, but none more recently than three years previous to the time of our study.


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(ij) None of the carriers subsequently developed diphtheria during the period that they were under obsen-ation.

(c) Fourteen gave a history of exposure to diphtheria at a period varying from 1 to 12 years previous to the time cultures were made.

(d) A painstaking investigation revealed no case of diphtheria among any of the associates of the 160 carriers.

As a result of these findings we felt Justified in emphasizing certain points as follows :

1. The wide prevalence of diphtheria bacillus carriers.

2. The great preponderance of non-virulent bacillus carriers over virulent bacillus carriers.

3. The inability of non-virulent diphtheria bacilli to produce diphtheria.

4. The harmless nature of non-virulent bacillus carriers.

5. The injustice of interfering with the liberties of carriers of non-virulent diphtheria bacilli by quarantine or other measures.

6. The erroneous nature of information concerning the part played by carriers in the spread of diphtheria unless consideration is given to the nature of the organisms harbored by them.

Certain additional information obtained from our study of these children but not embodied in the original report, illustrated in a striking manner one phase of the diphtheria carrier problem, and forms the basis of the present paper.

On looking over the list of 85 carriers detected in the first 800 cultures, some very interesting facts were noted. First, a very large number of these carriers — 26, or 30.59 per cent — came from the same street address ; second, among the 50 carriers selected at random for repeated examination, 22, or 14 per cent, came from this address ; third, among the 81 children from this address, who were examined, 32.09 per cent gave positive cultures. This state of affairs seemed to demand further investigation, which showed that the street number in question was that of an orpha-n asylum. The information obtained concerning this institution from the superintendent who has had charge of the asylum since 1894 was as follows : The asA'lum was founded in 1863 and has occupied its present location since 1874. White children only are admitted, but no distinction is made as to nationality or religion. Beyond this the only requirements are (1) that the child is an orphan, (2) is from 3 to 10 years of age, (3) is pronounced sound by the regular medical examiner of the institution and (4) that the financial condition is such as to require aid. At the time our cultures were taken there were 123 inmates, exclusive of the executive staff and attendants, 57 boys between the ages of three and 13 years, and 66 girls ranging in age from three to 17 years. Eighty-five, or 69.17 per cent, of these 123 children attended the public school in which our cultures were taken and 81 of them were included in the first examination of our series and so came under subsequent observation. Of these 81 children, 45 were boys from five to 13 years of age and 36 were girls from six to 14 years of age. Twenty-two of


them chanced to be among the 50 carriers selected for repeated examination and thus were recultured at intervals of two weeks over a period of three months. At the final examination practically all of the original 800 children were recultured. Seventy-nine of the 81 children previously studied from the asylum had cultures taken at this time. As was mentioned before, observations on the condition of the throat were also made at each examination and the temperature taken at each examination except the first. The detailed results obtained have been analyzed and are here presented briefly, followed by such comment as seems warranted.

1. Incidence of 'Positive Cultures. — A total of 270 cultures was taken from the 81 inmates of the asylum and 56 positive cultures were obtained; in other words, 20.70 per cent of the cultures t^ken showed diphtheria bacilli.

Cultures positive at 1st examinati^


of 81 childre


n = 26 (32.09 per cent)


'• 22


= .3 (59.09 " ' )


" 22


= 7(31.81 ' " )


" 22


= 1 ( 4.54 " " )


" 22


= 3 (13.63 " " )


" 22


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Total cultures 270. Positive 56 (20.70 per cent)

Thirty, or 37 per cent, of the 81 children, at some time showed a positive culture. A total of 168 cultures was taken from these 30 individuals and of these cultures 56, or 33.21 per cent, were positive.


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Of the 21 carriers cultured seven times, 8 were positive at only the first examination; 8 were positive twice; 1, three times ; 3, four times ; 1, six times ; and none showed a positive culture at all of the seven examinations.

We failed to find diphtheria organisms in the cultures from 51 of the 81 inmates of the asylum examined but it should be pointed out that each of these 51 children had only two examinations, three months apart.

We were unable to discover any relation between the age or sex of the children and the occurrence of positive cultures.

2. Character of the Organisms Present in the Positive Cultures. — This has been dealt with at some length in out earlier report to which reference has been made. In this place it will be sufficient to say that organisms were isolated from 48 of the 56 positive cultures encountered, and these pure strains examined as to morpholog}', staining characteristics and cultural reactions. The results showed these strains to be typical diphtheria bacilli, not " pseudo-diphtheria bacilli," nor diphtheroids.

Cultures from 26 of the 30 carriers were tested for virulence. From a number of these children who repeatedly showed positive cultures, pure strains were isolated from the successive


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positive cultures and virulence tests made upon each of the pure strains, as follows :

1 strain tested from each of 15 carriers =15 strains

2 strains " " " "7 " =z 14

3 " " " " "2 •' = 6 "

4 " " " 1 carrier = 4 "

5 " " " 1 •• zzz 5 "


26 carriers 44 strains

Unfortunately four strains which had been isolated , were lost before this test could be made and from 8 of the positive cultures no isolation was made. We are thus unable to say whether the strains of diphtheria bacilli in these 13 cultures were toxin producers or not, and mere speculation on this point is unprofitable. Concerning the 44 strains from 26 carriers which were tested, however, there is no doubt; all of these strains were avirulent.

3. Occurrence of Pathological Throat Conditions. — As has been mentioned, the throats of these children were examined and the occurrence of outspoken pathological conditions such as pharyngitis and enlarged or diseased tonsils was noted each time that cultures were taken. Of the 81 children from the asylum who were included iu our study, 35, or 43.20 per cent, at some time showed a throat condition regarded as definitely pathological. Of these 35 children who at some time exhibited a diseased condition of the throat, fifteen were examined twice, one was examined six times, and 19 were examined 7 times, making in all 169 examinations. At the 169 examinations on the 35 children, a pathological condition of the throat was noted 78 times, as follows: 17 children showed it but once; 6 showed it twice ; 5, three times ; 3, four times ; 3, five times ; and one individual showed it on seven successive examinations. Of the 81 children studied, 46 or 56.79 per cent did not show a pathological throat condition but it should be pointed out that only two of these individuals were examined 7 times ; 43 of them had but 2 examinations and one child was examined only once, thus making 101 examinations on these 46 children as contrasted with 169 examinations on the 35 children who at some time showed pathological throat conditions. It is quite probable that more frequent examinations would have materially increased the number of children discovered to have diseased throats. It should be stated that in no instance was a tliphtheritic false membrane or pathological membrane formation of any sort observed.

4. Relation of Pathologiml Throat Conditions to the Carrier State. — This matter also has been considered in the earlier report and the impression which we have gained has been expressed in the resume at the beginning of this paper. This impression has not been modified by the findings in this particular group of children. The occurrence of pathological throat conditions and their association with positive throat cultures is presented in this place for a reason which will later be apparent.

The number of children in whom positive cultures and pathological throats w-ere found at the same examination was 14, which is 46.66 per cent of the 30 individuals with positive


cultures and 40 per cent of the 35 individuals with pathological throats. Ninety-two cultures were made from these 14 children and of these 35, or 36.95 per cent, were positive. Of these 35 positive cultures, 23, or 65.71 per cent, were obtained from throats noted as pathological at the time the culture was taken. Of the 35 children who at some time showed a patliological throat 22, or 62.85 per cent, at some time showed a positive culture. From these 35 children 169 cultures were made and 45, or 26.62 per cent, proved to be positive. As mentioned above, 22 children who at some time showed pathological throats, at some time were found to be harboring diphtheria bacilli ; from these children 143 cultures were taken and 45, or 31.46 per cent of the cultures were positive.

Positive cultures were found in only 8 of the 46 children who at no examination showed a pathological throat condition. From these 8 children 25 cultures were taken and 11, or 44 per cent of the cultures, were positive. In all, 101 cultures were taken from children not noted as having diseased throats and 11, or 10.89 per cent, were positive.

Thirteen of the 35 children w-ith pathological throats had negative cultures, 37.14 per cent. From these 13 children 26 cultures were taken.

Thirty-eight, or 44.44 per, cent of the total of 81 children examined from the institution, showed neither pathological throat nor positive culture. From these 38 children 76 cultures were taken.

5. Temperature Observations. — Many of the children had an elevation of temperature above 99° F. and in one child it was 100.6° F. although all were attending school at the time our observations were made. These elevations occurred in children showing positive cultures and in those whose cultures were negative ; in children with pathological throats and in those whose throats seemed normal; and in children having the various combinations of cultural result and condition of the throat. We did not gain the impression that the carrier state was in itself sufficient to cause an elevation of temperature, altliough not infrequently associated with such elevations. The condition of the throat noted in many of the children would offer a plausible explanation for an elevation of temperature, but the slight fever present in those with normal throats is not to be explained in this way, nor is it necessary for our purpose to search for the underlying cause in these cases. It is merely desired to emphasize the point that many of the children with positive cultures had also elevations of temperature and pathological throat conditions.

7. Inmates of the Same Institution Examined the Previous Year (1911). — During an investigation of diphtheria bacillus carriers in the previous year (1911) *, cultures were taken from 200 children attending the same public school from which the material for our later report was secured. Included among these 200 children were 17 from the orphan asylum in question, about 14 per cent of the inmates at that time. Twentyone cultures were made from the 17 children and onlv 1 was


Moss, W. L., Guthrie, C. G., and Gelien, J.: Diphtheria Bacillus Carriers, Trans. XV Internat. Cong, on Hyg. and Dem., 1912, IV, 156.


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found positi\«. In the course of the present inquiry, 8 of the same children who had been examined during the previous year came under observation and the number of cultures taken from them was 31. None of these 8 children had shown a positive culture in 1911, but 2 of them proved to be carriers when examined in 1912.

8. Belation of the Carriers to the Occurrence of Clinical Diphtheria. — Subsequent investigation of the 30 carriers from this institution foiuid in the course of our study of 800 children from one of the Public Schools of Baltimore showed that a history of diphtheria previous to the time of our examination coiild be obtained from only three individuals. Concerning one child a history was obtained of diphtheria " when a baby"; regarding another, a history of diphtheria "when a small child "; the third had had diphtheria five years before the time that our cultures were taken. In each of these three instances, the disease had occurred before the child became an inmate of the asylum.

None of the 30 carriers developed diphtheria during the period covered by our study, from three to four months. None gave a history of previous exposure to diphtheria. We were unable to discover any eases of clinical diphtheria developing among the associates of these carriers. Six of the 30 carriers gave a history of sore throat during the year, but all had recovered witliout the aid of a physician.

Perhaps the most interesting information with regard to the relation of these carriers to the community was obtained from the superintendent of the asylum, who was interrogated in 1914 and again in November, 1920. This man has been in charge of tlie institution since 1894 and his records show that during the 36 years of his incumbency there have been only five cases of diphtheria among the inmates of the asylum. These five cases had occurred in the form of a small outbreak in 1897, 15 years before the time of our investigation. No cases had occurred since that time ; on this point he was quite definite.

The question naturally arises as to why we did not investigate the remaining 43 inmates of this interesting orphan asylum and it must be confessed that the explanation, which then seemed adequate, now appears distinctly feeble. Although we had the sanction of the Health Department for our investigations ill the public schools we had no authority to invade private institutions. The superintendent of the orphanage, who regarded us with open suspicion, did not take kindly to the idea when casually approached on this subject and no pressure was brought to bear on him, as we were particularly anxious not to call attention to the caiTier situation existing in the asylum at that time. Our discovery of this situation was merely incidental in the course of a rather extensive investigation of carriers in which we were engaged and which occupied us fully, so the matter was not pushed.

Summary. — The high incidence of B. diphtheriw in the throats of children from this institution was very striking, as 37 per cent of the 81 inmates examined at some time showed positive cultures, and 30.7 per cent of the total 270 cultures taken contained diphtheria bacilli. There is no reason to sup


pose that the incidence differed among the other inmates of the asylum, but if the 42 children not examined had all shown negative cultures, there would still have been 24.39 per cent of carriers in the entire institution, a remarkably high figure. Owing to conditions not understood, the ordinary percentage of carriers was in this instance greatly exceeded ; this, in turn, served to increase markedly the percentage of carriers found among 800 children from the public school attended by the inmates of this asylum. The incidence of carriers was also much higher than that revealed by the examination of 21 cultures from 17 inmates of the asylum during the previous year, when only one child was found to have diphtheria bacilli in the throat. During the period covered by our observations there was a marked fall in the incidence of carriers; at the first examination 36, or 32.09 per cent of 81 children, had positive cultures; three months later only 4, or 5.06 per cent of the 79 children examined, were found to be harboring diphtheria bacilli in their throats. There was a progressive decrease also in the number of positive cultures obtained at successive examinations of the 23 carriers included by chance in the list selected for repeated study (22, 13, 7, 1, 3, 2, 0). No relation could be discovered between the age or sex of the children and the occurrence of positive cultures.

The identity of the organisms found in the throats was not a matter of surmise, as diphtheria bacilli were isolated from 48 of the 56 positive cultures encountered and these pure strains subjected to careful tinctorial and cultural tests. All proved to be typical in their morphology, staining characteristics and cultural reactions.

Virulence tests were carried out on 44 of the 56 positive cultures encountered, representing pure strains from 26 of the 30 carriers found in this institution. All of the strains were non-virulent.

Many of the children (43.2 per cent) showed throats which were regarded as definitely pathological in appearance and of these children 63.85 per cent had positive cultures. Among the children whose throats seemed normal, only 17.39 per cent had positive cultures. The percentage of positive cultures was also higher among the children with pathological throats (26.62 per cent) than among those with normal throats (10.89 per cent). None of the throats examined showed a diphtheritic membrane or pathological membrane formation of any sort.

Temperature elevations above 99° P. were frequently noted among the inmates of the asylum examined. Such elevations occurred among the children with normal-looking throats whose cultures were positive and among those whose cultures were negative ; they occurred in children with evidently pathological throats who showed negative cultures, but the point of interest to us was that many of the carriers with diseased throats also showed a slight fever.

Only 3 of the 30 carriers discovered among the inmates of the institution had previously had diphtheria, none less than five years before the date of our examination, and none since admission to the asylum. None of the children gave a history of previous exposure to diphtheria. A thorough investigation did


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not reveal a single case of diphtheria developing among any of the associates of these carriers. There had not been a case of diphtheria in the asylum for 15 years prior to our study ; there has not been a case in the eight years which have elapsed since that time.

Extensive comment on these findings seems unnecessary ; it will suffice to correlate some of the points brought out by our study and indicate their practical bearing on the problem of diphtheria bacillus carriers. It has been shown that 30 diphtheria bacillus carriers were found on examination of only two-thirds of inmates of the asylum ; that pathological throat conditions were common and were frequently found among the diphtheria carriers ; that slight fever was also common among the children and occurred among the bacillus carriers having pathological throat conditions. The discovery of a positive culture in a child with an evidently pathological throat and an elevation of temperature might readily suggest the diagnosis of diphtheria and, indeed, many diagnoses are made on no more evidence than this. It should be recalled, however, that in none of these pathological throats was there observed a false membrane or new membrane formation of any sort. Moreover, the 44' cultures tested were all avirulent and therefore presumably incapable of producing any lesion whatever, much less clinical diphtheria. Finally and most important, there is the practical result. Xo one but ourselves knew of the carriers in the orphanage, consequently the lives of these children were not interfered with in any way and the daily routine of the institution remained undisturbed. The carriers themselves did not develop diphtheria; so far as we could learn their associates did not develop diphtheria; to the best of our knowledge there has been no diphtheria in the asylum for 23 years.


Nevertheless, the possibilities of trouble for the institution at this time were tremendous. Had a case of diphtheria occurred in the public school attended by these children some of them might have had throat cultures taken as contact suspects, and this in turn might have led to investigation of the orphanage. There the apparently alarming state of affairs outlined above would have been discovered, at least in part, ilany of these harmless carriers of non-virulent organisms would probably have been regarded as cases of diphtheria, on the basis of a pathological throat, an elevation of temperature and a positive culture. The establishment of a flourishing pseudo-epidemic only awaited the arrival of some well-meaning enthusiast. The institution would have been placarded at once, the children excluded from school, and many of them needlessly subjected to the discomfort of injections of antitoxin for curative or prophylactic purposes. At the end of 12 weeks, as we have seen, the incidence of positive cultures had dropped from 32.09 per cent to 5.06 per cent; this might plausibly have been attributed to the antitoxin used and the measures employed for isolation of the patients. All of these things might very readily have occurred in this orphan asylum ; similar occurrences probably take place very frequently.

Conclusions

1. The carrier of avirulent diphtheria bacilli is not a menace to the community.

2. A positive throat culture, an elevation of temperature and a pathological throat condition without definite membrane formation are insufficient evidence on which to base a diagnosis of diphtheria with entire certainty.

3. Virulence tests are necessary to avoid inflicting needless hardships on carriers of avirulent diphtheria bacilli.


STUDIES WITH LECITHIN AND CHOLESTERIN IN RELATION TO THE ANTIHEMOLYTIC PROPERTY OF HUMAN SERUM

By Hallie il. Clark and Frank A. Evans

{From the Diiision of Clinical Pathology of the Medical Clinic, The Johns Hopkins Universiti/ and Hospital)


It has been well established that human serum has power to inhibit hemolysis by many different agents,' among others soluble soaps and fatty acids, substances occurring in the blood under normal conditions. It is probable that because of this power of the serum the hemolytic substances present in the blood do not cause destruction of the red blood cells in tlie body. This consideration is of interest since it has been shoMTi' that the serum from patients with anemia, as compared with that from normal persons and patients with no anemia, exhibits a diminution in protective power against hemolysis of guinea-pig corpuscles by sodium oleate. The diminution in the protective power of the serum against this hemolytic agent is much more pronounced, both in degree and the regularity with which it is found, in the so-called hemodytic anemias, Addisonian anemia and hemolytic icterus, and in conditions in which the liver or spleen is extensively or prominently involved in the disease process. The experiments from which tliis observation was drawn, although affording no proof for the following suggestion, at least raised the possibility that the hemolysis in the hemolytic anemias may be due to hemolytic agents normally in the blood, enabled to act as hemolysins because of the diminution in the property of the serum which normally inhibits such activity. For these reasons it appeared important to study closely the substance or substances in the serum responsible for the protective power exhibited by serum against hemolysis.



VARIATIONS IN THE BACTERIAL FLORA OF THE UPPER AIR PASSAGES DURING THE COURSE OF COMMON COLDS

By Aethdr Bloomfield (From the Biological Divis-ion of the Medical Clinic, The Johns Hopkins University and Hospital)


Introduction

Despite the frequency and prevalence of the common cold remarkably little accurate information is available bearing on the exact nature and cause of tliis malady. Yet this is not surprising, for the very mildness of the disease, as a rule, keeps the patient, from seeking- medical aid until some grave complication supervenes. Furthermore, even if the physician is consulted, the circumstances are usually not conducive to careful study and observation, since the patient is ambulant, and is not seen under conditions which promote the keeping of careful records. Finally, the mildness of the symptoms makes exact definition of the disease difficult, and the primary cold is often confused with sinus infections, ton.sillitis, laryngitis, or other complicating disturbances of the upper air passages.

None the less it seems of the utmost importance that the problem of the common cold be solved. Although one does not die of this disease, the total morbidity is tremendous — few people go through a winter without at least one acute coryza, and the sum total of inconvenience to a community from tliis cause can hardly be overestimated. In addition, a cold is often the starting point for a variety of more serious and intractable disturbances, such as sinus and middle-ear infections, lar}'ngitis and bronchitis. Furthermore, it seems quite possible that an acute coryza may be related to the development of carrier states involving organisms which may cause even more serious diseases, such as pneiunonia and meningitis ; in fact the ultimate pathological sequences of the cold may be vastly more extensive than one would at first sight suppose. Finally, were the cause and nature of tliis malady elucidated much important knowledge on epidemiological matters might be obtained, and the study of other respiratory diseases, such as influenza, might be simplified.

During the past winter we have made certain bacteriological studies on colds which we desire to present, but it seems advisable first to review the literature and to discuss the clinical features of the disease.



HEMOLYTIC INFLUENZA BACILLI

By T. M. ItiVERS and Erida L. Leuschxer

(From the Department of Patholotiy and Bacteriology, The Johns Hopkins Z'niversity)


Members of the pneumonia commission working at Fort Sam Houston in 1918 noticed, in throat cultures from patients with measles, colonies of Gram-negative bacilli surrounded by a zone of hemolyzed red blood cells. The incidence of hemolytic streptococci in throats was being studied at the time and the similarity in the types of hemolysis caused by these two organisms was striking enough to be of interest. Later some of these men, studying measles, influenza and pneumonia at Camp Pike, encountered this same Gram-negative hemolytic bacillus in throat cultures. They recognized that the types of hemolysis caused by this liaeillus and by the hemolytic streptococcus were similar, but that the growths were different, the fomier making clear dew-drop colonies, the latter opaque, whitish colonies. They also noticed that the bacillus would not grow in meat-infusion broth.

Very little can be found in the literature about Gramnegative, non-motile, aerobic, hemolytic, hemoglobinophilic bacilli. Pritchett and Stillman' recovered an organism of this kind from throat cultures and called it "Bacillus X."' Evidently at that time they did not consider it in the B. influenzas group, as they say, " The colonies most readily confused on inspection with those of B. influenza were those of Micrococcus catarrhalis. Meningococcus, diphtheroids, and especially an unidentified organism called ' Bacillus X." " In a previous paper on the biological classification of influenza bacilli, one of the authors," after showing that B. influenza could be differentiated from B. pertussis culturally and that the former group could be sub-divided culturally, reiJorted having studied some of the hemolytic hemoglobinophilic Ijacilli and having found that they, also, were not all alike culturally, and at that time suggested that they might be classified as hemolytic influenza bacilli. In a recent paper by Stillman and Bourn ' all of the above statements have been confirmed and much valuable information has been added. Nevertheless they speak of non-hemolytic hemoglobinopliilic bacilli as B. influenzas and hemolytic hemoglobinophilic bacilli as " Bacillus X."

Pfeiffer^ originally described a small, Gram-negative, nonmotile, aerobic, hemoglobinophilic bacillus which he called the influenza bacillus. Then he found the pseudo-influenza bacillus. The distinction was made on morphology alone. Later he decided there was no real difference between the false and the true forms and that all influenza bacilli were alike. This view cannot be held at present for there is enough evidence to show that tliese bacilli are not all alike even in their


cultural characteristics. In fact, all Pfeiffer did was to discover a new group of organisms and call them influenza bacilli. The question of hemolysis did not enter into the earliest descriptions of these bacilli. That point would have been hard to determine as they were first cultured by streaking bloody or purulent sputmu on hardened agar plates and later by streaking a pure culture with blood on the surface of agar. From later descriptions it can be gathered that they were nonhemolytic, at least all bacteriologists considered them so. There is, however, a group of bacilli which coincides in everj' respect with the meager descrijjtion given to influenza bacilli by Pfeiffer with the excei>tion that they are hemolytic. The object of this paper is to show, if possible, that they belong in the large group' of influenza bacilli just as hemolytic and non-hemolytic streptococci fall into the great group of streptococci and to suggest that bacteriologists in the future speak of hemolytic and non-hemolytic influenza bacilli.

In October, 1919, the throats of forty nonnal medical students were swabbed and from twelve (30 per cent) a Gramnegative, hemolytic, hemoglobinophilic bacillus was recovered. Later these cultures were lost, btit during the epidemic of influenza in the early ]>art of 1920, from 25 per cent of 52 throat cultures, 13 strains were isolated from influenza patients. None was isolated from the lungs or from blood cultures at autopsies, and so far as is knowii, they are not pathogenic for man. These strains have been studied but all have not been carried through, as some have died. However, five strains have been successfully carried through all the work and have been under constant observation for nine mouths.

x\ll the throat cultures were made on 2 per cent fresh rabbit blood meat-infusion agar, pH 7.5. Both the hemolytic and the non-hemolytic groups grow well on this medium and they can be differentiated inunediately, whereas it is impossible to do so on the oleate or cooked blood media. In a previous paper Elvers ° showed that fresh human blood inhibited markedly the growth of B. influenzse. Those were non-hemolytic. The same, however, is true of the hemolytic group and their growth is inhibited to such an extent by fresh human l>lood that it is impossible to use it in the work of isolation of these organisms with any degree of satisfaction. Fresh rabbit or cat blood, 2 per cent, can be used and as far as growth is concerned is just as satisfactory as the oleate or cooked blood media ; moreover in other respects it is more satisfactorj-. since the hemolytic and non-hemolytic bacilli can be differentiated on the


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original plates, giving the relative number of the two organisms present.

JSTaturally, the first question to be ansvrered is. Are these bacilli hemoglobinophilic ? Much iivork has been done to show that this is untrue of Pfeiffers influenza bacillus and it is to be supposed that the same ol)jections will be raised in regard to these hemolytic bacilli. Anyway, it can be said that one gj-oup is as hemoglobinophilic as the other. Pritchett and Stillman,' Stillnian and Bourn ' and one of \is (Rivers)" have found them so. Meat-infusion agar or broth, pH 7.1-T.-J, enriched with blood free ascitic fluid, is lacking in something necessary for groii\'th, yet growth takes place in almost any kind of medium if a very little blood is added. The amount of blood necessary is very small and at times is hard to detect after it has been added. The hemolytic as well as the nonhemoljrtic bacilli show the phenomenon of symbiosis on unfavorable media and like the uon-hemolytic ones will also grow for some generations on hemoglobin-free media in symbiosis with the proper organisms.

When 3 per cent rabbit blood meat-infusion agar plates were inoculated with these 13 strains, within 2-t lioure a zone of hemolyzed cells' could be seen immediately around the streaks or the individual colonies. The cells were actually destroyed and the hemoglobin had difl'used through the medium causing a deeper red color at the junction of the hemolyzed with the unhemolyzed portions of tlie plates. It was the beta type of hemolysis as applied to hemolytic streptococci. Some strains constantly formed wider zones of hemolysis than others but the type was always the same, the difference being merely one of degree. Hemolysis occurred in liquid as well as on solid media. After the cultures in liquid media were about a week old, long after the hemolysis had been completed, some would develop a greenish brown, others a dirty blackish brown color, and in some there was a fine whitish sediment sticking to the sides of the tubes, seen best at the top of the cultures.

Apparently a free hemolysin was demonstrated by growing the bacilli in "chocolate blood"' meat-infusion broth. When the blood was coagulated dnd precipitated by heat a fairly clear medium was produced which could be used for the study of free hemolysin formation. Eight- to twelve-hour cultures were centrifuged till the supernatant fluid was clear. Half of the supernatant fluid was heated at 56° C. for 30 minutes and then to both portions 1 per cent washed rabbit cells were added and incubated at 37° C. for several hours. SUght hemolysis occurred in the unheated portion whereas none appeared in the heated one. Filtering the cultures through Mandler filters removed much of the hemolysin, but its presence was thought to have been demonstrated several times.

The addition of dextrose to the medium prevents hemolysis of red blood cells by hemolytic streptococci. Four strains of these hemolytic bacilli were grown on solid and in liquid media with and without dextrose to determine whether hemolysis could be influenced. The hemolysis produced by three of them was retarded and diminished in amount by the presence of dextrose ; that produced by the fourth strain did not seem to be affected. All four strains fermented dextrose, but the


fourth did so slowly, and hemolysis was not affected, while the others fermented the sugar fast enough to diminish the hemolysis but not fast enough to inhibit it completely as is the case with hemolytic streptococci. Dextrose should be omitted from all media which are used to show the presence or absence of hemolysis by members of the hemoglobinophilic group.

Pf eiffer s bacillus has been spoken of by many as a strict aerobe. In the seventh edition of the text-book by Park and Williams " it is called a facultative anaerobe. It seemed interesting to determine what relationship there is between the hemolytic and the non-hemolytic groups in regard to this matter. Meatinfusion agar with 2 per cent rabbit blood was inoculated with five of the hemolytic strains and one meningitic strain obtained from Dr. Wollstein. The cultures were put in a large vacuum jar, the air was exhausted (29-30 inches) three times, the jar being filled, between the evacuations, with hydrogen from a Kipp generator. After 24 hours' incubation the vacuum was tested and found to be satisfactory^ The cultures were examined and a good growth was obtained in all. It seems from this that the hemolytic as well as the non-hemolytic bacilU are facultative anaerobes.

The colony formation of both groups, hemolytic and nonhemolytic, is almost identical, and if it were not for the hemolysis, it would be impossible in many instances to distinguish one from the other. Some of the hemolytic ones form large colonies which are more or less imiform in size; others grow in small tmiform colonies, while still others show an irregularity in colony formation. Young colonies are clear and oval with smooth edges. Older colonies have brownish granular centers, and become checkerman, cone, or truncated coneshaped, with irregular edges due to the formation of daughter colonies. Some are moist and soft, others somewhat tough, but all of them leave a shallow pit in soHd media when a colony is moved. Streak cultures have lobate edges.

It is rather difficult to discuss the morphology of either the hemolytic or the non-hemolytic group, as this is rarely the same twice in succession. In general it may be said that the hemolytic bacilli are slightly longer, heavier, show squarer ends, and stain more deeply and regularly than the non-hemolytic ones. Some, however, are small cocco-bacilli and as far as morphology is concerned cannot be distinguished from those of the non-hemolytic group. No motility has been observed in 8- to 10-hour blood-broth cultures. AU take the ordinarv stains fairly well but irregularly, are distinctly Gram-negative, and do not form spores.

Blood-broth tubes inoctilated with the 13 strains of hemolytic bacilli were incubated for varying periods of time, three to ten days. Then they were extracted with a small amount of ether. This ether extract was decanted and layered vrith Elirlich's reagent. Three strains always gave a positive test for indol, the other ten were constantly negative.

Tubes of potassium nitrate blood-broth inoculated with the 13 strains were incubated for five days and then tested with the sulphanilic acid and naphthylamin reagent for nitrites. The uninoculated control tube gave a negative result, but all


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of the inoculated tubes gave a positive test, a deep pink or reddish color showing the presence of nitrites.

Five of the hemolytic strains were grown in milk to which a little blood had been added. All produced alkali. Pritchett and Stillman * showed this previously. Many of the non-hemolytic ones, if not all, also produce alkali in blood-milk mixtures.

In another paper Bivers,' early in the work, stated that none of the hemoglobinophilic bacilli fermented certain sugars. This is incorrect, although he was unable at that time to demonstrate it. This point will not be taken up here but will be dealt with in a later paper. This much can be said; both the hemolji;ic and the non-hemolytic groups femient certain sugars. Tliis has been well shown by Stillman and Bourn.^ There is nothing in the sugar fermentations to prevent the hemolytic group from being called influenza bacilli.

DISCUSSION

Thus far no reason has been found why the hemolytic group of these hemoglobinophilic bacilli should not be called influenza bacilli just as much as the non-hemolytic ones. There is no proof that some of the original organisms described by Pfeiffer as B. influenzEe did not belong to the hemolytic group. Very likely, using the methods described early by him, he worked with both groups and thought they were alike.

An interesting observation was made during the course of the work. One of the 13 strains, after cultivation for seven months on artificial media, lost completely its ability to hemolyze blood both on solid and in liquid media, while retaining all of its other cultural characteristics unchanged. Enough was known of its sugar fermentations and other cultural characteristics to exclude the possibility of a mistake. Any doubt is further excluded by the fact that the hemolytic stock strains were kept separate and transferred at a different time from the


non-hemolytic ones. If the classification suggested, or implied, by Stillman and Bourn ° be followed, the designations to be given to this strain would also imply fundamental differences in its character which its history denies. The organism, once a hemolytic hemoglobinophile, would be called " Bacillus X " of Pritchett and Stillman,' now, a non-hemolytic hemoglobinophile, should be called B. influenza-. This is not believed to be the case. It has always been an influenza bacillus. Once it had many cultural characteristics, one of which was the ability to hemolyze red blood cells. Xow it is the same bacillus except it has lost one of its many cultural characteristics, its power to produce hemolysis.

COXCLUSIOX On account of the meager description given to the original B. influenzae, especially concerning hemolysis, it seems best to regard both hemolytic and non-hemolytic aerobic, nonmotile, Gram-negative, hemoglobinophilic bacilli as influenza bacilli and disregard any such confusing terms as " Bacillus X " which in itself represents not one organism but a group. After all, it makes very little difference what any of these bacilli, non-hemolytic or hemolytic, are called, so long as everyone recognizes that they belong to the same big group.

BIBLIOGRAPHY

1. Pritchett, I. W., and Stillman, E. G.: .Jour. Exper. Med., 1919, XXIX, 259.

2. Rivers, T. M.: Bull. Johns Hopkins Hosp., Feb.. 1920. XXXI, .50.

3. Stillman, E. G., and Bourn, J. M.: .Jour. Exper. Med., 1920, XXXII, 665.

4. Pfeiffer, R.: Ztschr. f. Hyg.. 1893, XIII, 35".

5. Rivers, T. M.: Bull. Johns Hopkins Hosp., May, 1919, XXX, 129.

6. Park, W. H., and Williams, A. W. : Pathogenic microorganisms, Phila. and New York. 7th edition, 1920, 457.


EXPERIMENTAL OBSERVATIONS ON BONE MARROW

By Geoege B. Wislocki

(From the Department of Anatomy, Johns Hopkins Medical School)


The deposition of pigments in the bone marrow under physiological and experimental conditions has been studied by a number of investigators. Ponfick (1869) and Hoff'mann and Langerhans (1869) observed the intracellular deposition of granules of cinnabar in the bone marrow after injecting it into the circulation of the living animal. They thought that the cells concerned in the phagocytosis of particulate matter in the bone marrow were lymphocytes. Cousin (1898) injected suspensions of carmine or litmus blue into animals and made the important observation that the pigment was phagocytosed by the endothelial cells lining the capillaries of the bone marrow. Eibbert (1901), using lithium cannine, confirmed Cousin's observations. Xasse (1876) and Quincke (1880) described the normal presence of pigment in the bone marrow of different animals, but it remained for Brass (1913)


to demonstrate that this material is also stored within endothelial cells.

Finally, Evans (191o), using vital dyes such as trypan blue and pyrrhol blue, found that these also were deposited in the bone marrow. He observed, however, that although a large quantity of the dye was concentrated in the cytoplasm of endothelial cells, there were other phagocytic cells in the marrow — the so-called reticulum cells — whose connection with the endothelium is not clear. Eecent experiments by Xagao (1920), who injected a suspension of carbon particles into the bloodstream of rabbits and guinea-pigs, confirm Evans' observation that, in the marrow, reticulum as well as endothelial cells participate in the phagocytosis of foreign particles.

The observation that the endothelial and reticular cells of the bone marrow phagocytose solid particles brought to them by the circulating lilood led to the present experiment. It


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was known that is was possible to inject into the blood stream of the living animal a pigment which would be phagocytosed by the marrow cells, and that after the animal was killed the bones of the entire lx)dy could be decalcified and the tissues cleared by the Spalteholz method. It was hoped that in this way the bone marrow of the entire body would he delineated by the presence of the opaque jjigment in its cells.

The first series of experiments was performed on rabbits. The pigment used was a suspension of carbon particles, available in ordinary India ink. The ink, diluted one-half with distilled water, was injected into the ear vein of adult rabl)its in doses of from 5 to 10 e. c. in two successive days. Newborn rabbits received 0.5 c. c. on two successive days. Two or three days after the last injection the animal was killed.

At autopsy the characteristic distribution of carbon particles in the body was observed. The carbon was confined practically to the liver, spleen, lungs, and bone marrow, to which tissues it imparted a gray or black appearance readily visible to the naked eye. On gross inspection the bone marrow appeared conspicuously black. The remaining tissues of the body were normal in color. Microscopic examination showed that carbon granules were abundantly present in the liver, spleen, lungs, and bone marrow. In the liver they were deposited in the Kuptt'er cells; in the spleen, in the reticrdo-endothelial cells; in the lungs, in macrophages, possibly of endothelial origin ; in the bone marrow granules were observed, for the most part intracellular, in the endothelium of the vessels and in the cells of the reticulum, although here and there granules were encountered lying free in the vascular channels.

It is interesting to note that the carbon particles, administered in the quantities named, produce no serious effects on the animal's health. The animals may be allowed to live for periods of months without showing any symptoms attributable to the foreign particles stored in the liver and other organs. Gross and microscopic examination of the tissues after a period of months reveals that the carbon deposited in endothelial cells has not diminished in amount nor produced any pronounced pathological changes. It appears that the inert foreign material is permanently stored in the endothelial cells without severe damage to the tissue, much as carbon is deposited in the lungs by inhalation.

The animals which were injected for clearing were sacrificed on the third or fourth day following injection. The bodies were skinned, eviscerated, and fixed in 10 per cent formalin. After fi.xation the bones were decalcified by placing the bodies in -5 per cent nitric acid iintil decalcification was complete. The specimens were then washed thoroughly, bleached with hydrogen peroxide, and dehydrated by alcohol. They were finally cleared by the method described by Spalteholz (1914). which consists in transferring them from absolute alcohol to benzol for 48 hours, then into several changes of oil of wintergreen and one part of benzyl benzoate, in which they are kept permanently. In the specimens prepared in this way the bones and tissues surrounding them become perfectly transparent, ' while the bone marrow stands out conspicuously as deep black patterns (Figs. 1 to 5).


The findings in the adult skeleton will be first described. Carbon was abundantly present in the cervical, thoracic, lumbar, sacral, and caudal vertebne. It extended from the bodies of the vertebrffi through the pedicles into the vertebral arches, whence it was continuous with deposits of carbon in the transverse and spinous processes. The carbon consequently completely outlined the shape of the vertebrae.

Carbon was deposited heavily and uniformly throughout the ribs. On close inspection the rib marrow appeared fenestrated. The sternebras were also conspicuously black. The sixth segment of the sternum, the xiphoid process, exhibited an elongated black strip of marrow, to which a broad, flat plate of colorless cartilage was attached.

In the skull the deposition of carbon occurred in both membrane and cartilage bones. It was confined, however, to those bones which are in whole or in part cancellous. Thus, the occipital, posterior sphenoidal, anterior sphenoidal, interparietal, parietal, and frontal bones stood out prominently as a result of the black pigmentation between the outer and inner tables (Figs. 4, 6, 7, 8) . In other bones, namely the squamosal, the petrotympanic, the maxillary, the zygomatic, and the mandible, in which the cancellous portions are restricted, pigmentation was scant. In the ethmoidal, inferior turbinate, premaxillary; nasal, lacrimal, palatine, and vomer bones no deposition of carbon granules was observed. The distribution of carbon granules in the bones of the skull is dia,g:rammatically shown in Figures 6, 7, and 8.

The hyoid bone was deeply pigmented, as were also the lesser and greater comua, two independent elements which articulate with it.

The deposition of carbon in the scapula was confined, as in the bones of the skull, to the cancellous regions. Thus, the head and neck of the bone, the axillary and superior borders, the scapular spine, the acromion and metacromion, were deeply pigmented. The vertebral border and the supraspinous and infraspinous fossee were transparent. The clavicle, which in the rabbit, as in many other mammals, is an imperfectly developed bone, was visible as a narrow black line attached to the sternum by the sterno-clavicular Ligament.

The humerus, radius, and ulna were completely outlined by a continuous, opaque black mass. The carpal and metacarpal bones and the phalanges of the digits contained only traces of carbon.

The coxal bone was clearly outlined as a heavy black structure. The femur, tibia, and fibula were deep black. The tarsal and metatarsal bones and phalanges contained traces of carbon. In a three week.s' old rabbit the distribution of carbon differed somewhat from that in the adult (Fig. 5). The heaviest pigmentation occurred in the long bones of the extremities. The carpal, metacarpal, tarsal, and metatarsal bones, and the phalanges were deeply pigmented. In the long bones, in which the epiphyses and diaphyses were still ununited, carbon was visible in the cancellous portions of the epiphyses as well as in the shafts of the bones. The coxal bone contained three distinct masses of carbon corresponding to the iliimi, ischium, and pubis. The distribution of carbon in the scapula


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resembled that in the adult. The clavicles were visible as two thread-like lines. The hyoid bone contained a tiny black center. In the skull only traces of carbon were \isible in the as yet only partially ossified occipital, parietal, frontal, superior maxillary, zygomatic, temporal, posterior sphenoidal, anterior sphenoidal, and mandibular bones.

In a rabbit one week after birth carlion particles were abundantly phagocytosed and stored in those bones in which ossification had commenced. Thus the separate ossification centers of the vertebne stood out as well-defined black masses. The ribs each contained a prominent band of black marrow, and there was abundant carbon in the stemebrffi. The bones of the extremities, in which ossification had commenced, were filled with carbon-colored marrow. In the skull the deposition was limited to portions of the basioccipital, the exoccipital, the supraoccipital, the basisphenoidal, the presphenoidal, the squamosal, and the mandibular bones.

The different bones were examined microscopically. . Clusters of blood-forming cells occurred fairly luiiformly throughout the cancellous portions and shafts of all the bones and consequently in the rabbit a distinction between yellow and red marrow could not be made. Particles of carbon were abundantly present in the cytoplasm of reticulum cells and in the endothelial cells lining the marrow capillaries. The distribution of carbon particles was found to coincide closely with that of the hemopoietic tissue. In the adult animals carbon was found nowhere else than in the marrow of the bones, but in the developing animals a few granules of carbon were obsei-ved in some of the osteoblasts in the regions of the epiphyseal lines.

From these observations it will be seen that the bone marrow of the rabbit contains cells which are extremely phagocytic toward inert particulate material afloat in the blood stream. Some of these are endothelial cells which line the vascular channels of the marrow, others are reticulum cells which form the supporting tissue for the blood-forming elements of the marrow. This phagocytic power is present at birth. Jlicroscopic examination reveals that the distribution of these phagocytic cells in the bones closely coincides with that of the bloodforming elements. The cleared tissues of rabbits injected during life with carbon particles give us an accurate picture of the gross distribution of the marrow. The amount of marrow in flat bones is in direct proportion to the amount of cancellous or spongy structure which the bone possesses.

As the experiments described above were confined to the rabbit, it was deemed important to observe the behavior of the bone marrow of other mammalia towards particulate matter, for the purposes of comparison. To this end several dogs, cats, and guinea-pigs were similarly injected with suspensions of carbon. In the dog and cat carbon was not grossly visible in the marrow, and on microscopic examination only an occasional carbon particle could be discovered in the endothelial cells. In the guinea-pig the marrow appeared in the gross definitely blackened by the presence of the carbon, but not to the same extent as in the rabbits receiving corresponding injections. Microscopically the marrow of the guinea-pig was found


to contain numerous carbon-laden phagocytic cells, less numerous, however, than in the rabbit.

There exists, therefore, a difl'erence in the ability of the bone-marrow cells in different mammalia to phagocytose and store particles of carbon. In the cat and dog the storage of inert particulate matter, so far as can be determined by quantitative observation, is confined to the liver, spleen, and lungs; in the guinea-pig the bone marrow plays an additional though subordinate role ; while in the rabbit the material is distributed equally between the liver, spleen, lungs, and bone marrow.

The method herein described of observing the distribution of inert particles in cleared bones may prove valuable in the study of the pathology of bones. It would be of interest to use this method in the experimental study of healing fractures and in experimentally produced disturbances of bone duriiii: development and growth.

REFERENCES CITED

Brass. H.: 1913. Ueber physiologische Pigmentablagerung in den Kappillarenendothelien des Knochenmarks. Areli. f. mikr. Anat.. LXXXII, 61.

Cousin, G. : 189S. Xotes biologiques sur rendothelium vasculaire. Corapt. rend. Soc. biol., p. 454-456].

Evans, H. M. : 1915. The macrophages of mammals. Am. J. Physiol., XXXVII, 443.

Hoffmann, F. A., and P. Langerhans: 1869. Ueber den Verbleib des in die Cirkulation eingefiilirten Zinnobers. Arch. f. path. Anat. u. Physiol., XLVIII, 304.

Nagao, K.: 1920. The Fate of India Ink Injected into the Bkui.l. Jour. Infect. Dis., XXVII, 52".

X'asse: 1876. Ueber das Vorkommen eisenhaltiger Kiirner ini Knochenmark. Marburger Sitzungsberichte.

Ponfick, E. : 1869. Studien iiber die Schicksale korniger Farbstoffe im Organismus. Arch. f. path. Anat. u. Physiol., XLVIII, 1-54.

Quincke. H.: 1880. Zur Pathologic des Blutes. Arch. f. klin. Med., XXV. 567; Ihid.. XXVII, 193; Ibid., 1883, XXXIII. 22.

Ribljert. H. : 1904. Die Abscheidung intravenos injizierten gelosten Karmins in den Geweben, Ztschr. f. allgem. PhysioL, IV, 201-214.

Spalteholz. W.: 1914. Ueber das Durchsichtigmachen von meiischlichen und tierischen Praparaten. Leipzig.

DESCRIPTION OF PLATE

Fig. 1. — Lateral view of thorax of a rabbit decalcified and cleared by Spalteliolz's method, showing distribution of carbon in the ribs.

Fig. 2.— Anterior view of thorax of a rabbit decalcified and cleared by Spalteholz's method, showing distribution of carbon in the sternebrse.

Fig. 3. — Anterior extremity of a rabbit, showing the distribution of carlx)n in the bone marrow. Tlie specimen has Ijeen decalcified and cleared by the Spalteholz method.

Fig. 4. — View of a decalcified, cleared skull of a rabbit, showing the deposition of carlxjn granules in the marrow.

Fig. 5. — Decalcified, cleared rabbit, 3 weeks of age. The animal had received two injections of a carbon suspension (India ink) intravenously and was sacrificed 48 hours after the second injection.

Fig. 6. — Diagram of dorsal view of skull of an adult rabbit. The black dots show the exact distribution of carbon granules in the bone marrow. (The outlines of the bones of the skull in Figs 6, 7, and 8 are after Bensley, "Practical Anatomy of the Rabbit," 1910, and Gerhardt, "Das Kaninchen," 1909.)

Fig. 7. — Diagram of ventral view of a skull of an adult rabbit, tlie black dots indicating the deposits of carbon in the marrow.

Fig. 8. — Similar diagram of mandible.



BOOKS RECEIVED

Vol. XXXII— No. 363

BALTIMORE, MAY, 1921

CONTENTS

  • Epidemic Enceplialitis. A Clinical Study. (Illustrated.) By W. M. Happ and V. R. Mason
  • Studies on Experimental Rickets. III. A Pathological Condition Bearing Fundamental Resemblances to Rickets of tlie Human Being Resulting from Diets Low in Pliosphorus and Fat-Soluble A: The Phosphate Ion in its Prevention, lllhistrated.) By P. G. Shipley and E. A. Park and E. V. McCoLLUJr and Nina Simmonds
  • Giardia (Larablia) Intestinalis. A Common Protozoan Parasite of Children. By Kenneth F. Maxcy
  • Notes on New Books .
  • Books Received .


EPIDEMIC ENCEPHALITIS A CLINICAL STUDY

By W. M. Happ and V. R. Mason

(From the Harriet Lane Home and the Department oj Medicine, The Johns Hopkins Hospital, Baltintorr)


The recent epidemic of encephalitis began in Europe during the winter of 1916-1917 and the first cases were reported by von Economo ' from Austria and by Cruchet ' from Northem France at about the same time. Early the next winter the disease appeared in epidemic form in Paris where it was studied by Netter ' and others. ° Following these publications instances of the disease were recognized in many localities throughout Europe. The first cases observed in England were mistaken for botulism,'- ' but the error was soon corrected and the identity of the British and continental cases was established as the result of the investigations of McNalty, James, Marinesco and Mcintosh,' and others."' "

The malady did not remain confined to Europe, but probably favored in its spread by extensive troop movements, soon appeared in Africa, Asia, Australasia and America."- " It was apparent, tlierefore, that the various local epidemic-.-^ were in reality parts of a great pandemic of a disease of the nervous system.

Since the appearance of the epidemic in the United States during the winter of 1918-1919 we have had an opportunity to observe a large number of patients affected with the disease in the wards of The Johns Hopkins Hospital, and in many instances it has been possible to follow them for a considerable period of time after their discharge. We believe,


therefore, that a presentation of the chief clinical features and of the late symptoms and sequelae of the disease in this series of cases may be of interest at this time.

aSTOMEXCLATURE

The disease, originally described under the headings " Encephalitis lethargica " by von Economo ^ and " Diffuse Encephalomyelitis" by Cruchet in 1917, has recently Ix-en given a number of different names, such as Encephalitis myoclonica,"- " Encephalitis choreiformis '° and Encephalitis coniatosa, depending on the predominant clinical symptoms presented by the patient. The tendency to diversity of nomenclature is unfortunate, because the numerous types of the disease so merge one into another that no one name based on the clinical features is applicable to a large number of cases. Thus, Bourges and Marcandier " reported an instance of the disease in which choreiform, myoclonic, catatonic, lethargic, athetotic, delirious and comatose stages were observed successively.

Moreover, it is incorrect to combine the term " encephalitis " indicating a pathological process with the descriptive term " lethargica," " choreatica," etc. It would be more logical and more convenient, therefore, to include all cases


138


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 363


of the disease under the heading " Epidemic Encephalitis "' and, if necessar}' for descriptive purposes, to add the modifying phrase "with lethargy," " ^nth myoclonia," etc.

The name " Epidemic Encephalitis " was first employed 1j\ Buzzard" in 1918 and has lately received wide usage. It i> open to two objections which, however, are not serious. In the first place, the lesions in many instances are not limite'l to the encephalon but may be present in the meninges, spinal cord and peripheral nerves, and it would be more correct to employ the more comprehensive term " meningo-eneephalomyelo-neuritis " in some instances, as proposed by Barker. Cross and Irwin." Unfortunately this designation is too cumbersome for popular usage. In the second place, the term " epidemic " is not applicable to sporadic cases, as Netter has pointed out. Despite these minor objections, the name " Epidemic Encephalitis " will be employed throughout this paper as the most suitable designation so far proposed.

Epidemiology

It is of particular interest that the pandemic of encephalitis occurred almost simultaneously with a pandemic of severe influenza and, as was to be expected, the causal and epidemiological relationship of the two maladies was carefully investigated by a large number of epidemiologists ami medical historians. Crookshank " concluded, from a study of the historical features of encephalitis and influenza, that epidemics and endemics of a disease similar to the epidemic encephalitis of recent years have been observed for at least four centuries. In great part they have appeared shortly before or after or in geographical proximity to epidemics known variously as " influenza," " la grippe," or " sweating sickness."

The simultaneous occurrence of the two great pandeniies in recent years is, therefore, not especially remarkable, for as pointed out above, the two diseases have often occurred in close temporal relationship. Furthermore, although the two pandemics appeared at about the same time, they seem to have been disseminated by somewhat different paths, so that in one part of the world encephalitis preceded influenza, in another influenza preceded encephalitis and in other localities the two occurred simultaneously. Epidemiological investigations of the diseases, therefore, lend little support to the. conception of certain authors that epidemic encephalitis is a post-influenzal aifection. Moreover, we have as yet no methods of differentiating influenza from certain other acute infections or epidemic encephalitis from similar cases of acute or sub-acute non-suppurative encephalomyelitis. Ophthalmological '" as well as neurological " literature prior to the recent epidemic contains records of cases similar to if not identical lx)th clinically and histopathologically with epidemic encephalitis. A number of these have occurred sporadically. It is probable, therefore, that influenza and epidemic encephalitis frequently occur in sporadic form and that, in conse quence, epidemics of either or both of these diseases are possible when conditions at present not well imderstood are favorable to their wide dissemination.


A study of the records of our cases of epidemic encephalitis has shown that influenza in a recognizable form has seldom preceded directly the onset of encephalitis. In a number of instances, moreover, the patients were born after the major epidemic of influenza. The evidence at hand, therefore, does not favor the assumption that the two diseases are causally related, but since our knowledge of the etiology of each aft'ection is still incomplete, a certain solution of the problem is not possible.

Epidemic encephalitis, although in all probability an infectious disease, is only slightly contagious. It is remarkable that the affection became world-wide in distribution with so few evidences of its direct transmission. Xetter could find but eight cases in France and an equal number reported from England in which the disease occurred in more than one member of a family. Although a large number of patients with the disease have been cared for in hospitals, reported instances of bed to bed or even of ward infection are rare. An outbreak in an institution for girls has been reported' — the only instance of the kind we have encountered in the literature. Guillain and Lechelle "* reported a case of the disease which occurred between 15 and 30 days after the patient had visited the home of his father who had died of the disease seven months previously. Eoger," in a recent article, stated that, although about 10,000 cases of encephalitis had occurred in France, direct contagion could be traced in only 174. cases. In no locality had a true epidemic occurred. He believed that the disease was transmitted by means of healthy carriers or unrecognized cases.

James," ISTetter,"" and Bernard and Eenault,"^ studied the epidemiology of a large number of cases in France and in England and concluded that, although widely distributed, the disease occurred chiefly in the more thickly populated districts. The precise mode of dissemination could not be determined from their studies.

In our series of 81 cases we have not encountered a single instance in which more than one member of a family or household was affected, nor has it been possible to determine the mode of infection.

The accompanying chart (Table I) shows the age, sex and color of the patients and also the date of the onset of symptoms. It will be seen that thei-e were 46 males and 3.5 females. The ages varied from seven weeks to 65 years. Over half of the patients were iiast the tenth year. The chart shows furthermore that the greatest number of cases developed during the months of January, February and March, although cases appeared throughout the entire year.

Clinical Consideeatioxs

It will be convenient to preface the discussion of the symptomatology of epidemic encephalitis by some important inferences which may be drawn from the histopathological studies of the disease.

The wide distribution of the lesions of the nervous system which may be surmised from clinical examination during the course of the affection readily explains the multiplicity and


May,


1921]



JOHI


^S HOPKINS


HOSI


'ITAL


i3ULiii^:TiJN



L6y






TABLE I


(THE CASE NUMBER REFERS TO CASES CITED IN THE TEXT)





Age


Sex


Color


1

Date of onset of symptomB


Cerebrospinal fluid


Case No.


Day of

disease


Number of cells


WasBermanii. reaction


Globulin


Gold chloride curve


1


4 years.

11 years.

12 years.


M. M.

M.


W. W.

W.


.January Hi, 1»20. February 19, 1920.

October, 1919.


90-1 102±

leOit

3

6

23

45

65

8


10 3 5

7 28

1 10


Negative.





+

-1+



0000000000

looonooooo




oooooonoiio


2


Negative.





1111000000


3


Negative.


000100000"


4


16 years.


F.


W.


November, 1919. 5 6


6 years. 65 years.

24 years. 37 j-ears.


F. M.

M. il.


W.

w.

w. \v.


November 9, 1919. August, 1919.

January, 1920. February, 1920.


4 11

60± 62-<77±; 19 43 120


4 3 200 90 40 30 17 70


Negative. Negative.


+



+ +



1121000000 0011000000





7 8


Negative. Negative. Negative.


Negative. Atvpical paretic. 1122210000


9 10


6 years. 24 years.


F. F.


w.

w.


September Iti, 1920. February, 1919.


4

8

20


14 26 17


Negative. Negative.


+ -t++


2244211000


11


36 years. 35 years.


M. M.


w.

B.


March, 1920. March, 1920.


23 26 49 65

42


19

44

3

1


Negative.


-l-l ++

-1 + +


Luetic zone. Luetic zone.




Luetic zone.




Luetic zone.


12


Negative.


2222200000


13


5 j-ears.


M.


W.


February 4, 1920.


.->


55


Negative.


-1

1111221000


14


8 years. 18 months.


M. F.


w. w.


May 18, 1920. September 26, 1920.


1 2 3 9 16 4


50 40 250 66 11 33


Negative. Negative.


+ +

+ + -1


IIUIIOOOO


15


Negative.



16


34 years.


M.


w.


December, 1920.


14


26


Negative.



0000000000


17


7 weeks. 28 years.


F. F.


w.

B.


April 1, 1919. May, 1920.


5 10 5


28 10 9


Negative.


-1


+


1122210000


18


Negative.



19


19 years.


M.


B.


March, 1920.


4


308


Negative.



1444110000


20


2 months.

4 months.

5 years.


F. F.


w. w. w.


April 2, 1920. March 17, 1920. February 1, 1920.


4 7

12 17 1 9 17 28 49


56 34 22 11 10 20 11 8 6


Negative.


+ + + +


-1 -t -f ++



21




Negative.


0110000000





22


Negative.


1222100000


23


10 years. 2 years. 37 years.


F. M. M.


w.

B.

w.


May 15, 1920. August 8, 1920. March, 1920.


75

79

86

95

2

4

7

16 21


28 11 6 3 18 21 5 3 70



++

-1+ +




+



Negative. Negative.


2233443210 0112011100


24


Negative.



25


Negative.


1222100000


26


25 years.


M.


w.


March, 1920.


120±


3


Negative.



0000000000


27


26 years.


M.


w.


.June, 1920.


60-1

15


Negative.


+



28


3 years.


F.


w.


September 6, 1920.


6 22


7 6


Negative.


340


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 363


TABLE I — Continued



Cerebrospini


1 fluid



Case No.


Age


Sex


Color


Date of onset of symptoms


Day of


Number of cells


Wassermann reaction


Globulin


Gold chloride curve


20


17 years.


F.


B.


February, 1920.


30


225


Negative.


+


1111000000 35


20


Negative.


+


1111000000


30


27 years.


F.


B.


October, 1920.


5


3


Negative.



3442100000


31


4'i years.


M.


W.


September, 1919.


30


22


Negative.


+



32


23 years.


M.


W.


February, 1920.


10 40


25

58 4


Negative. Negative, Negative.





33


3 years.


F.


VV.


February, 1920.


120±


3


Negative.



1121100000


34


9 years.


M.


W.


February 27, 1020.


180±


Blood.


Negative.




35


2 years.


M.


B.


March 1, 1920.


27 31

34 45


19 26

18 26


Negative.


+



+ +

+


1111000000 66


10




36


6 years.


M.


W.


February 3, 1920.


90


2


Negative.



37


9 years.


F.


W.


April, 1920. . 38


7 years.


M.


W.


February 19, 1920.


5


36


Negative.


+


1110000000


39


9 years.


M.


W.


February U, 1920.


8


51


Negative.


+


01 inoooono


40


29 years.


M.


w.


February, 1920.


J


8


Negative.




41


13 years.


F.


B.


April, 1920.


59


60


Negative.




42


\i years.


M.


W.


September 20, 1920.


1


8


Negative.


+



43


2i months.


M.


W.


June 9, 1920.


6


36


Negative.


+


1111110000


44


5J years.


F.


W.


Slay 6, 1020.


60


20


Negative.


+


1111100000


45


2 years.


F.


W.


October 2, 1918.


8


92


Negative.





2 years.


F.


w.


August, 25, 1010.


17 3


9 30






46


Negative.




20 years.


F.


\v.


December, lOlS.


6 11


12

42




++



47


Negative.


0122110000 13


70


Negative.


+


1122100000 16


74


Negative.



1143210000 46


13


Negative.


+++


4555421000 64


6


Negative.


+


5443210000


48.


47 years.


F.


w.


February, 1910.


42


2


Negative.


+


Luetic zone. 50


7


Negative.


+


Atypical paretic.


49


48 years.


M.


\\.


February, 1919.


22


97


Negative.


+++


Meningitic curve. 27


133


Negative.


++++


Paretic curve. 52


50


Negative.


+++


Atypical. 65


3


Negative.


+



50


33 years.


F.


w.


March, 1019.


"


Blood.


Negative.




51


32 years.


F.


w.


March, 1919.


60±


4


Negative.



0122100000


52


40 years.


M.


B.


.July, 1019.


24


40


Negative.


++


2244210000 38


7


Negative.


+


1223211000


53


37 years.


-M.


w.


November, 1919.


35


30


Negative.



1121000000 ?,9


46


Negative.



1111100000 55


10


Negative.



OllUOOOOO


54


7 years.


F.


w.


February 24, 1020.


120±


3


Negative.


+


0000000000


55


9 years.


M.


\v.


January 6, 1020.


300-1390±


38 6


Negative.


+

+


0001110000 4223010000


56


3 years.


M.


w.


May 9, 1020.



3


Negative.


+




8 years.


F.


w.


January 16, 1020.


9


3 132




+



57


Negative.


7 11


72 51



+ +



1122100000





58


8 years.


M.


w.


June 2, 1919.


4


160


Negative.


6


250



+



12


230





5 years.


F.


w.


November 27, 1019.


17


8 27



+



59


Negative.


0111000000 17


7



+ Mat, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


141


TABLE I— Continued



Cerebrospina


1 fluid



Case No.


Age


Sex


Color


symptoms


Day of disease


Number of cells


Wassermann reaction


Globulin


Gold chloride curve


60


6 years. 25 years.


F. F.


W. B.


June 18, 1919. March, 1020.


4 5 ?


55

56

3


Negative.





61


Negative.


1111200000


62


44 years.


F.


W.


December, 1919.


300+


23


Negative.


+


Negative.


63


48 years.


M.


W.


February, 1920.


330+


5


Negative.


+ +


Luetic zone.


64


37 years.


M.


w.


December, 1920.


26


23


Negative.


+


0000000000


65


13 j'ears.


F.


w.


December, 1920.


42


3


Negative.




66


19 years.


F

B.


.Tanuary, 1920. 67 68

69


20 years. 26 years.

34 years. 43 years.

32 years.


F. M.

M. M.

M.


B. B.

B. B.

W.


•lanuary, 1920. February, 1920.

February, 1920, March, 1920.

April, 1920.


60 100 21 27 37 07

42 ± 72+ 22 41 56 7


25

10

150

150

60

1

30

20

87

18

17

3


Negative. Negative. Negative. Negative. Negative. Negative. Negative.


+

+ +


X


+



4411100000 2443311000 1121000000 2221100000 1222100000

1343210000


70 71


Negative. Negative. Negative. Negative.


1112210000 1111100000


72


3 years. 9 years.


F. M.


w. w.


July 17, 1919. February S, 1020.


1 3 5 7 12


2 23

59 96

72 1


Negative.



+ + + +

+


1100000000





73


Negative.


1111100000


74


42 years.


M.'


w.


January 20, 1921.


19


27


Negative.




75


13 years.


M.


w.


•January, 1921.


11


280





76


19 years.


M.


w.


December, 1920.


eoit


18


Negative.



0000000000


77


10 years.


M.


w.


February, 1921.


7


114


Negative.


+


0000000000


78


6 years.


F.


w.


December 15, 1920.


42


5


Negative.



1111100000


79


8 years.


M.


w.


February 7, 1921.


4


70


Negative.


+


1111100000


80


5 weeks.


F.


B.


January 28, 1921.


5


270


Negative.


+



81


8 years.


M.


\v.


January 17, 1921.


14


8


Negative.


+


0000000000


diversity of the neurological symptoms encountered. Moreover, these changes are produced by a virus which is capable of damaging functionally important brain areas without necessarily producing permanent anatomical changes (Marinesco*). It has been demonstrated, furthermore, both by clinical and histological methods that as one affected area of the nervous system is recovering another area may be attacked, thus adding, in certain instances, new clinical features to an already complicated symptom complex. It is apparent from these considerations, therefore, that the chief characteristic of the malady is the kaleidoscopic appearance of transient neurological symptoms dependent chiefly on alterations in the midbrain and the basal ganglia, and in some instances in the spinal cord and periplieral nerves (Burrows ") .

In this report no attempt will be made to construct clinical types of the disease depending on the proininenre«of this or


that symptom complex. The important symptoms, however, will be discussed seriatim and illustrated when possible by case reports.

Symptoms and Types op Onset

It is not necessar\' here to discuss the various sj-mptoms encountered during the early stages of the affection except in a general way, because the sequence of events at onset is clearly set forth in the detailed case histories recorded below.

However, it will be advantageous to call attention to a general division of symptoms at onset which is necessary for a proper understanding of the disease. These manifestations fall into two fairly well defined groups as follows : First, those dependent on a general reaction of the individual to an acute infectious disease; and second, those referable to involvement of the nervous system. These symptoms are fever, headaclie, malaise, nausea and vomiting, abdominal pain,


142


JOHNS HOPKINS HOSPITAL BULLETIN


[Xo. 363


irritability and restlessness. In children delirium and convulsions were also frequent at the onset. Dfowsiness, insomnia, diplopia and other visual difficulties, involuntary movements, muscular jerkings, tremors, spasticity, root pains, general weakness and psychoses occurred with especial frequency.

The onset may be abrupt or gradual, but in general a period of time elapses between the appearance of the general symptoms of infection and the development of the neurological symptoms.

DiSTUKBANCES OF GeNEEAL CoXSCIOUSXESS

Disturliances of general consciousness often combined with psychical disorders have been prominent features of the clinical course in most instances. No constant type of disturbance has been encountered but, on the contrary, all gradations between sleeplessness at one extreme and coma at the other have been observed.

In a few cases sleeplessness of days" or weeks' duration was present and preceding or subsequent lethargic states were not observed. The following case may serve as an example:

Case 1. — W. J., a white boy, aged 4 years, was admitted to the Harriet Lane Home April 23, 1920, because of inabihty to sleep at night. He had been periectly well until January 16. That evening he was not able to go to sleep and since that time this condition had persisted. Because of this nocturnal restlessness and acti\'ity, he was thought to have chorea. The mother stated that the child stayed awake all night spending the time in constant activity, talking, playing, singing, whistling, etc. Toward morning he would go to sleep and sleep a variable length of time, sometimes all day, sometimes only an hour or so during the entire 24 hours. Various means to combat the insomnia had no effect whatsoever, nor did keeping him awake during the day induce sleep at night.

Paralyses had never been noted. Examination on admission showed a well-nourished boy. No definite abnormal findings were obtained on physical examination. The cerebrospinal fluid was normal. The behavior of the child, however, was very striking. As night-time approached, he became very active, jumping up and down in bed and talking incessantly. He would often stay awake all night, at times talking to himself, at other times whistling and singing, fretting and crying, but never lying absolutely still. He spat a good deal both in the bed and on the floor. He would frequently wet the bed. When excited, he would stammer. The greater part of the night would be spent in ceaseless activity. Toward morning he would fall asleep. As a rule he slept from 3 to 12 hours in the 24 ; always between 5 a. m. and 6 p. m. The striking point about his sleep in the daytime was that it was very deep and when awakened for meals he would fall asleep immediately, sometimes in the act of eating. It was found very difficult to keep him awake during the morning. On awakening he would behave quite normally until evening when the same behavior would be repeated. Continuous tubs and packs were \msiiccessful in bringing on sleep. He was discharged Jidy 11, without any definite improvement in the insomnia. Since hi.s return home there has been but little improvement in his condition.

Again, the insomnia of the acute stage of the disease might be followed by lethargy of several weeks' duration as in the following case :

Case 2. — W. D., a white boy, aged 11 years, was admitted to the Harriet Lane Home Februarj' 21, 1920. The past history was uneventful. On February 19, 1920, while at school, he became very excited and talkative and was sent home. His mother noted that he was


irrational at times. The following night he became delirious. There had been no convidsions. Examination on admission showed a well-nourished boy, in active delirium, thrashing about in bed. There were no abnormal physical findings. The leucocyte count was 9800. The cerebrospinal fluid was normal (for subsequent examination see C. S. F. chart). The temperature was 100° F. but rose rapidly to 104° F., remaining there for six days, gradually falling to normal on the 15th day, with frequent slight elevations thereafter. He remained in acti\-e delirium for seven daj's. muttering constantly and pulling at the bed clothes. Typhoid fever was suspected, but excluded by the various laboratorj' examinations. Following the subsidence of the delirious state the patient passed into a state of lethargy in which he remained for ten weeks. At firet he could be aroused and made to respond to questions, but he soon passed into deep coma, so that for five weeks it was necessary to administer both food and fluids by gavage. The mask-like facies during this period was striking (Fig. 1). Beyond the somnolence no striking neurological features were made out, until March 12, when external strabismus, a bilateral ankle clonus and a positive Babinski were noted. Hyperpnoea followed with diminished bicarbonate content of the blood serum (26 volumes per cent (Van Slyke)), which was not relieved by sodium bicarbonate. In spite of the administration of 1000-1500 calories per day by ga\-age, the patient lost considerable weight. From the first of May, he gradually improved, responded to questions, talked and mo\-ed his limbs. The ankle clonus, Babinski and strabismus disappeared. The facies remained, however, immobile (Fig. 2). He was allowed to leave his bed and was discharged June 20, apparently well save for weakness and general spasticity. By July he was walking about the house and sleeping well at night. When seen in August, there was noted a slight tremor of the hands and constant clearing of the throat. There were no abnormal movements. He had developed the habit of spitting and was disobedient at times. There was general spasticity and marked stiffness of the carriage in walking. The speech was monotonous (Fig. 3). In September he developed sleeplessness at night, which, though less marked, was still present when seen in December. At this time he seemed fairly well, but was disobedient. He was permitted to go to school.

Sleeplessness at night alternating with deep sleep during tlie daytime was a characteristic symptom in a few cases during the acute stage and also during the period of convalescence {v. L, under Insomnia) .

In other instances drowsiness or sleepiness of a few hours' or a few days' duration often combined -(vith transient diplopia were the only .symptoms of a verv- mild form of the disea.se.

Case 3. — M. E., aged 12 years, was admitted to the hospital October 30, 1919. He complained of dizziness. He had not had influenza. On October 22, 1919, he had double vision but went to school. He came home and slept all the afternoon. The drowsiness increased steadily until admission. On examination the patient was drows>' but clear when aroused. The legs and arms were somewhat spastic and there was a positive Babinski oh the left. The spinal fluid contained 10 lymphocytes per c. mm. The patient slept constantly for four days. Thereafter recovery was rapid and complete.

Case 4. — M. C, a white girl, aged 16 years, was admitted to the hospital November 22, 1919. She had not had influenza. From November 8 to 17, 1919, she felt abnormally sleepy and slept several afternoons. On November 17 she noticed diplopia. This lasted several days, then disappeared, to return again No\'cmber 21, 1919, for a few hours. The patient returned to school and has remained well (August 30, 1920).

Lethargy was present in many eases and in the severe forms of the disease was usually followed by deep coma.


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Case 5. — A. V. F., a white girl, aged 6^ years, was perfectly well until the evening of November 9, 1919, when she complained of slight headache and had fever. The following day she had a generalized convulsion and was unconscious for the remainder of the day. Following this she became stuporous with periods of consciousness, but at all times was difficult to arouse. There were no further convulsions and no vomiting. The patient was admitted to the Harriet Lane Home November 13 on the fifth day of her illne.*':. Examination at this time showed a poorly nourished girl lying in a state of deep stupor. When stimulated she cried out but immediately relapsed into stupor. There were no evidences of paralyses either of cranial nerves or of the extremities. The left arm, however, was held stiffly and there was a tremor of the left hand. The reflexes were active; there was a positive Babinski on both sides and a slight ankle clonus on the left. Examination was othei-wise negative except for otitis media on the left. The leucocj-te count was 12,000 and the spinal fluid was normal. The Wassermann test was negative with blood and spinal fluid. The child then went into a deep lethargj' so that she would not be aroused. She lay perfectly still, making no voluntary movements and was apparently' unable to swallow solid food. There was a fine tremor of the tongue and of the hands. The ankle clonus and positive Babinski persisted. At times there was fiexibilitas cerea. By December 9 the patient had become brighter and cognizant of her surroundings. The evidences of pyramidal tract involvement had disappeared. Bj- the middle of December she had recovered arid was able to sit up. At this time she developed a mild arthritis of the right shoulder and of the right hip. She was discharged Januarj- 13, apparently well. Since this time reports from her parents indicate complete recoveiy without sequelje.

C.4SE 6. — A. R., a white male, aged 65 yeare, was admitted to the hospital October 22. 1919. complaining of dizziness and trouble with vision. The present illness began two months before admission with sleepiness and drowsiness which had constantly- increased. On October 19, 1919, he felt dizzj' and weak and stopped work. On examination his temperature was 103.7° F. and he was comatose. He muttered incoherently. There was bilateral ptosis. The pupils were active and the fundi normal. Coarse muscular jerkings of the arms and legs were obser\'ed. The extremities were fairly spastic. The tendon reflexes were normal. The spinal fluid contained 200 cells per c. mm. and a trace of globulin. The temperature remained above 102° F. The patient sweated profusely and emaciated rapidlj'. He died November 4, 1919.

Autopsy (Figs. 4 and 5). — The brain appeared normal in the gross. Microscopical sections showed marked perivascular infiltration about many of the small vessels in the caudate nucleus, lenticular nucleus, substantia nigra and mid-brain.

Characteristic, then, of the disturbances of general consciousness which may occur in the course of this disease are :

1. The variation of the disturbance from sleeplessness to coma with the intermediate stages wliich are called apatliv, drowsiness, sopor, lethargy, stupor, etc.

2. The long duration of the lethargic state in many instances. A patient may lie for weeks or even months in a state of deep lethargy varying hut slightly from day to day or week to week.

3. The fact that many of the patients, although apparently in a state of deep sleep, will respond promjjtly to a command or reply to a question in a perfectly rational manner, relapsing immediately into the former state of lethargy.

Jr. The frequent association of a stat* of general spasticity.

Lethargic states resembling those present in this affection may be observed in a number of acute diseases, such as typhoid fever, and in chronic affections, such as syphilitic basilar


meningitis. However, they usually lack the characteristics outlined above, although sometimes the differentiation cannot be made until the patient has been observed over a considerable period of time.

Disorders of psychical activity, when present, are generally combined with some of the disturbances of general consciousness described above. The psychosis in a few instances was the only important symptom and a group of such cases has been reported from this hospital by Hohman."* In the majority of our patients, however, abnormal mental reactions, when present, were incidents in the unfolding of the symptom complex of the disease. We shall discuss here only a few of the more frequent mental sATiiptoons encountered during the early stages of the malady. Delirium was infrequent in the adult cases, but was observed often in tlie early stages of the disease in children (see Case 2).

In the following case there were few symptoms other than delirium and excitement to suggest the diagnosis of epidemic encephalitis :

C.4SE 7. — \V. H. E., a white male, aged 24 years, was admitted to the hospital Januarj' 27, 1920. The past history was unimportant. The present illness began January 25, 1920, with moderate fever and general malaise. A few days later he had aching of the limbs. Moderate delirium soon appeared, accompanied by visual and auditory hallucinations. The patient was restless and very talkative and confabulation was a striking feature. Transient diplopia, moderate tremor of the hands and slight nystagmus were present. The spinal fluid contained 30 cells per c. mm. The Wassermann test, with the blood and spinal fluid was negative. When last seen, Januarj' 1, 1921, the patient was mentally clear but restless, talkative and rather expansive. He was also suffering from marked insomnia.

Other patients had irrational periods of variable duration with visual and auditory hallucinations. Occupational delirium was occasionally obsen^ed and in rare instances mental reactions not unlike a Korsakoff psychosis were present. One patient worked in the wheat field for days at a time. Another prayed constantly because voices told him " to get right with God." A young colored girl knew someone was hiding in the room waiting to kill her. Spontaneous, unprovoked outbursts of laughing or crjing were present in several of our patients. These attacks were not provoked by adequate emotional stimuli and must be looked upon as abnormal. It is of interest that many of these patients had a mask-like fades and bilateral rigidiiy of slight extent (pseudo-bulbar syndrome).

It is not necessary at this time to detail all the mental symptoms encountered; a full discussion of this phase will be found in the papers by Abrahamson," Hohman "* and others.'"

OCCLAE DiSTUEBANCES

Disturbances of innervation of the extra-ocular muscles were often present during the active stage of the disease. Diplopia was frequently the first symptom referable to involvement of the nervous system noticed by the patient and in some instances preceded the appearance of any other symptoms by many days. The characteristic feature of these palsies was their transient and variable character. Thus, in


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some cases diplopia was present on one examination and

absent the next, or an internal strabismus, present for a short time, was followed by an external strabismus of variable duration. Furthermore, although most of the muscles innervated by the third nerve might be palsied successively, it was rare indeed to observe involvement of all of them at the same time.

Ptosis was frequent, usually bilateral, although often more marked on one side. It was seldom complete. It frequently contributed considerably in the production of the expressionless facies of the patients. In some instances it was impossible to decide whether the slight bilateral ptosis was dependent on faulty innervation or on lethargy, for drooping of the upper lids occurs in the somnolent state."

Disturbances of associated eye movements were comparatively rare. One patient could not rotate the globes above the horizontal plane. A few had weakness on lateral deviation. Inability to converge was common, althougli usually transient.

' We encountered a few instances of paralysis of accommodation. These patients complained of inability to see near objects clearly and to read fine print. In such cases we assumed that true paralysis of accommodation was present, unless there were optic nerve changes or conspicuous disorders of innervation of the extra-ocular muscles.

Nystagmus was present in a large number of cases and was of two types. In the first, it was similar to that observed in early multiple sclerosis, viz., the common rhythmical oscillations with a quick and slow phase. In the second, the eyes s_eemed as if lield in place by springs, and attempts at fixation produced wide, irregular oscillatory movements of the globes in all planes, including the anterio-posterior, until the eyes came to rest, often in good alignment. The characteristic quick and slow phases were absent in such eases. Rarely, attacks of coarse jerking of the globes occurred without obvious provocation. So far as we know, this phenomenon has not been described in any other disease. Sicard and Kudelski "^ gave the name ocular myoclonia to this type of nystagmus.

Ophthalmoscopic examinations were made repeatedly in most cases. Hypera?mia of the discs was occasionally present. Optic neuritis with swelling of the discs was obsen'ed in the following case and also in Case 23 below :

Case 8.— E. F., male, white, aged 37 years, was admitted to the hospital July 29, 1920, complaining of headache. The present illness began February 1 with dizziness and weakness. About March 1 walking became difficult and he had pain in the back. For several days there was incontinence of urine. Frontal and temporal headache was constant ; the left arm became weak and there was some dimness of vision. He noticed a few muscular jerkings. Examination sliowed a mask-like face with slight bilateral ptosis. The left optic disc was raised and hyperaemic; the edges were indistinct. The right disc was normal. There were no muscular jerkings. The spinal fluid contained 70 lymphocytes per c. mm. and a trace of globulin. There was no fever at any time. The patient was often irrational at night. He improved slightly and left the hospital against advice Augu.st 16, 1920.


DisoHDEKs OF ^Motility

Disorders of motility were present in the majority of our cases. They were so diverse in character that it is impossible to classify them in well-defined groups. For descriptive purposes, however, we shall group all the motor phenomena under three heads as follows :

1. Disorders of tonicity.

2. Paralyses and Pareses.

3. Hyperkinetic phenomena.

1. Disorders or Tonicity. — At the onset of the malady general spasticity associated with other evidences of meningeal irritation, the so-called meningismus, may be present, as in the following case :

C.4SE 9. — K. R., a white girl, aged 6 years, was admitted to the Harriet Lane Home September 19. 1920. She had been well until September 16 (three days before admission) when she complained of headache and vomiting. Throughout the day she was nauseated, drowsy and had no appetite. Toward evening her neck became stiff and a physician who was called regarded the condition as due to meningitis. The patient soon became unconscious but there were periods when .she could be aroused. Examination on admission showed a poorly nourished white girl lying in a stuporous state with head retracted and back somewhat stiff. When spoken to she opened her eyes, relapsing immediately into stupor. There was retraction of the neck and apparently pain on flexion. There was no evidence of paralysis, the reflexes were active and there was a suggestive Kernig sign. The leucocyte count was 12,000; the spinal fluid showed 14 cells per c. mm. and a faintly positive globuhn reaction. The temperatm-e was noiTnal. The Wassermann test was negative with the blood and spinal fluid. The evidences of meningeal irritation quickly passed away and by September 21 the patient had come out of her stuporous state and appeared bright. A second lumbar puncture done on September 23 showed 26 cells and a positive globulin reaction. The patient was discharged September 30 and has remained well since that time.

Later, however, evidences of disturbance of the pyramidal or extra-pyramidal motor tracts may appear. The former will be discussed with the paralytic phenomena and we shall therefore confine our attention here to those disorders of tonicity which may not be associated with evidences of pyramidal tract involvement.

(a) Hypotonicity, associated with ataxia or weakness of the extremities, was present in the following instance :

C.\SE 10. — R. W., a white woman, aged 24 years, entered the hospital in March, 1919, complaining of jerking of the eyes and inability to stand. In October, 191S, she had had a febrile disease, called influenza, which had kept her in bed a week. Februaiy 23, 1919, she had severe headache and dimness of vision. Her eyeballs and eyelids were iu constant motion. She felt poorly and went to bed, where she remained until admission to the hospital. About two weeks after the onset her legs seemed stiff and she could not walk. Her jaws jerked violently so that speaking was difficult. Since March 24, 1919. she had been unable to stand alone or to walk. Examination showed a well-nourished woman, mentally clear, not drowsy. There were frequent spasmodic contractions of the jaw and eyelids. The eyeballs jerked violently in all directions, both spontaneously and on attempts at fixation. Upward deviation was limited. There was slight bilateral ptosis. The speech was thick and scanning. The right abdominal reflex was not obtained. The muscles were markedly hypotonic and the movements were inco-ordinate. The spinal fluid contained 17 cells per c. mm. and a considerable amount of globulin.


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The Wassermarm test with the blood and spinal fluid was negative. There was a slight elevation of temperature during the first two weeks. At intervals the patient was drows>' ; at other times there were attacks of unprovoked laughing and crj'ing. By July 5, 1919, the jerking of the jaws had ceased and the jerking of the eyeballs was less marked. The incoordination had improved considerably and the patient could walk a few steps alone. It is possible that the hyjjotonicitj', incoordination, scanning speech, nystagmus and motor weakness were dependent on a cerebellar localization of the process, but of this we have no definite proof. However, the resemblance to certain cerebellar syndromes is striking.

(b) Hypertonicity, often widespread, was a more frequent sjinptom. It was present in all the severe or fatal cases and often associated with waxy flexibility, as in the following instances :

Case 11. — C. B., a white man, aged 36 yeare, was admitted to the hospital in March, 1920. The past history was unimportant. The present illness began March 12, 1920, with fever and dizziness. The family noticed that the patient was restless, euphoric and talkative. He complained of pain in the elbows and general tremor. On March 29 his speech was thick and there was inability to swallow. There was double vision. When first examined March 30, 1920, the patient was well oriented but depressed. There was marked tachypncea and attacks of " smothering." The pupils were unequal. There was slight nystagmus. Dysarthria was present and the patient was unable to swallow. The face was mask-like. There was slight strabismus. The tendon reflexes were normal. There was verj' marked general rigidity with waxy flexibility. The patient remained in about the same condition for nine months. Incontinence of urine and feces was present at all times The rigidity persisted and was of so high degree that he was practically incapable of voluntary motion. He was fed by gavage. The face was expressionless and speech was absent or markedly dysarthric. At times there were attacks of fever, often associated with tachycardia and marked tarhypncea and hyperpnoea of several daj^s' duration. The respiratory rate was 50 per minute for several days. The patient at present (after a year) is a rigid vegetating organism incapable of voluntary motion or of continuous thought.

C.\SE 12. — C. D., a colored man, aged 35 j-ears, complained of difliculty of vision of four weeks' duration. The present illness began March 27, 1920, with pain over the heart which lasted a day. The next day he felt giddy and sleepy but continued to work. That evening he had diplopia and was told his eyes were crossed. On examination the face was expressionless and mask-hke. There was bilateral ptosis with weakness of both external recti. There was paralysis of accommodation. There was a coarse, iiTegular nj'stagmus and tremor of the lips and tongue. Coarse tremor of the arms was also present. The tendon reflexes were active. There was slight catatonia. The blood and urine were normal. The cerebrospinal fluid contained six cells per c. mm. and a trace of globulin. The Wassermann test was negative with the blood and spinal fluid. The lethargy increased and generalized spasticity appeared. The facial muscles became weak and transient dysphagia appeared. The patient was clear mentally until a few days before death. Rhythmical to and fro movement of a hand, arm or leg, and myoclonic movements of muscle groups were frequently observed. There was no fever. Lethargy increased to coma and the patient died two months after the onset of symptoms.

In other instances hypertonicity occurred in association with a coarse Parkinsonian tremor and a mask-like facies — the so-called Parkinsonian type of the disease. This syndrome occurred both in adults and children * and was often


See Case 2 above.


present for a considerable period of time. Indeed, Souques, Moreau and Pichon " '* state that they have observed instances of epidemic encephalitis followed by true paralysis agitan.s. However, this observation needs confirmation, for these are the only cases that we could find in which the syndrome persisted. Even in these a sufficient period of time has not elapsed to form a definite conclusion.

2. Paralyses and Pareses. — Paralyses of upper or lower motor neuron type may be present during the active stage of the disease.

(a) Monoplegias, hemiplegias, paraplegias or diplegias associated with exaggerated tendon reflexes and other evidences of pyramidal tract involvement may occur. In most instances they were of short duration, followed by complete recovery. The following cases illustrate this t}'pe of motor disturbance :

C.\SE 13. — C. B., a white boy, aged ok years, had been well until February 6, 1920, when he complained of headache and had fever. The following day he seemed better but that afternoon he vomited and had a general convulsion. Following this he became drowsj' and the convulsions became more numerous, occurring every few minutes. He was admitted to the Harriet Lane Home Februarj' 9. Examination at this time showed a fairly well-nourished boy lying in a state of coma. Convulsions similar to the tj'pe described occurred at five to ten minute inten-als. Examination was othem-ise negative. These convulsive attacks became less frequent and ceased February 11. The following day he regained consciousness and performed voluntary movements. There seemed to be weakness in the left hand, but othei-wise no paralysis was noted. The spinal fluid on admission showed 55 cells per c. mm. and a positive globulin reaction. Tho temperature was about 101° F. for the first, three days after admission and gradually fell to normal. The patient improved, became bright and co-operative. The weakness of the left arm, however, persisted. He was discharged March 14. When seen in September, the patient was quite well and the weakness in the left arm had entirely disappeared.

Case 14. — M. J., a white boy, aged 8i years, had been well vmtil May 1, 1920, when he complained of slight headache and of burning of his eyes. The evening of May 18 he behaved queerly. He seemed dazed and would not respond to questions and the mother noted twitching of the right side of the mouth ; he rapidly became unconscious and was brought to the Harriet Lane Home. Examination at that time showed a well-nourished boy lying in a stuporous state, from which he could be aroused at times in response to stimulation. Involuntary movements were noted which were almost entirely of the left side. The temperature was 100° F. but rose rapidly to 105° F., and then gradually fell, becoming normal on the sixth day after admission. The leucoc.\i:e count was 19.000. The spinal fluid showed 50 cells per c. mm. and a positive globulin reaction. The Wassermann te-st was negative with the blood and spinal fluid. There were no further convulsions but shortly after admission a right hemiplegia was noted. This, however, was transient and on tnc following day there were no evidences of weakness. On this day the child roused from his stupor, seemed bright and mentally clear. He was discharged perfectly well June 2. When seen three months later he showed no evidence of his former illness.

Case 15. — R. A. G., a white girl, aged IJ years, had developed normally and was perfectly well until September 17. 1920. At that time she became irritable and a few days later the mother noticed that the child was feverish. On September 24 she vomited and the fever continued, reaching 103° F. On September 26 the child could not walk because of stiffness of the right leg. The left leg became involved the following day. This spasticity relaxed during


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sleep, but even then spasmodic contractions were noted which were severe enough to awaken the child. Examination on admission showed a well-nourished female infant, conscious and \ery irritable. The legs were extended and markedly spastic, and passive motion of the limbs evidently caused pain. There was a peculiar brawny condition of the skin and subcutaneous tissue. The deep reflexes were hyperactive, the Babinski and Kemig signs were negative. The upper extremities were imaffected and there was no e\-idence of cranial nerve involvement. The temperature was 101° F., the leucocyte coimt was 8500 and the spinal fluid showed 33 cells per c. mm. and a negative globulin reaction. There was no incontinence. This spasticity and general iiTitability became less marked by October 2 and the patient was able to walk with assistance. She was discharged and in two weeks was walking in a normal manner. At this time restlessness and wakefulness at night were noted. The child would sleep well until midnight but during the remainder of the night was wakeful. This wakefulness was not relieved by the administration of chloral hydrate. Gradually, however, this condition subsided and at the present time the child sleeps well and there are no evidences of residual paralysis.

(b) Cranial nerve palsies vrere present at some time in the majoritj' of cases during the active stage of the disease. As a rule they were transient or recurrent and referable to involvement chiefly of the third, fourth, sixth and seventh cranial nerves or their tracts. Since these have been described above, we shall group together here the disorders of motility dependent on faulty innervation of the facial^ masticatory and bulbar muscles.

The mask-like facies was so frequent that the diagnosis

without that sjanptcnn was ha:;ardous. The photographs

(Figs. 1, 2, 3, 6, 7, 8, 10) show clearly this striking feature.

« The cause of the phenomenon is not clear. It was associated

constantly with defective mimicry.

Dysarthria was present in a number of cases. As a rale, the patients complained that the tongue felt thick and the face stiff. In a few instances it was dependent on twitching of the muscles of the tongue. Dysphagia was often combined with the dysarthria as in Cases 11 and 26 and the following case, Xo. 16 :

Case 16. — W. D., a white male, aged 24 years, was admitted to the hospital December 31, 1920, complaining of giddiness. In October, 1920, he had an acute febrile illness for three days. The present illness began rather suddenly December 17 with roaring in the left ear. On the following day he had intermittent attacks of pain down the left arm and behind the left ear. December 21 he had diplopi;i and " thickness of the tongue." He also noticed that he could not hear well. Drowsiness became marked and there were frequent painful jerkings of the left arm. He also developed difficulty in sivallowing and a nasal voice. Difficulty in starting urination soon appeared. Examination showed a drowsj- and dull patient with a mask-like face. He was clear when aroused but was partially deaf. The left pupil was larger than the right and there was slight nystagmus. Both optic discs were slightly hypenrmic. There were a few coarse non-rhythmical fascicular twitchings of the muscles of the face and limbs. The reflexes were normal except for a jjositive Babinski on the left. Mastication and swallowing were possible but were performed slowly and carefully. There was marked disturbance of pronunciation of the labials and lingiials. He complained of numbness of the face and tongue. His temperature was 102° F., but in four days reached normal. The spinal fluid contained 26 lymphocytes per c.mm., and a slight increase of globulin; the gold chloride curve was normal. The Wassermann test was negative with the blood and spinal fluid.


Unilateral and bilateral facial weakness was frequent and often transient. The following case is a good example :

Case 17. — M. H., a white infant, aged 7 weeks, was admitted to the Harriet Lane Home April 4, 1919. She was bom at term and had been considered normal until the first of April when she became dull and drowsy. Following this she could not be roused ; there was slight fever. Examination on admission showed a well-nourished infant in coma. When stimulated she became spastic, but when relaxed had the appearance of a sleeping infant. Examination showed right facial weakness, bilateral ptosis, and slight general spasticity (Fig. 6). The temperature was 101° F. on admission but fell within 24 hours to normal. The leucocj'te count was 8.500 and the spinal fluid showed 28 cells per c. mm. and a faintly positive globulin reaction. The child improved and became less drowsy and the facial weakness and spasticity disappeared. She was discharged May 3, 1919, and did well at home. She died in June following an acute illness, the details of which were not obtainable.

Trismii-'^, associated with tender mas.seters, was present in the following instance :

Case 18. — M. W., a colored woman, aged 28 years, was admitted to the hospital May 14, 1920. Four days previously her mouth and tongue had become very sore on attemps to move them and she was unable to open her mouth on account of pain. On examination the temperature was 99° F. but soon reached 102.5° F. The masseters were ven' tender on pressure and the patient could not open her mouth. She was drowsy and there was dysarthria. There was a double external strabismus which developed under obsen-ation. There was incontinence. The cerebrospinal fluid contained 5 cells per c. mm. and a trace of globulin. The reflexes were slightly hyperactive. The Wassermann test was negative. May 15. 1920, the fever reached 103.5° F. and the patient died suddenly.

Tachijcardia was occasionally obsened and in some instances Avas j>ossibly referable to involveanent of the vagus.

Hi/perpna'a was present in six of our cases and deserves special mention. In each of these this SATuptom occurred during the early stages of the disease and was associated with a diminished bicarbonate content of the blood plasma. However, in several instances it was not relieved by the administration of sodium bicarbonate. The hyperpnoea was therefore not the result of acidosis but dependent on disturbance of the central resi)irator\- regulatory mechanism. Brief records of patients manifesting this symptom may be of interest.

Case 19. — J. C, a colored man, aged 19 years, was admitted to the hospital March 4, 1920. The patient's mother stated that " he sees double and talks out of his head." The present illness began March 1, 1920, with staggering following a slight injur\- to the head. The next day the patient was irrational, weak and drowsy, and complained of double vision. On examination he was ver>' lethargic and talked irrationally. When aroused he was rational and talked in a low monotonous tone. The face was mask-like (Fig. 7). There was bilateral ptosis with slight internal strabismus. There were many coarse jerkings of the muscles of arms, legs and abdominal wall. The reflexes were normal. The leucocyte count was 11.400. The cerebrospinal fluid contained 368 cells per c. mm. The globulin test was negative. The Wassermann test was negative with the blood and spinal fluid. The incoordination of the eye movements, slight nystagmus and fascicular twitchings persisted for many days. The temperature, which was 104° F. on admission, gradually returned to normal. The tachycardia and tachypnoea persisted; the respirations were usually about 36 to the minute. Lethargy diminished gradually. April 4, 1920, the patient was found in collapse. The respirations were ver>' deep and more than 60 per minute. The pulse was rapid.


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The CO2 tension of alveolar air was 15 mm. Hg.; the bicarbonate content of the plasma was 40 volumes per cent (Van Slyke). Morphine gr. i was given and this was repeated in one hour. The respirations fell to about the normal rate and the tachypncea did not return. The patient gradually recovered and when lost seen nine months after the onset of the disease was well except for a peculiar stiffness of carriage, an expressionless facies, and a few tic-like movements of the face.

Case 20. — A. W., a white boy, aged 8 weeks, was admitted to the Harriet Lane Home April 16, 1920. He had been born at term and breast fed up to the onset of the present illness which had begun eight days before admission when it was noted he did not nurse well and had fever. Four days before admission he had a convulsion, which was followed during the next few days by a series of similar attacks, generaUzed in character. He refused to nurse. On admission to the hospital, examination showed a poorly nourished infant lying quietly in bed ; there was marked hyperpnoea and general muscular rigidity. There was a transient ptosis of the right eyelid and hyperactive reflexes. Otherwise examination was negative. The temperature was normal. The leucocj'te count was 22,000 and the spinal fluid showed 06 cells per c. nmi. and a positive globulin reaction. The bicarbonate content of the blood was 28 volumes per cent (Van Slyke). There were no evidences of tetany. It was necessary to feed the child by gavage for the first 24 hours. In spite of the administration of sodium bicarbonate to the point of rendering the urine alkaline, the hyperpnoea continued. By April 20 this symptom had disappeared and the child was discharged in good condition except for slight spasticity. When seen November 30 he had completely recovered. (See also Cases 2 and 11.)

Case 21. — A. Y., a white infant, aged 4 months, had been well until March 17 when following her bath she vomited and had a generalized convulsion. Following this she became unconscious and an internal strabismus was noted. She was admitted to the Harriet Lane Home the same day. Examination on admission showed a well-noiu-ished female infant lying in an apathetic state ; she could be aroused, however, and was rather fretful. There was definite hyperpnoea. A slight internal strabismus and i)tosis of the left eyelid were noted ; otherwise the examination was negative. The spinal fluid was normal. The bicarbonate content of the blood serum was 19 volumes per cent (Van Slyke). There was no acetone in the breath (Higgins). The urine was normal save for a few white cells and the phenolsulphonephthalein excretion was 65 per cent in two and a half hours. There were no evidences of tetany. On account of the hyperjmcea and the diminished bicarbonate content, sodium bicarbonate was administered by mouth to the point of rendering the urine alkaline, without effect on the hyperpnoea which continued when the bicarbonate content reached 48 volumes per cent (Van Slyke) . Evidently then the acidosis was secondary to the hj'pei-pncea which was probably due to stimulation of the medullary center. The patient became les-s drowsy but the internal strabismus and ptosis persisted, and a slight facial weakness appeared. The hyperpncea varied during the following three weeks ; sometimes it was well marked, at other times slight. Several courses of sodium bicarbonate were given without effect. The spinal fluid on March 26 showed 20 mononuclear cells per e. mm., and a positive globulin reaction. On April 14 the child seemed brighter; the hyperpncea, the ptosis and facial weakness had disappeared. The spinal fluid returned to normal and she was discharged with slight internal strabismus on April 28. She has since been entirely well.

(c) Symmetrical paralysis of peripheral nerve type was observed in six eases. These were characterized by a gradual onset, extensive ilaccid paralysis of upper and lower extremities, more marked in the distal portions, slight sensory disturbances, muscular atrophy, and usually slow but eventual recovery.


Case 22. — C. J., a white girl, aged 5 years, had been perfectly well until the onset of her present illness February 1, 1920, when she awakened complaining of aching in her knees. The following day the child appeared perfectly well but that night again complained of aching in her knees. On the third day her parents noted that the child walked stiffly. This stiffness increased and weakness of the legs developed to such a degree that three weeks after the onset the patient was unable to walk. No swelling or tenderness of the knees developed. The patient then complained of headache and about one week before admission weakness in the hands was noted. Beyond slight irritability, there was no change in the patient's mental condition. She was admitted to the hospital on March 25, seven weeks after the onset of her illness. Examination at that time showed a well-nourished white girl who was unable to stand, was quite irritable, but well oriented and apparently normal mentally. There was neith' r facial nor ocular paralysis but a general muscular weakness of upper and lower extremities. The legs were moved but little even on stimulation. There was some atrophy but this was not marked. The grasp of both hands was weak. There was ataxia. No disturbance of sensation could be demonstrated. The deep reflexes were absent at elbows, knees and ankles. The spinal fluid was under normal pressure with 6 cells per c. mm. and gave a strongly positive globulin reaction. The Wassermann test was negative with the blood and spinal fluid. The patient remained in the hospital one month. During that time the muscular weakness became noticeably less marked. This muscular weakness was symmetrical and more marked distally than proximally. The deep reflexes remained absent and there was never any sensoiy change. At the time of discharge, April 24, the patient could move her arms and legs well and could stand with assistance. By the middle of July she had recovered strength in her limbs and was able to walk with support. By September she was able to run and play with apparent control of her extremities, and by the last of November seemed completely recovered.

The other causes of symmetrical paralysis of lower motor neuron type were excluded in this case and there remained a widespread paralysis of upper and lower extremities developing rather suddenly with complete recovery.

Case 23. — F. S., a white girl, aged 10 years, was brought to the Harriet Lane Home July 30, 1920, because of weakness. She had been well up to May 1, 1920. At that time she fell. A week after this she complained of headache and vomited. This was repeated several times. There was no fever. Her appetite became poor and on June 1 weakness in her legs was noted, at first only after walking. Subsequently this increased until she was unable to walk, and about the middle of July weakness was noted in the arms as well. There was no visual disturbance. Examination on admission showed a poorly nourished child with general muscular weakness. She was unable to walk without assistance and after making a few steps complained of feeling very tired. There were no cranial nerve palsies. The eyes reacted to light and on accommodation. There was a definite optic neuritis more marked on the right. The legs showed generalized muscular weakness with some muscular atrophy. The arms showed muscular weakness to a less extent with a verj' weak grip. The deep reflexes were all absent. The superficial reflexes were present. The spinal fluid was under slightly increased pressure with 28 mononuclear cells per c.mm. and a strongly positive globulin reaction. The Wassermann test was negative with the blood and spinal fluid. There was no disturbance of sensation, nor had the patient complained of any sensorj' disturbance. The child remained in the hospital until August 19. During this time her condition improved. The appetite became better. The optic neuritis became slightly less marked and the spinal fluid returned gradually to normal (see c. s. f. chart). The weakness of the arms and legs became definitely less, so that the patient was able to sit up without assistance and to walk a few steps. The knee kicks were still absent but the arm reflexes returned. There was a slight foot drop and some muscular atrophy particularly in the


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hand. The galvanic stimulation of muscles of the legs gave the reaction of degeneration. This was not present in the muscles of the forearm. The patient was seen again September 22 and had improved during her month at home. She had been sitting up in bed but had not been allowed to walk. There was definite improvement in muscular strength and control, and she was able to sew. Ophthalmological examination showed a mild optic neuritis. There was an ataxic tremor of the hands with atrophy but no wrist drop ; ataxia of the legs with definite improvement in muscular power. The deep reflexes were still absent. A letter from the mother on December 22, 1920, stated that the child was steadily improving, walking around the house without tiring and sleeping well at night.

In summary, an acute polyneuritis in a previously well girl with evidences of increased intracranial pressure, inflammatory reaction in the spinal fluid, optic neuritis, generalized muscular weakness of lower motor neuron type, more marked in the legs; absence of sensory disturbance, with recoveij within seven months.

Case 75. — A white boy, aged 13 years, was admitted to The Johns Hopkins Hospital February 15, 1921. complaining of soreness in his back and legs. His past history was negative. The present illness began January 1, 1921, with pain while chewing. The next day he had tingling of his fingers, and a few days later numbness, pain and weakness of the legs developed. About tliat time he also had severe headache and pain in his back. Examination showed a well-developed boy. The fundi and ocvilar movements were normal. There was slight general atrophy of the muscles of the hands, feet, arms and legs. The muscles were tender on pressure. There was weakness of the muscles of the extremities and back and slight weakness of the muscles of mastication. Sensation was intact on objective testing. There was hypersesthesia over the feet. There was no fever. The blood counts were normal. The Wassermann test with the blood was negative. The spinal fluid on the Uth day of the disease contained 280 cells per c. mm. and gave a positive reaction for globuhn. The muscles of the legs and arms gave either complete or partial reaction of degeneration. The urine contained a few leukocytes. The boy left the hospital February 23, 1921 much improved. The tenderness on pressure had disappeared and he could rise to a sitting posture which was impossible on admission. By the middle of March the muscle strength had returned to such a degree that he could walk alone.

Case 25.— D. F., a white man, aged 37 years, was admitted to the hospital April 2, 1920. He complained of vomiting and numbness of the feet. The present illness began the middle of March, 1920, with "aching all over" especially of the legs and head. He felt feverish and had a chilly sensation. These symptoms lasted about a week, when repeated nausea and vomiting appeared. He became so weak that walking was impossible. On examination the patient was drowsy and answered slowly but accurately. The face was expressionless. There was slight nystagmus on upward deviation. The pupils were active and the fundi were normal. There were we.akness and atrophy of the muscles of the feet, legs, hands and arms. Sensation for touch, pain and temperature and recognition of position was diminished below the knees and elbows. The knee jerks were sluggish : the ankle jerks were not obtained. The tendon reflexes of the elbows were present. The leucocyte count was 2S40. The cerebrospinal fluid contained 70 cells per c. mm., with a trace of globulin. The Wassermann test was negative with the blood and cerebrospinal fluid. While the patient was in the hospital there was no fever. The calf and arm muscles wasted rapidly and the reaction of degeneration was present. The patient left the hospital against advice and died six days later.

Case 26.— A white man, aged 25 years, was admitted to The Johns Hopkins Hospital August 20, 1920, complaining of inability to walk. His present illness began in March, 1920, when he noticed that liis


hands were numb. He began to have pains in his arms, legs and eyes. Seven weeks before admission he had fever and chilly sensations. Three weeks later he had difficulty in speaking and trembling of the limbs and face. He soon developed hiccup, great weakness and difficulty in swallowing. He vomited frequently. On examination he showed poor memory and disorientation for time. The facial muscles were weak and deglutition and articulation were very difficult. The eyes were normal. The tendon reflexes were exaggerated and there was an equivocal Babinski sign. The muscles of the extremities were weak and there were numerous and widespread fibrillary twitchings. Reaction of degeneration was present in some muscles of the calves and arms. The leucocyte count was 6200. The cerebrospinal fluid contained 3 cells per c. mm. and gave a negative globulin reaction. Except for the rather abrupt onset the resemblance to progressive muscular atrophy was striking. However, when the patient was last seen, the fibrillary twitchings and bulbar palsy had disappeared and the muscles had attained nearly normal size and strength.

.'). Hyperkinetic Phenomena. — Under this heading we shall descriJie a group of symptoms referable to neuromuscular hyperactivity which we have observed in patients with epidemic encephalitis. Eecent medical literature contains many reports of cases presenting various types of hyperkinesias."^ In some of these such names as " encephalitis myoclonica " and " encephalitis choreiformis "' were employed to designate the disease type. In others the close resemblance of the involuntary movements to those observed in Sydenham's chorea,"' ""• °°' " in Parkinson's disease,^- " in Friedreich's myoclonia " and in other less well-known maladies,^ has been pointed out. However, until the pathology of these phenomena is better known, it is not desirable to attempt to divide encephalitis into types depending on the character of the hyperkinesias. Furthermore, our knowledge of the pathological alterations in the large group of affections characterized by the presence of hyperkinetic phenomena is still too meager to allow completely satisfactory correlation of the clinical symptoms and structural alterations.

The hyperkinetic phenomena encountered during the active stages of encephalitis consist of non-rhj-thmical muscular twitchSngs, fibrillary twitchings, tremors, choreifbrm and athetotic movements, myoclonias and certain rhythmical spasmodic movements. In some instances, furthermore, convulsions may occur.

(a) Mti^cular twitcliings were present in the majority of the adult cases, rarely in children. They may be fibrillary, fascicular or involve a whole muscle or group of muscles. In many instances only the muscles about the mouth or in the eyelids were affected, but in other cases the twitchings were widespread. The movements were quick, usually nonrhythmical and often violent. At times tliey were accompanied by pain. They differed from the more rhythmical myoclonias and also from the usual fine fibrillary tremors.

(b) In one case observed by tis (Case 2G) triLe fibrillanj tremors of the muscles of the limbs and of the intrinsic muscles of the hands with widespread muscular atrophy were present. This patient also presented many other symptoms commonly observed in progressive muscular atrophy such as dysphagia, dysphonia and signs referable to pyramidal tract involvement, but it is fairly certain that the picture was pro


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duced by the virus of epidemic encephalitis. In the following case, also, fibrillary twitchings were observed:

Case 27. — W. B., a white man, aged 26 yeare, was admitted to the hospital complaining of burning of the eyes. The present illness began three months before admission with " aching all over," shootmg pain.s in the joints, burning of the eyes, and painful micturition. There were also photophobia and difficulty of vision. On examination the patient was drowsy and the face was expressionless. There was slight nystagmus. An occasional quick jerk of the right arm was observed. The legs were stiff and painful on passive motion. The arms were ataxic. The tendon reflexes were normal. There was numerous fibrillary twitchings of all the muscles of the extremities, especially of the interossei. The face was paraesthetic. The temperature occasionally reached 99.5° F. The spinal fluid contained 15 cells per c. mm. and a trace of globulin. The Wassermann tests were negative.

(c) Tremor was frequent, especially in patients with slight general spasticity. As a rule, it was rather coarse and fairly regular, but unlike that observed in paralysis agitans. In other instances fine tremor of the lingers was present. Types of tremor accentuated by voluntan,- movement (intention tremor), however, were not observed by ns.

(d) Mifoclonia, viz., rapid, rhji;hmical contractions of a muscle or group of muscles, with or without movement at the joints, was observed in a large number of cases. In some instances a rapid to and fro movement of a whole segment was produced by the involvement of synergistic groups of muscles. As a rule, the attacks of myoclonia were spontaneous, but in some instances they were precipitated by voluntary motion. Case 11, recorded above, affords a good example of this type of motor disorder, as does the following :

C.^SE 28. — E. T., a white girl, aged 3 years, was admitted to the Harriet Lane Home September 9. 1920. Previously the child had been well except for tantrums of erj-ing and wanting her own way, which she had had for about a year. One month before admission she vomited and during the month this was repeated se\eral times. On September 6 the child seemed sleepy and on the following day had fever and was unable to sit up. She remained drowsy but could be aroused. On September 8 twitchings about the mouth and slight tremor of the left hand were observed, which became more marked up to the time of her admission. Speech had become less distinct. There had been none of the temper tantrums since the onset of the present illness. Examination on admission showed a well-nourished girl lying in a state of semi-stupor, occasionally rising to a sitting position. There was constant twitching of the left side of the face and occasionally the muscles of the left side of the neck and deltoid and upper arm would twitch also. When offered an object, the child would grasp it with the right hand. There was general spasticity. more marked on the left. The deep reflexes were present, there was no clonus. The leucocyte count was 7000 per c. mm. and the temperature never went above 100° F. The spinal fluid was normal. The child remained in the hospital until September 30. During the first part of her stay the twitchings of the left face, ami and to a less extent of the leg were marked. A few days later, however, it was noted that the twitching was present also on the right side. There was no actual paralysis of any part. These muscular twitchings-never involved all the muscles of an extremity at one time, but there would be twitchings of parts of one muscle group now here, now there. These movements resembled the muscular twitchings produced by a weak galvanic current. By September 30 they had entirely stopped and the patient was discharged apparently recovered except that .she refused to grasp objects with her left hand. This condition


was stiU present when she was last seen (January 6, 1921). There were no other sequelae.

(e) Choreiform movements indistinguishable from those of acute chorea were present in a few cases. The following; record demonstrates clearly the difficulties of diagnosis in such instances:

C.4SE 29. — K. B., a colored woman, aged 17 years, was admitted to the hospital March 23, 1920, complaining of jerky movements and pain in the neck. The patient was dehvered by normal labor February 14, 1920. Nine days later she had sharp shooting pains in the limbs and neck. The pains recurred about every ten minutes and were veiy severe. She felt veiy weak. On March 18, 1920, the patient was delirious and her temperature had reached 105° F. Marked jerking of the arms, legs and body appeared. There was diplopia. Examination revealed violent, generalized, purj^oseless movements, indistinguishable from those in acute chorea. There was delirium with visual and auditor>' hallucinations. The patient was sure someone was in the room waiting to kill her. There was slight ptosis on the right. The spinal fluid contained 225 cells per c. mm. and a trace of globulin. Her temperature was 103° F. but slowly fell to normal. The violent choreiform movements gradually disappeared and the patient became lethargic. Succeeding the chorea extensive myoclonia was observed. The attacks of the latter occurred spontaneously or were precipitated bj' voluntary movement. They occurred in various groups of muscles. Following these, quick fascicular jerks were observed. The ptosis was variable — often bilateral. The face was expressionless and rigid and masseter tenderness was present (Fig. 8). From time to time sharp pains were present in the extremities. Marked internal strabismus appeared associated with coarse jerky mo\'ements of the globes in all directions, even anteroposteriorl}'. These were usually caused by attempts at fixation but were occasionally spontaneous. There was also coarse intention tremor of the arms. The sj'mptoms gradually disappeared and when last examined eight months after onset the patient had practically recovered. The eyes still oscillated slightly and there was some strabismus.

(f) In the following instance peculiar movements consisting of hilateral rhythmical ionic spasms were obser\-ed:

Case 30. — M. G., a colored woman, aged 27 years, entered the hospital October 5, 1920, unable to talk on account of peculiar motor phenomena described below. Her illness began October 1 with vomiting. In a few hours she was irrational and delirious. On examination the face was smooth and expressionless. There was shght nystagmus. The optic discs were verj- red, but the margins were sharp. About ten times everj' minute the patient had a tonic spasm consisting of bilateral contraction of the neck, abdominal and limb muscles. The contraction produced flexion at the neck, elbows, wrists, hips, knees and ankles. These spasms gradually became less severe and ceased. There was marked sweating, at first limited to the face but eventually involving the whole body. The patient was lethargic at intervals. Recoverj- was uneventful and complete.

The striking characteristic of these tonic spasms, whether limited to an extremity or generalized, is their rhythmicity. In the case just recorded they occurred every 5-6 seconds during one period of observation. Later they became less frequent but still remarkably rhythmical. In another instance only the left leg was involved and the spasm occurred every 3-4 seconds. Marie and Levy have given the name '• bradycinesia " to this type of motor disorder.


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(g) Hiccup of long duration, usually occurring iu attacks alternating with free intervals, was present in the following instance :

Case 31. — A white man, aged 42 years, was admitted to the hospital October 6, 1919, complaining of hiccup and depression. The present illness began in September, 1919, with an attack of hiccup of three days' duration. Then there was a period of freedom for a week when the symptoms reappeared. The patient also felt weak and unsteadjon his legs. He had a fine tremor of the hands and con-stant hiccup when first examined.

It is of interest that during the Canadian epidemic" of encephalitis a number of instances of continuous liiccup were observed. Their relationship to encephalitis is still obscure, for apparently no other symptoms referable to the nervous system involvement were observed. At the present time a widespread epidemic in which hiccup is the only symptom is present in the eastern part of the United State.'* and in Austria." Siccard *" and others " " laave called attention to the prevalence of epidemic hiccup in France and it,-; relation to abdominal and diaphragmatic myoclonia.

(h) Convulsions were frequent at the onset in the young but occurred in only one instance in an adult. Case 13 illustrates a frequent form of onset of the disease in children.

A few generalizations may be drawn from the study of the hyperkinetic phenomena. First, a variety of movements may be present in one case. Thus choreiform movements may be replaced by myoclonia and this in turn by muscular twitcbings. Secondly, none of these, with the possible exception of ocular myoclonia described above, is of much diagnostic importance when considered alone. However, a historj- of the sequence of events will usually direct attention to the probable diagnosis. Thirdly, a variety of disorders of motility have been observed as late symptoms or sequela? of tlie malady. These will be discussed below.

Dlstuebaxces of Sexsatiox

The sensorj' disorders encountered during the active stages of epidemic encephalitis are of considerable interest, although not frequent. In the early stage of the disease general hyperesthesia, dependent in all probability upon meningeal irritation, is not uncommon. It is usually very transient. Occasionally also marked tenderness of the masseters may be demonstrated.* In one patient this phenomenon was so marked that chewing was impossible and the mouth could not be opened. The patient was given anti-tetanic .«erum, although a few hours later diplopia and strabismus developed.

Headache is a frequent symptom and although usually present only for a few days at the onset, may persist for weeks or months. In the later instances it may be considered as a direct neurological symptom and not as a part of the general reaction to the toxins.

Special interest is attached to a type of radiating pain, occasionally constant but more often paroxysmal in character, which resembles closely the familiar root pains of tumors of

First called to our attention bv Dr. H. M. Thomas.


the cord or the lancinating pains of tabes dorsalis. This type of pain was usually present in those patients who later developed marked muscular twitcliings or choreiform or myoclonic movements. The following case record is typical :

Case 32. — W. H., a white man, aged 23 years, was admitted to the hospital March 1. 1920, complaining of nen-ousness and drooping of the eyelids. He had had a mild attack of influenza in September, 1918. The present illness began February 22, 1920, with severe intermittent pain in the left ring finger which radiated upwards to the elbow. The jiain occurred every 10-15 seconds and lasted in all two days. Following this he felt shaky and had a severe generalized tremor. Chewing was difficult. The speech was jerky. Drowsiness and diplopia appeared and the patient noticed that his eyelids drooped. On e.xamination the temperature was 102° F. The face was expressionless and there was bilateral ptosis. The pupils were active. There was a coarse rapid tremor of the hands. The extremities were quite spastic. The tendon reflexes were very active and there were bilateral patellar and ankle clonus. The cerebrospinal fluid showed 25 cells per c.mm. and the globulin reaction was negative. The Wa&sermaun test was negative with the blood and cerebrospinal fluid. The fever soon disappeared. The pains in the arms became less severe. The left forearm muscles became weak and the arm reflexes were increased on that side. The pain down the left arm was the last symptom to disappear. When last seen, eight months later, the patient felt much better, but had developed insomnia at night with drowsiness during the daytime. He was able to continue his medical studies.

In another patient tlie radicular pains in the limbs were followed by marked atrophy of the distal muscles of all tlie extremities associated with extensive fibrillary twitcliings.

Numbness or parai-sthesia of one-half of the body, of an arm, a leg or of the face, was occasionally complained of by the patient. Objective sensory disturbances, however, were seldom demonstrated in such instances.

The polyneuritic form of the affection, discussed above, may occur with sensory changes similar in all respects to those encountered in an alcoholic polyneuritis. In other cases of this form of the affection no sensory changes could be demonstrated.

MlSCELLANEOnS SYMPTOMS

Sweating is often a prominent feature of the disease. In one instance (Case 29) it was limited to the face for several days but later became general. The gowns of some patients were constantly drenched with sweat, althougli they liad little or no fever at the time (see Case 6).

Urinary incontinence was present in a few instances. .\s a rule the patients were comatose or very lethargic, but in other cases transient loss of sphincter control was probably dependent on involvement of the mechanism controlling the bladder and rectum.

Late Sy.mi'toms and Seqcel-e

It might be expected that a disease characterized histopathologically by inflammatory alterations widely distributed throughout the nervous system would produce, after the cessation of the acute process, changes in the delicate regulatory mechanisms which manifest themselves in various psychic and neuromuscular disorders. Such, indeed, is the case. But the


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c-hronicitj of the disease, the development of new symptoms after apparent recover)' and the rapid changes tliat may occur, lead us to believe that in many instances these apparent sequelte are in reality evidences of a disease process still active.

The phenomena, described below, may appear at any time during the course of the disease. As a rule, however, they occur after the subsidence of the acute stage or after apparently complete recovery.

(1) Psychic disorders are present during the period of convalescence in a large number of cases. They consist of mental depression, a feeling of unreality and inferiority, changes in disposition, irritability, increased psychomotor activity, disobedience in children, inability to concentrate and often marked mental fatigue. Occasionally delusional and eonfusional ]>sychoses may appear. Emotional instability consisting in uncontrollable laughing or crying is not uncommon. In some instances these mental residuals are not striking when the patient is in the ward. They appear, however, as soon as he returns to his home or his business. These imfortunates, usually aware of their abnormalities, often develop marked neurasthenic and psychasthenic states. The papers of Bramwell," Claude," Berge and Hufnagel." Papen ef al." McNalty,' Abrahamson,"" Leahy and Sands "' and others mav be consulted for interesting details of this phase of encephalitis.

(2) Insomnia as a late symptom or sequel of the affection is so characteristic, especially in children, that it will be discussed in some detail. During the active stage of the disease .sleeplessness is often present, especially in instances of the disease in which hyperkinetic features were noted (^IcXaltv,* Ellis," McAlpine," Sicard,'"' Boyd." Laporte and Eouzaud."" Roger," Dimitz," Xeal," Abrahamson,"" Findlay and Shiskin ™ and others). During the later stages, often some time after apparent recovery, a syndrome described by one of us in a previous report '° may make its appearance.* This consists of sleeplessness at night alternating with marked drowsiness or even lethargy during the daytime which manifested itself as follows :

Towards night the parents note a change in the child's behavior; he becomes restless, excited and runs about the house prying into things. He will not obey. When put to bed he does not go to sleep but jumps up and down, shakes the bed, calls frequently to his parents, talks incessantly, sings, blows, whistles and spits on the floor. He becomes destructive, tears the linen, shouts, runs out of his room and when confined will not remain quiet. He spends the whole night in constant activity. He is able to recognize his parents but makes queer sounds and strange gestures. He frequently soils the bed, plays with his feces or masturbates. At dawn he falls a.sleep and is difficult to arouse. This sleep usually lasts imtil noon. When awakened during this sleeping period, he is stupid and falls asleep again during a conversation or examination. For a few hours in the afternoon he seems fairly normal, but at dusk the restless, sleepless period begin?


This syndrome has since been observed in \'arious European countries. fSee J. .\m. M. Ass. 1921, LXXVI, 934.)


again. We have observed this symptom-complex in 12 children (and in a mild form in two adults),- a remarkably high percentage of the total cases. The striking features of the syndrome are the similarity of behavior of the affected children and the chronicity of the symptoms. In none of them has a return to normal taken place (February, 1021), although improvement has been noted in some.

The symptom-complex may follow closely " recovery " from a typical acute attack, or develop late in convalescence ; or it may even appear as the only recognizable clinical feature of the disease. It may not be as severe as outlined above, but be manifested as a mild disturbance in sleep of brief duration. Illustrative cases are as follows (see also Cases 1, 2, 7, 15 and 32 above) :

Case 33. — M. F. G., a white girl, aged 3i years, had been well until late in February, 1920. At that time she complained of feeling tired and her parents would notice that frequently during the day she would lie down and sleep for a while and then get up and play again. She would do this from three to five times during the day. About tho 1st of May she became restless at night and would not go to sleep before early in the morning. Bromides were ineffective. Towards the middle of Maj' her mother noticed weakness of her legs and jerky movements of the arm when grasping objects. No strabismus or facial weakness had been noticed. She was admitted to the Harriet Lane Home for obseiTation June 12, 1920. Examination at that time showed a small poorly nourished child, thrashing about restlessly in bed and quite iiTitable. However, she seemed bright mentalb'. Physical examination was negative except that the patient was disinclined to stand, although she would use her legs fairly well in bed. The deep reflexes were obtained with difficulty. The child did not sleep until after midnight. The spinal fluid was normal. A letter from the father December 22 saj'S that the patient has greatly improved except that she does not always sleep well at night. However, she sleeps better than she did previously. She will oecasionally drop off to sleep during the daytime. She was active and mentally normal.

C.^SE 34. — H. G.. a white boy, aged 9^ years, had been previously well until February 27, 1920, on which night he was unable to go to sleep, was restless and had a peculiar staring expression. Since that time he had not slept well at night. A facial paraly.sis was noted by the mother four days after the onset. Up to the time of admission he had been going to sleep about 4 a. m., sleeping often until noon. He was admitted for observation July 13, 1920. Examination at that time showed a rather thin boy, somewhat apprehensive, with a definite left facial paresis (Fig. 9). The pupils were unequal, but reacted to light. There was definite internal strabisnius and hyperactive reflexes. The spinal fluid was contaminated with blood. During the night in the hospital the patient slept verj' little. He was seen again in September, somewhat improved but he still remained awake most of the night, during which time he was excitable, in constant motion, wanting to do something all the time, but generally rational when spoken to. The left facial weakness was still ]iresent but veiy slight. He was said to be not as bright as he had been before his illness. No abnormal muscular movements had been observed, but at times there was increased salivation. His voice was monotonous and his expression blank and worried. A communication from his mother, December 27, stated that there was very little improvement. At times he seemed better, at others he relapsed int". insomnia.

C.4SE 35. — C. J., a colored boy, aged IJ years, had developed normally and had been well up to March 1, 1920, when he had fever and was fretful. The fever subsided in a few days but toward the last of the month the child became very lethargic, sleeping most


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of the time. He refused food and seemed to have some difficulty in s\vaIIowing. There were no convulsions and he vomited only once, which was at the' beginning of the illness. Examination on admission March 27, 1920, showed a well-nourished colored boy lying in a state of lethargy from which it was difficult to arouse him. The facial expression was quite blank with a flattening of the nasolabial fold suggesting a "mask-like facies " (Fig. 10). However, there was no paralysis present. The extremities were freely moved and the reflexes were active. The temperature was 100° F. The leucocyte count was 6000. The spinal fluid on admission showed 19 cells per c.mm. and a positive globulin reaction. During the day the patient w.ould at times sit up in bed and occasionally stand. There was a ptosis of the eyeUds and a lack of attention to his sw-roundings. His facial expression is well illustrated in the accompanying photographs. The patient had frequent attacks of naso-pharj-ngitis with elevations of temperature but gradually became brighter, took fliore notice of things and was discharged in good condition May 20. The following month he was admitted for tonsillectomy and appeared normal (Fi". 11). He did well until September 20 when he was wakeful and restless all night, tossing about in bed. Following this he did not sleep well at 'nightl waking up generally around 11 o'clock, screaming and pointing at imaginary objects. Sometimes he would st,ay awake all night and at other times he would go back to sleep after a couple of hours of wakefulness. Occasionally during the waking period waving movements of the arms were noted. This condition gradually improved and when last seen, Januarj- 6, 1921, he was sleepmg better, although he woke up every night for an hour or two. However, he was less irritable and excited than before. He had developed enuresis and the mother had recently noted an increased amount of saliva with drooling particularly at night.

Case 36— H. W., a white girl, aged 9 years, had been previously well except for the ordinary exanthemata until March, 1920, when she had an acute attack of scarlet fever. She recovered from this and in April a tonsillectomy was performed. It was observed at this time that the child was restless at night and during the month of April jerky inco-ordinate movements were noted and certain tic-hkc movements such as constant pulling at her neck. From this time wakefuhiess had persisted. She generally slept four to six hours in the twenty-four, usually between 4 a. m. and 10 a. m. She gradually became more excited at night so that she was admitted to a private sanitarium on June 13, 1920. There was no history of paralysis or ocular sj'mptoms. Physdcal examination at that time was entirely negative. During the day the child was bright and cheerful. As mght came on, she became excited, over-active, laughing loudly at times, at others talking incoherently, standing up in bed, pulling at her neck, whistling and singing. She usually went to sleep about 3 a. m. The patient was placed in an ideal environment in a quiet place in the country with a special day and night nurse. However, there has been no material change in her condition and up to the present time she still suffers from inability to sleep at night.

Case 37.— B. J., a white boy, aged 6 years, had been perfectly well until Februarj' 3, 1920, on which day it was noted that he was restless and delirious. This excitable state lasted for three days and nights. During this time pui-poseless movements of the hands and arms were observed which had disappeared by February 20. At this time also a tremor of the hands was noted and a change in speech, the child talking much more slowly than formerly. No paralyses were noted, but inabiUty to sleep, at night, developed. He was admitted to the Harriet Lane Home May 3, 1920. Examination at this time showed a well-nourished boy, apparenth- of normal mentality; his speech was slow and scanning and there was a coarse tremor of the hands. The cerebrospinal fluid showed 2 cells per c.mm. and a positive globulin reaction. The Wassermann test was negative with the blood and spinal fluid. The child remained in the hospital until May 31. During this time he slept fairly well at night, but the tremor of the hands and the slow scanning speech persisted. When seen July 15 this speech de


fect had entirely disappeared and the patient talked in a normal manner. He was bright and responded readily to questions. The tremor had also disappeared, but the insomnia had become woree, the patient usually getting to sleep at 2 or 3 a. m. and sleeping until noon the following day. This condition improved so that by September he was sleeping fairly well at night. A report from the parents stated that the child died the middle of November following an acute abdominal condition, the nature of which was not clearly understood. No autopsy was performed.

2. N euromiiscular phenomena of various types may appear during the period of convalescence and are rather characteristic of the disease. In general these consist of muscular twitchings or jerkings, tremors, choreiform and athetoid movements, tics, general psychomotor overactivity, spasticity and rarely paralyses (Buzzard and Greenfield,'^ Marie and Levy,'" Sicard,"' better," Claude," Papin et al.^'^ Lortat-Jacob and Hallez," Kahn, McNalty,' Leahy and Sands °" and others).

A state of general psychomotor overactivity, characterized by restlessness, is often present. The patients seem unable to remain still ; they must be doing something constantly and are always hun-ying. Simple acts are performed with exaggerated movements. In one patient, an adult, this condition has been present for nearly eight months but is gradually disappearing. In children, due to lack of conscious control, this abnormal state is even more marked.

Tic-like movements are commonly present and have been described by various authors."' " " They consist in the frequent repetition of some act and are indistinguishable from the common tics of psychasthenics. The following cases illustrate these movements:

C.\SE 38. — C. S., a white boy, aged 7 years, was admitted to the Harriet Lane Home Febniarj- 24, 1920. He had been perfectly well up to February 19, at which time it was noted that he talked strangely. That night delirium, restlessness and muscular twitchings were noted. The following day the restlessness continued and a physician who was called thought the boy had chorea. After a sedative was given, the movements stopped, and the boy became stuporous. On admission to the hospital he was in stupor and slept a great deal of the time. However, he could be aroused and would respond to questions. There was no paralysis and the physical examination was practically negative. The temperature on admission was 103° F. It dropped in the course of five days to normal. The leucocyte count was 16.000 and the spinal fluid contained 36 cells per c.mm. and gave a positive globuhn reaction. There were no choreiform movements obser\"ed in the hospital. The patient gradually reco\-ered from his stupor and was discharged April 5, 1920. A few days after his return home lie became restless at night and up to the present time (nine months) has not slept well at night. According to the description- of the mother, he would stay awake at night talking to himself. He generallj' went to sleep about 4 a. m. and slept until noon. He became very emotional and shy. Shortly after discharge various tic-like movements made their appearance. Thus when he was seen in May he would repeatedly touch his forefinger to his tongue and place the wet finger to his cheek and also on various objects of furniture. He was very nerv'ous and in constant activity. Since his illness his disposition had changed. He was afraid of everybody and had become morose and queer. His memon.- had become impaired so that he did not remember having been in the hospital. This condition has persisted except that other tic-like movements have followed, replacing the earlier ones, such as licking the back of his hand and wiping his forehead, making beckoning movements with fingers, snapping his


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fingers, making circular swinging movements of his arms, going about the room rapping on various articles of furniture, etc. In July he began to spit and when seen was constantly expectorating on the floor so that at the end of an hour there was quite a collection of fluid. His speech became more indistinct and mumbling. When seen December 20, there was no improvement in his condition, he still remained awake and active all night and it was necessary to place him in an institution.

Case 39. — P. E., a white boy, aged 9j years, was well until February 11, 1920. On that night he slept poorly. Two days later he had double vision and was at times delirious. Insomnia followed and he was admitted to the Harriet Lane Home February 19, 1920. Examination on admission showed a well-nourished boy, at times rational but at other times threshing about in bed in active delirium. The pupils were dilated but no palsies were made out. The reflexes were active. The leucocyte count was 12,600. The spinal fluid showed 51 cells per c. mm. and gave a positive globulin reaction. The Wassermann test was negative witli the blood and spinal fluid. During the periods of delirium the patient made exaggerated uncoordinated movements of the limbs and sedatives were required. The temperature on admission was 101° F. and fell to normal on the fourth day. At this time the delirium and movements had stopped, the patient was mentally clear and co-operative, slept well at night, and the physical examination was entirely negative. He was discharged March 5. AJmost immediately after his return home he developed wakefulness at night and a series of tic-like motor phenomena, present both night and day. These consisted in, first, " stretching " motions of the arms, in which the arm was extended and several quick motions made as one does in stretching. A similar movement was made with the legs. When asked why he did this, he said he felt better after the motion had been made. There was no marked pain in the extremities. Second, the forefinger and middle finger were raised to the nose and a wiping movement made, the patient blowing through the nose at the same time. There was no nasal discharge. Third, constant movements of the fingers, as placing the middle finger on the forefinger, the ring finger on the middle fingeiand the little finger on the ring finger. Fourth, the patient would take a deep breath and make a quick expiration as one does in clearing the throat. However, there was no production of mucus or sputum. The boy talked in a whisper and was very fidgety and excited. Mentally he was clear and there was no return of the delirium. Physical examination was negative. The spinal fluid was normal except for the presence of globulin. He was kept in the hospital several days, and on account of his activity and inability to sleep was transferred to the psychiatric ward. He remained there for several weeks without marked improvement. When seen at home in July these movements were still present and he had developed the habit of spitting. In September the arm motions had stopped but the insomnia had not improved. By the last of October he was sleeping fairly well at night, though waking up frequently. No ticlike movements were obsei-ved and he had stopped spitting. Howe\'er, he was very nen'ous and excitable, crying easily and extremely fidgety, constantly using his hands to handle objects on the desk, to fumble with his clothing, etc. He was sent to school and has done fairly well.

The characteristic features of these movements are,, first, their constant repetition, and second, their short duration. Thus, after one tic-like movement has vanished, another movement or habit spasm appear.? in its place. These movements are especially marked at night in many instances.

General spasticiiy as a late symptom or sequel of the disease occasionally associated with a coarse tremor or with choreiform or athetoid movements was present in a number of our cases. There is often a peculiar stifPness of the carriage, the arms, back and shoulders scarcely moving and the


steps very short. The face may be expressionless and the voice monotonous, as in Case 2 above.

Hemiathetosis was present in the following case:

Case 40. — W. S., a white man, aged 29 years, complained of jerking of the left arm and left leg. In February, 1920, the patient had a febrile disease said to be infiuenza. Following this he was very drowsy and went to sleep while driving or eating. Subsequently there was a period of insomnia. About the middle of April, 1920, the left arm became weak; then the left arm, left leg and left side of the face began to jerk. On examination the patient was mentally clear. There were continuous choreo-athetoid movements of the left arm, left leg and left face without changes in the reflexes or tonicity. The hyperkinetic phenomena were gradually becoming less marked when the patient was last seen (November, 1920).

Paralyses of long duration were rarely observed. In the following instance, however, the paralysis present for many months was rapidly cured by persuasion and was therefore of hysterical origin. In another patient (Case 28) the weakness of the left hand was organic.

Case 41.— H. H., a colored girl, aged 13 years, stated that in March, 1920, she had measles. On April 1, 1920, she began to have headaches accompanied by nausea and vomiting. She was very drowsy — sleeping constantly for a week. On examination the patient was drowsy and listless and the face was expressionless. There was slight fever. The spinal fluid contained 60 lymphocytes per c. mm. The patient was discharged in June, 1920, apparently well. A week later her right arm became rigid and paralyzed and vei-y tender to the touch. After this condition had persisted for five months, the patient was again admitted to the hospital. The right arm was held rigidly and was veiy hyperaesthetic. The sensory disturbance was distributed in a shirt sleeve " area. The condition was believed to be hysterical and was quickly cured by suggestion.

.Salivation. — Increased production of saliva and frequent spitting were often observed as late symptoms of the disease in children. One child while being examined would spit to such an extent that there was quite a collection of water on the floor at the end of a half-hour. These children are usually trained by their parents to expectorate into a handkerchief and it was not unusual to see a child coming into the clinic holding a saliva-soaked handkerchief in his hand and constantly spitting into it. In our experience it usually comes on late in convalescence and is frequently more marked at night than in the daytime. At first we were inclined to attribute this habit to the peculiar mental attitude of these children, but it seems more likely that an actual increased production of saliva is present. Ifetter " has called attention to this symptom and makes it the basis of his pilocarpin treatment. Berge and Hofnagel,"" Pierre Marie and Levy," and Leahy and Sands report salivation in several cases and Babonneix " and Netter " acute parotitis (not epidemic) developing in the course of the disease.

It is interesting in this connection to recall Gordon's paper" on an epidemic in 1913 of a peculiar malady characterized by enlargement of the salivary glands, salivation, nervous symptoms and spinal fluid changes. The condition, he stated, was not mumps.

Enuresis nocturna was frequently observed in children following recovery from this disease. These children drink a


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great deal .of water, especially at night during the waking period.

Labokatoky Exajiixations

The leucocyte count according to various authors " ^' '" '"• is usually nonnal or slightly increased. The average given is between 10,000 and 14,000 per e. mm. The differential formula is usually not altered, unless there is a leucocytosis, and then there is a polymorphonuclear increase.

It should be mentioned that the variability of the leucocyte count may depend somewliat on the stage of tlie disease when the count is made. The erythrocyte count and the hemoglobin content were not altered in uncomplicated cases. The leucocyte count in our cases varied between 2600 and 20,000. Jn general, however, the leucocyte count was nonnal or slightly increased.

Spinal Fluid. — The earlier reports of the disease stated that abnormalities of the cerebrospinal fluid were infrequently ol)served.'- ^ Later studies, however, have demonstrated tliat alterations of the spinal fluid are usually present during the acute stage of the disease. Benard " reviewed this subject in 1920 and from his studies and those of other authors "• *• "• °' the following description of the cereljrospinal fluid in epidemic encephalitis is taken :

( 1 ) The fluid is clear and colorless.

(2) The pressure is normal or slightly increased.

( 3 ) There is a cellular increase early in the disease, wliich rajndly disappears, although Netter " stated that the pleocytosis may reappear during a relapse. The cells are usually mononuclear in type. Polymorphonuclear cells may be present in a small percentage. The total cell count varies from normal to 200 or more per cubic millimeter, averaging from 25 to 40.

(4) The amount of globulin is normal or increased. The increase in the amount of globiilin, however, is generally not as marked as the increase in the number of cells (" dissociation cytoalbuminique " (Bernard")): an important point in differential diagnosis.

Table I above shows the results of the examinations of the cerebrospinal fluid in our cases. This table brings out the following points:

(1) The fluid from cases during the acute stage of the disease practically always shows some change, either (a) increase in cells, or (b) increase in globulin, or (c) both.

(2) The cell count at the onset may be only slightly increased, rise quickly to a peak and then fall rapidly. For this reason several examinations of the fluid are of more value than a single examination in showing abnormalities, and especially in differentiating from tuberculous meningitis {r. i.).

(3) The globulin content is usually only slightly increased except in cases showing evidence of cord involvement ; these may show strong globulin reactions. This increase may persist for months after recovery.

(4) The gold chloride curve reveals notliing of special diagnostic value (see Table I).


Urine. — The examination of the urine reveals nothing of diagnostic value. The findings are these of any acute infectious disease.

Bacteriology. — Various observers * have reported the isolation both ante and post mortem of a variety of organisms with which they claim to have reproduced pathologic changes in animals similar to those found in human epidemic encephalitis. These organisms fall into four groups : First, Grampositive cocci ; second. Gram-negative cocci ; third, filterpassing globoid bodies, and fourth, a filtrable virus (l)acteriafree). If each of these produce similar lesions in animals on intracerebral injection, then one must conclude either that they are all different forms of the same organism, or that the lesions reproduced are non-specific. This uncertainty, together with the negative findings of so many competent observers, make us feel that, although the bacterial nature


Von Wiessner'" in 1917 in Vienna isolated a Gram-positivo diplostreptococciis with which he produced pathologic changes in animals. This organism was also found by von Economo"^ in the spinal fluid, blood and nasal secretions of patients. Dimitz " found the same organism during life and post mortem in cases of the choreiform type of the disease, as did Cohn and Lauber'" in Munich. The latter were unable to reproduce the disease in animals. Maggiora, Montovani and Tombalato " found a small Gram-positive diplococcus. which was agglutinated in a dilution of 1 : 100 by the patients' serum and by the serum of convalescents from the disease but not by normal serum. They were able to produce lesions in guinea-pigs on inoculation with cultures of this organism. Maggiore and Sindoni*' isolated from the blood and spinal fluid of five patients a Gram-negative coccus which on passage through rabbits produced the pathologic picture of encephalitis. They liken these cocci to those isolated by Noguchi in poliomyelitis. Ottolenghi and his co-workers ^ were able to produce pathologic changes in guinea-pigs with a filtrable virus obtained from the blood, spinal fluid and nasal washings. Gabri cultivated an organism (M. tetragenus) from the blood in three cases, but his animal inoculations proved negative. Boccolari and Panini*' found a Gram-negative diplococcus in the blood. Marineseo' in England saw in stained sections Gram-negative diplococci and Grampositive bacilli, but considered their etiological relationship to the disease open to question. Mcintosh and TurnbuU *" and more recently Mcintosh " obtained positive inoculations in monkeys and rabbits with a virus from the brain of a fatal case, but were unable to grow an organism.

Bradford, Bashford and Wilson *'• '^' ™'" " recovered from the brains of cases of encephalitis and polyneuritis a filtrable virus, and Basher, Caldwell and Coombie"" a Gram-positi\'e organism.

In America Stafford "" and Moree and Crump * recovered Grampositive cocci and the latter succeeded in producing lethargic states in rabbits after intra-cerebral injections. Loewe, Hirschfeld and Strauss "^ isolated a minute filtrable organism from the brain, cerebrospinal fluid and nasal washings, which on injection into rabbits and monkeys produced jiathologic changes. Thalheimer* recovered a similar organism. House " recovered a Gram-positive diplococcus from the brain in a fatal case and Dunn and Heagey "* a green streptococcus from the blood. Levaditi and Har\ier,"° in France, obtained a filtrable virus from the brain of a fatal case which they claimed reproduced in rabbits typical lesions of epidemic encephalitis. This virus could be passed through several rabbits and then become pathogenic for guinea-pigs. However, the \irus was not neutralized by the sera of patients convalescing from the disease. Amoss '°° found that the blood serum of recently convalescent cases of epidemic encephalitis does not neutralize the virus of poliomyelitis, whereas the senim of convalescent cases of poliomyelitis possesses this neutralizing power.


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of epidemic encephalitis is highly probable, the causative organism has not yet been definitely demonstrated.

DiAGXOSIS

The clinical features of this disease are so polymorphous that the diagnosis is often particularly difficult even in the presence of an epidemic. At best it is an exclusion diagnosis, for a large number of affections of the nen'ous system may ])roduce symptom complexes similar to those observed in epidemic encephalitis. Only by elimination of all other known sources of nerve cell damage and by observation over a considerable period of time can the diagnosis be made with any degree of certainty.

The most important diseases which may simulate epidemic encephalitis are the various other types of encephalitis, tuberculous meningitis, abscess and tumor of the brain, acute poliomyelitis and syphilis of the nervous system.

Four types of non-purulent encephalitis are encountered with sufficient frequency to be of importance in differential diagnosis.

, (a) Acute non-suppurative encephalitis following the acute infectious diseases such as typhoid fever, measles, mumps, scarlatina and pertussis, is not uncommon, especially in children. In most instances the history of the preceding illness, the presence of numerous convulsions, the short duration and the absence of prolonged lethargy and ocular palsies help in their differentiation. In a few instances the two diseases may be indistinguishable clinically and the diagnosis must rest on the history of the preceding illness. The following case is an example :

Case 42. — W. E.. a white boy, aged 6 years, was taken ill April IS, 1920, with cough, coryza and conjunctivitis. The following day an eruption appeared. The description of this eniption suggested measles. He did fairly well until the night of April 22 when he had several con\-ul.sions. He was admitted the following day to the Harriet Lane Home. Examination at this time showed a well-nourished boy, conscious, l.ving quietly in bed. There was a faded morbilliform eruption over the face, body and e.xtremities. Examination was otherwise negative. Lumbar puncture showed a clear fluid with 130 mononuclear cells per e. mm. and a positive globidin reaction. No tubercle bacilli were found in the fiuid. At first the patient seemed dull mentally and the question of tuberculous meningitis was raised. However, the following day the patient was bright and promptly recovered. The spinal fluid on April 27 showed 23 cells and a faintly positive globulin reaction and on May 1 was noiTnal. The child wa.? discharged well the following day. When seen a month later, he seemed to have completely recovered without sequelae. The diagnosis of an acute encephalitis following measles was made.

(2) Infanlile cerebral paralysis (hemiplec/ia et diplegia simstica infantilis of Striimpell '"") is characterized by a sudden onset with fever, convulsions and vomiting and followed hy spastic hemiplegia or diplegia often with ocular paralysis and later by athetosis, epilepsy and mental retardation.

(3) The encephalific type of acute poliomyelitis is similar to the disease described above. This type is so rarely observed even during epidemics of acute poliomyelitis (Wickmann,"' Eomer,"" Peabody, Draper and Dochez"") that its relationship to acute poliomyelitis is still questionable.


Typical cases of the two types described above can be differentiated from epidemic encephalitis by the clinical course, the persistence of paralysis and the sequela?.

(4) Encephalitis from lead is occasionally observed in infants.'"' Other evidences of lead poi-soning, the history of ingestion of paint and the presence of frequent convulsions usually lead to a positive diagnosis.

Tuberculous Meningitis. — Great difficulty, especially in children, is found in the differentiation of epidemic encephalitis from tuberculous meningitis. Early in the course of either disease the clinical pictures may be so similar that not until several days have elapsed, or until characteristic changes have occurred in the spinal fluid, does the diagnosis become clear.

Case 43.— E. G. R., a white girl, aged 3i years, was admitted to the Harriet Lane Home July 17. 1919. Her father had active tuberculosis and there had been intimate contact between the child and the father. The past history had been uneventful. The present illness began suddenly the night of July 13 with vomiting. On the following day the patient vomited again and for the next few days felt tired and weak. July 17. while on a street car. she had a convulsion which was generalized. Following this there were five or six general convulsions. The patient was admitted in a state of stupor with a temperature of 101° F. Phj-sical examination revealed nothing at that time but an unconscious, convulsive child with hyperactive reflexes. The leucocyte count was 13,000 and the spinal fluid practically normal. The tuberculin test was positive. The following day in'egular respiration of the Cheyne Stokes type was present and the convulsions continued. Strabismus and a facial weakness developed. The lumbar puncture was repeated on July 19 showing 23 cells per c. mm., a positive globulin reaction and film formation. Subsequent punctm'es revealed a steady increase in cells (see c. s. f. chart) but no tubercle bacilli could be found. (Guinea-pigs inoculated with the fluid showed no evidence of infection eight weeks later). However, in view of the exposure, positive tuberculin reaction, spinal P.uid changes and comatose state with Cheyne Stokes breathing, tuberculous meningitis was considered the most probable diagnosis. The temperature rose on July 23 to 105° F.; following this it fell to normal and remained so. During this period the patient remained in a stuporous state and when aroused was very iiTitable. On July 27 she began to recognize her surroundings and became less drowsy but extremely irritable. She steadily improved and by the middle of August was walking about the ward apparently normal. She was discharged at this time and reports from the mother indicate complete recovery without sequelae.

Case 44. — M. W., a colored girl, aged 2 years, was admitted to the Harriet Lane Home May 20, 1920. with the complaint "' sleeps all the time." This condition began the middle of March with trembling of the hands, weakness and unsteadiness in walking. She became less playful, but otherwise nothing abnormal was noted imtil April 25, when she fell. After this her gait became unsteady, and the tremor of the hands was more noticeable. On May 13 she became veiy drowsy and following this remained in bed sleeping most of the time. No vomiting, convul.sions, or paralyses were noted. Examination on admission showed a well-nourished colored girl lying in a state of deep lethargy from which it was impossible to arouse her. The extremities were somewhat spastic, but the reflexes were not exaggerated. The temperature was normal, the leucocyte count 10,000, the Pirquet and intracutaneous tuberculin reaction with 0.1 mgm. O. T. negative. Lumbar puncture showed a clear fluid, 41 cells per c. mm. and a positive globulin reaction. No films formed in the fluid. The Wassermann test was negative with the blood and spinal fluid. The X-ray picture of the chest showed normal lungs. The


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eye-grounds were likewise normal. The diagnosis of epidemic encephalitis was made. On April 22 retraction of the head was noted ; the first evidence of meningeal irritation that the patient had shown. This became more marked and on the following day there was opisthotonos. The temperature remained normal. Successive lumbar pimctures showed an increase in cells up to 152 with a positive globulin reaction. The patient's condition grew rapidly worse and she died May 24. The question as to diagnosis between epidemic encephalitis and tuberculous meningitis was not settled until autops}'. The development of signs of meningeal imtation and the steady increase in the number of cells with an inci-easing amount of globulin spoke in favor of the latter, although the ab.sence of fever, the negative tuberculin tests, X-ray examination and inability to demonstrate tubercle bacilli in the spinal fluid were against this diagnosis. Autops\- showed a typical tuberculous meningitis.

There are several points that aid one in this problem, particularly as far as children are concerned :

First. The onset in tuberculous meningitis is more gi-adual while in encephalitis it is often abrupt and acute, as a rule, resembling the onset of any acute infectious disease.

Second. The temperature in encephalitis is high at the onset, subsiding rather rapidly, whereas in tuberculous meningitis it is not high at onset, but rises toward the end.

Third. Clinical course. — Tuberculous meningitis in cliildren is usually fatal in three weeks, whereas encephalitis may be prolonged over a period of months.

Fourth. Evidence of tuberculosis elsewhere (tuberculosis of the skin, tubercles of the choroid. X-ray of chest, tuberculin reaction).

Fifth. The cerebrospinal fluid.

(a) The pressure is usually normal or very slightly increased in encephalitis, whereas it is usually under increased pressure in tuberculous meningitis.

(b) The cell count in encephalitis may be high at onset, rapidly falling to normal. In tuberculous meningitis, it is not much increased at onset, but rises rapidly as the disease progresses.

(c) The amount of globulin is greater in tuberculous meningitis than in epidemic encephalitis.

(d) Films rarely form in encephalitis in typical manner as in tuberculous meningitis, probably because the amount of globulin and fibrin are less.

(e) Tubercle bacilli may be demonstrated in the films in tuberculous meningitis if repeatedly searched for. Guineapig inoculation may be positive.

Poliomyelitis. — In its typical form, poliomyelitis is easily distinguishable from epidemic encephalitis. The nature of the paralyses is entirely different, as are the clinical course and the sequelae. The chief difficulty lies in the following types of eases:

1. Acute fulminant cases with high fever, great prostration, changes in the spinal fluid and death in a few hours.

Case 45. — D. G., a white girl, aged 6 years, was taken ill on June 18, 1919, with fever and drowsiness. Anorexia developed and she became more lethargic. On June 21 she became unconscious. The fever continued and she was brought to the hospital June 22. Examination on admission showed a somewhat poorly nourished white girl lying in an imconscious state with eyes half closed. The respirations were slow and irregular with periods of apncea. There was drooling of


saliva from the mouth. The deep reflexes were obtained and there was a positive Kemig's sign. The Babinski was positive on the right. The temperature was 101° F. ; the leucocyte count was 18,000. Lumbar puncture showed a clear fluid with .55 mononuclear cells per c. mm. and a negative globulin reaction. On the following day the patient had repeated convulsions. The temperature rose rapidly reaching 108° F. She died June 24. No autopsy was performed. In such cases it is impossible to make a differentiation clinically. The presence of an epidemic, however, may be an aid.

2. The Encephalitic Form of Poliomyelitis. — This form was discussed briefly above and is extremely rare, even during epidemics of poliomyelitis. One must depend here too on the presence of an epidemic.

We may add that during the period of observation of these cases (1919-1920) poliomyelitis was extremely infrequent in Baltimore. There is no evidence clinically, epidemiologicaUy, or histologically of the identity of the two diseases and one must assume, therefore, that they are distinct entities (see discussion by McNalty ') .

3. In the form of encephalitis described above (peripheral or polyneuritic type) it may be impossible to differentiate from the same form of poliomyelitis. Symmetrical flaccid paralysis does occur in the latter disease, but it is rare. The occurrence of other cases of encephalitis at the same time, the complete recovery and the optic neuritis in one patient inclined us to regard these cases as encephalitis rather than poliomyelitis.

Syphilis of the central nervous system must always be excluded by the result of the Wassermanu test with the blood and cerebrospinal fluid. It is possible for a patient with cerebrospinal syphilis to acquire epidemic encephalitis, but such an occurrence would be unusual. The pupillarj' changes and the transient pareses always make one think of syphilis. In general, however, the syphilitic diseases of the nervous system are more insidious in their onset and more chronic in their course, and changes in the optic discs are far more common.

Tumor of the Brain. — There is rarely diSiculty in differential diagnosis between epidemic encephalitis and tirmor of the brain. The former is usually a febrile disease characterized by transient and recurrent paralyses not referable to a single lesion. Moreover, choked disc, so common with intracranial neoplasms, has been rarely observed in instances of epidemic encephalitis. A rapidly growing infiltrating tumor of the pons or mid-brain must be excluded in everj- instance. A careful study of the sequence of the symptoms, together with repeated examination of the fundi and subarachnoid fluid throughout a period of observation, will usually prevent an error in diagnosis.

Abscess of the Brain. — We have met with one instance in which during life encephalitis was suspected, but at autopsy an abscess of tlie brain was discovered.

Case 46. — F. M., a colored boy, aged 3j years, was brought to the Harriet Lane Home September 27. 1920. with the history that he had been well until four weeks ago and since that time had been listless and drowsy, had complained of pains in the abdomen and had vomited after every feeding. There had been no con\-ulsions and thcmother did not think there had been fever. Examination on admis


Mat, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


157


sion showed a well-nourished colored boy lying in an apathetic state. However, he wns quite conscious and apparently understood what was said to him. There were no signs of meningeal irritation, there was slight right facial weakness and the deep reflexes could not be obtained; otherwise the examination was negative. Ophthalmological examination showed a bilateral choked disc. The temperature was normal and remained so during the entire stay in the hospital. The leucocyte count was 14,000. The spinal fluid was under slightly increased pressiu'e with 8 cells per c. mm. and a faintly positi\-e globulin reaction. Epidemic encephaUtis was considered, although the bilateral choked disc was evidence against this diagnosis. The patient became more drowsy, he vomited continually and went into coma on September 30. He died the following day. After his death the mother stated that two months before admission the child fell upon a plank, running a nail into his face. This wound healed promptly and the incident was forgotten. Autops>' showed an abscess of the left temporal lobe (staphylococcus aureus) with a punched out hole in the left temporal bone. There was no external evidence of this wound.

The clinical picture of abscess may be very similar to that of encephalitis with an acute onset, high fever, delirium or stupor, slight spinal fluid changes, coma and death. One's suspicions should be excited by the presence of a focus of infection ('chronic otitis or mastoiditis or sinusitis) or of an injury or evidence of infection elsewhere in the body as well as by localizing symptoms. Blood cultures may be of value here.

Dmg Poisoning. — Attention was called by Hassin and Wien'"" to the similarity of the state resulting from barbital (trional) poisoning to that of encephalitis. Such a condition may perhaps be produced by any hypnotic drug. The history and the absence of change in the spinal fluid should eliminate this source of error.

Typhoid and Other Acute Febrile Diseases. — At the time of onset it may be impossible to determine whether we are dealing with an acute infectious disease with mental and cerebral symptoms or with an encephalitis. This is particularly true in children who so frequently react to acute infections with delirium and psychotic states as well as stupor. The differentiation may be possible only after observing the course of the disease, or the results of the laboratory tests.

Urmmia. — iTrrpmic states may present a picture closely resembling that of encephalitis and this must be kept constantly in mind. We encountered this difficulty in the following case :

Case 47.— B. McC, a white girl, aged 4 years, was admitted to the Harriet Lane Home March 28, 1920. She had been well until March 7, at which time she had high fever, was drowsj' and complained of headache and pain in the eyes. There was a skin eruption which disappeared in a few days. The child continued to be drows>- and vomited repeatedly. There was fever but no paralysis was noted. On March 15 there was a tremor of both hands and, on the following day, the mother noted a strabismus. That evening the child had a general convulsion which was repeated on the succeeding day whereupon she was admitted to the hospital. Physical examination on admission showed a poorly nourished white girl lying in bed in a stuporous condition from which she could be aroused with difficulty. The respirations were slow and deep and suggestive of hyperpncea. Otherwise the physical examination was negative. Shortly after admission the patient had a general convulsion. The temperature was 101° F., the leucocyte count 18,000 and the bicarbonate content of the blood


serum 14 volumes per cent (Van Slyke). Spinal puncture showed clear fluid under somewhat increased pressure, 2 cells per c. mm. and a faintly positive globulin reaction. The urine was clear, its specific gra\-ity 1018, acid, albumin in large amount, sugar negative, acetone a trace, guaiac negative; microscopically it showed a few white cells but no casts. The Wassermarm test was negative with the blood and spinal fluid. The patient was given sodium bicarbonate by gavage. She rapidly became comatose, however, and the convulsions were repeated. The temperature rose rapidly to 105.5° F. and the patient died March 29. Lumbar puncture made post mortem showed 52 mononuclear cells per c. mm. and a positive globuhn reaction. The clinical diagnosis was epidemic encephalitis. The anatomical diagnosis was chronic, diffuse nephritis. The brain was entirely normal both in gross and on microscopical examination.

The urine, blood pressure, fundus changes and renal function tests should aid in eliminating this source of error.

Peripheral paralyses due to other causes (lead, arsenic, diphtheria, alcohol, beri-beri, etc.).

Before making a diagnosis of the polyneuritic form of this disease it is necessary to eliminate the other causes of peripheral paralysis by the history and appropriate tests.

Prognosis

The mortality varies within wide limits in the various reports. In Germany it has been 30 to 40 per cent (Economo, Dimitz"), in France 35 to 30 per cent (Netter,' Bernard), in England 20 to 50 per cent (McNalty,' Howeir") and in America 10 to 40 per cent (Abrahamson,"' Boyd," Wegeforth and Ayer "") .

In our series of 81 cases there were .six deaths, a mortality rate of 7.4 per cent. In general, if the patient survives the acute stage of the disease, the prognosis as to life is fairly good ; as to complete recovery, however, the prognosis must be reserved owing to the frequency of sequelae. Relapses are rare, but are said to have a high mortality (Netter).

Treatment

1. General ]\Iea.mres. — It is important, in the treatment of this disease, to bear in mind that epidemic encephalitis is not an acute disease of short duration, but may last over a period of many months and that convalescence is as a rule slow and tedious because of the frequency of psychic and motor disturbances as described above. Therefore, these patients should be carefully watched and protected over a sufficient period of time following the subsidence of the acute symptoms of the disease to make sure that recovery is complete before permitting them to take up their regular occupations. This becomes extremely difficult when we find that sequelae may arise months after apparent recovery.

At the onset of symptoms the patient should be placed in a separate room and kept as quiet as possible. Careful supervision is required because of the development of excitation reactions (delirium, mania, chorea, etc.). General isolation of the patient is advisable, but it is not necessary to isolate so strictly as with diseases of more infectious a nature. We know of no disease in which careful nursing plays a more important role, for these patients are generally quite helpless.


158


JOHNS HOPKINS HOSPITAL BULLETIN


[Xo. 363


The diet should be liquid or soft since difficulty in swallowing is often present and gavage may be necessary. One of our patients in deep lethargy had to be fed by gavage for five weeks. Sedatives may be necessary during the state of agitation, delirium and motor excitation. During convalescence, also, the patient should be protected in every way possible and fatigue and excitement avoided. It is a mistake to regard the patients as " cured " after the acute symptoms have subsided, for during convalescence the unpleasant sequela, insomnia, psychic disturbances, change in disposition and aeneral motor overactivity, often make their appearance. The parents and relatives should be forewarned of the possibility of the appearance of these symptoms, and parents should be advised not to punish children for odd and untidy acts entirely beyond their control. The insomnia is most diiScult to combat. We have had no success with hypnotics, baths or packs, and have allowed the patients to sleep during the daytiane, receiving their food when awake. Most of thean have improved with time, but great patience on the part of parents and relatives is required. Leahy and Sands advise that these patients be kept awake during the daytime and that occupational therapy be employed.

2. Drugs. — There is no specific for this malady, although a variety of drugs have been used. Netter,'" basing his opinion on the work of Crowe and Gushing, believes that hexamethylenamine is of value when given by mouth. If the urine be carefully watched there is no harm in giving this drug, although its value is problematical. The same author also advises pilocarpin in patients with sialorrhea, believing that in this way one may influence the elimination of the virus. Although sialorrhea was frequently observed in our cases, we have had no experience with the use of sialogogues.

Salvarsan has found favor with various observers (Netter,"" Fourrier""), the latter finding marked improvement following its administration. The specificity of arsenic in these cases is doubtful. Sedatives, as mentioned above, are helpful in the acute stage, although their use in the chronic sleeplessness of convalescence is disappointing.

3. Intraspinous Therapy. — Repeated withdrawal of spinal fluid during the acute stage of the disease, especially if the fluid be under increases pressure, is generally regarded as of value. Eeasoning by analogy with polioniyelitis I^etter,'"" Sabrazes and Massias,"' Marinesco,* Sicard "^ and others advise the intraspinous injection of the blood of convalescent ^^atients, and Cantieri and Vegni '" the intraspinous injection of the spinal fluid of convalescent patients. The scarcity of available convalescents makes this form of therapy limited, unless one encounters a large local epidemic. It is quite possible that the local irritation produced is the factor of value in this treatment as is probably the ease in the improvement after the injection of other sera intraspinously (antitetanic serum Laubie,"' grippe serum Fendel,"° etc.).

4. Miscellaneov.Si — Netter'^ has been an exponent of the use of the " abscess of flxation," that is, the production of a sterile abscess by injection of turpentine in a remote part of the body. He reports marked improvement following its use.


The injection of various sera (grippe serum Fendel,'" Oehming,™ auto-serum Brill,"" Bourges and Marcandier"'), the intravenous injection of hypertonic salt solutions (Hoftman "*) and the injections of colloidal iodin solution^-; (Claisse "") have been recommended. We have had no experience with these measures. We may say, in summarj-, that there is no specific therapy for this disease. Each case must be treated on its own merits with quiet, rest, hypnotics, careful nursing and feeding and spinal punctures during the acute stage, and careful attention during convalescence. Individual symptoms should be treated symptomatically as they arise.

BIBLIOGRAPHY

1. Economo, C. von; Wien. klin. Wchnschr.. 1917. XXX, 581.

2. Cnichet, R.; Bull, et mem. See. med. d. hop. de Par.. 1917, XLI, 614.

3. Netter, A.: Ibid., 1918, XLII, 307. Bull. Acad, de med., Par., 1918, LXXIX, 337.

4. Chauffard, A., and Bernard, M.: Bull, et mem. Soe. med. d. hop. de Par., 1918, XLII, 330.

5. de Saint Martin and Lhermitte, J.: Ibid., 1918, XLII. 457.

6. Harris, W.: Lancet, Lend., 1918, I, 568.

7. Hall, A. J.: Ibid., 1918, I, 568.

8. Rep. Loc. Gov. Board, Lend., n. s. No. 121, 1918.

9. Buzzard, E. F.: Lancet, Lond., 1918, I, 616.

10. Batten, F. E., and Still, G. F.: Ibid., 1918, I, 636.

11. Bassoe, P.: J. Am. M. Ass., 1919, LXXII, 971.

12. Pothier, O. L.: Ibid., 1919, LXXII, 715.

13. Sicard, J. A., and Kudelski, C.: Bull, et mem. Soc. med. d. hop de Par., 1920, XLIV, 121.

14. Sicard, J. A.: Presse med., Par., 1920. XXVIII, 213.

15. Dimitz, L.; Wien. klin. Wchnschr., 1920, XXIII, 163.

16. Bourges, H., and Marcandier, \.: Bull, et mem. Soc. med. d. hop. de Par., 1920, XLIV. 685.

17. Buzzard, E. F.: Lancet, Lond., 1918, 1, 715.

IS. Barker, L. F., Cross, E. S., and Irwin, S. V.: .\m. J. M. Sc, Phila., 1920, CLIX, 157; 337.

19. Crookshank, F. G.: Med. Press & Circ, Lond.. 1919. n. s., CVIII, 405 ; 423 ; 467. Bost. M. & S. J., 1920, CLXXXII, 34.

20. Wilbrand, H., and Sanger, A.: Die Neurologie des .\iiges ; [elc], Wiesb.. 1900, I, 297.

21. Fiirbringer, P.: Deutsche med. Wchnschr., 1892, XVIII, 45.

22. James, S. P.: Lancet, Lond.. 1918, II, 837.

23. Xetter, A.: Bull. Acad, de med.. Par., 1920, LXXXIII, 373.

24. Guillain. G., and Lechelle, P.: Ibid., 1920, LXXXIV. 321.

25. Roger, H.: Medecine, Par., 1920, II, 194.

26. Bernard. L., and Renault, J.: Bull. Acad, de med.. Par.. 1920 LXXXMII. 470.

27. BuiTows, M. T.: Arch. Int. Med., Chicago, 1920, XXVI. 477.

28. Hohman, L.: To appear later in .\rch. Neurol. & Psychiat., Chicago.

29. .4brahamson, I.; Arch. Neurol. & Psj-chiat., Chicago, 1921, V,33.

30. Jones, B. L., and Raphael, T.: Ibid., 1921, V, 150.

31. Wilbrand, H., and Sanger, A.: Die Xeurologie des .\uges ; [etc.], Wiesb., 1900, I, 518.

32. Sicard, J. A., and Kudelski, C: Bull, et mem. Soc. med. d. hop. de Par., 1920, XLIV, 450.

33. Souques, A.: Rev. neurol.. Far., 1920, XXVII. 463.

34. Souques, A., Moreau, R., and Pichon: Ibid., 1920, XXVII, 542.

35. Economo, C. von: Wien. klin. Wchnschr., 1920, XXXIII, 329; 361.

36. Boveri. P.: Rev. neurol., Par., 1920. XXVII. 275.

37. Hunt, J. R.: J. Am. M. Ass.. 1920. LXXV\ 713.

38. Stertz: Munch, med. Wchnschr., 1920. LXVII, 225.


THE JOHNS HOPKINS HOSPITAL BULLETIN, MAY, 1921


\ "^ PLATE XXI


BMHP"



Fig. 1. — (Case 2.) A patient with marked lethargy.



Fig. 2.— (Case 2.) Same p: disappearance of lethargy. Th


HI .K in V\\i. I. two mouths later, after la.sk-hke lacics was .-till jiresent.


Fig. 3. — Same patient as Figs. 1 and 2, five months later. The face was still mask-like.


THE JOHNS HOPKINS HOSPITAL BULLETIN, MAY, 1921


PLATE XXII


"Jir


» . y


•MfSi: :

Fig. 4.— (Case 6.) X 146. Marked perivascular round-cell infiltration. Area was in the substantia nigra.



Fig. 5. — (Case 6.) X 480. Hight power of area of substantia nigra to show a collection of round cells near a small blood-vessel.


^^^^^^^^^^^^^^"^


tmu. <«»» «MJ^


ft W^M **'

\



1



Fig. fi— iCiisf 17.) Bilater;il_ ptosis and mask-like fucics in an infant of 7 weeks.


Fig. 7. — (Case 19.) Unilateral ptosis — " ironedout " face.


THE JOHNS HOPKINS HOSPITAL BULLETIN, MAY, 1921


PLATE XXIII



Fig. S. — (('a>i' 2!).) Facinl expression after siibsnlcin choreiform mo\cments.


Fig. 9. — (Case 34.) Left facial pals>' in epidemic encephalitis.



Fig. 10.— (Ca.<r :j.y) K\|.iv.s.Munlcss fai


Fig. 11. — (Case 35.) Same patient as in Fig. 10, three months later.


May, 1921]


JOHNS HOPKINS HOSPITAL BULLETIN


159


39. Oehmig, O.: Ibid., 1920, LXVII, 660.

40. Harvier, P., and Levaditi, C: Bull, et mem. Soc. med. d. hop. de Par., 1920, XLIV, 583.

41. Sicard, J. A., and Paraf, J.: Rev. neurol.. Par., 1920, XXVII, lO-'i.

42. Marie, P., and Levy, G.: Ibid., .1920, XXVII, 513.

43. Dufour, H.: Bull, et mem. Soc. med. d. hop. de Par., 1920, XLIV, 263.

44. Boyd, W.: Canad. M. Ass. J., Toronto, 1920, X, 117.

45. Lhermitte, J.: Presse med., Par., 1920, XXVIII, 916.

46. Sicard, J. A., and Kudelski, C: Bull, et mem. Soc. med. d. hop. de Par., 1920, XLIV, 121.

47. Sicard, J. A., and Paraf, J.: Ibid., 1920, XLIV, 1484.

48. Bramwell, E.: Lancet, Lond., 1920, I, 1152.

49. Claude, H.: Bull. Acad, de med.. Par., 1920, LXXXIII. 215. .50. Berge, A., and Hufnagel, L.: Bull, et mem. Soc. med. d. hop. de

Par., 1920, XLIV, 848.

51. Papin, Denechau, D., and Blanc, C: Ibid., 1919, XLIII, 659.

52. Leahy, S. R., and Sands, I. J.: J. Am. M. Ass., Chicago, 1921, LXXVI, 373.

,53. Ellis, A. W. M.: Lancet, Lond., 1920, II, 114.

54. McAlpine, D.: Ibid., 1920, II, 353.

55. Sicard, J. A.: Presse med.. Par.. 1920, XXVIII, 213.

56. Laporte and Rouzaud : Bull, et mem. Soc. med. d. hop. de Par.. 1920, XLIV, 422.

57. Roger, H.: Ibid., 1920, XLIV, 246.

58. Neal.'J. B.: Arch. Pediat., N. Y., 1920, XXXVII, 321.

59. Fmdlay, L., and Shiakin, C: Glasgow M. J., 1921, XCV, IS.

60. Happ, W. M., and Blackfan, K. D.: J. Am. M. Ass., Chicago, 1920, LXXV, 1337.

61. Buzzard, E. F., and Greenfield, J. G.: Brain, Lond., 1920, XLII, 305.

62. Marie, P., and Levy, G.: Medecine, Par., 1920. I, 270.

63. Sicard, J. A.: Bull, et mem. Soc. med. d. hop. de Par., 1920, XLIV, 306.

54. Netter. A.: Ibid., 1920. XLIV, 761.

65. Lortat-Jacob, L.. and Hallez. G. L.: Ihid.. 1918, XLII, 811. Lortat-Jacob, L.: Ibid.. 1920, XLIV, 711.

66. Kahn, P.; Ibid., 1920, XLFV, 542.

67. Andrews, G. C: Neurol. Bull., N. Y.. 1919, II, 370.

68. Hammes, E. M., and McKinley, J. C. : .\rch. Int. Med., Chicago, 1920, XXVI, 60.

69. Marie, P., and Levy, G. : Bull, et mem. Soc. med. d. hop. de Par., 1920, XLIV, 661.

70. Babonneix, L.: Ibid., 1920, XLIV, 801.

71. Netter, A.: Bull. Acad, de med.. Par., 1920. LXXXIII, 45, 303; Presse med., Par., 1920, XXVIII, 193.

72. Gordon, M. H.: Lancet, Lond., 1913, II. 275.

73. Vaidya, S. K.: Ibid.. 1918, II, 322.

74. Alexander, M. E., and Allen, H. E.: Arch. Neurol, and Psychiat., Chicago, 1920, III, 485.

75. Benard, K. : Bull, et mem. Soc. med. d. hop. de Par., 1920. XLIV, 232; Pans med., 1920, XXXV, 474.

76. Netter, A.: Bull. Acad, de med.. Par., 1920, LXXXIII, 109.

77. Marie, P., and Mestrezat: Ibid., 1920, LXXXIII. 103.

78. Wiesner, R. R. von: Wien. khn. Wchnschr., 1917, XXX, 933.

79. Cohn, W., and Lauber, I.: Miinch. med. Wchnschr., 1920, LXVII, 688.

80. Maggiora, Mantovani, and Tombolato : Riforma med., Roma, 1920, XXXVI. 114.

81. Maggiore, S., and Sindoni, M. B.: Pediatria, Napoli, 1920, XXVIII, 985.

82. Ottolenghi, D., d'Antona, S., and Tonietti, F.: Policlin., Roma, 1920 (sez. prat.), XXVII, 1075.

53. Gabri, G.: Policlin., Roma (sez. prat.), 1920, XXVII, 106. 84. Boccolari and Panini: Riforma med., Napoli, 1920, XXXVI,

126.


85. Mcintosh, J., and Turnbull, H. M.: Brit. J. Exper. Path., Lond., 1920, I, 89.

86. Mcintosh, J.: Ibid., 1920, I, 257.

87. Bradford, J. R., Bashford, E. F., and Wilson, J. A.: Quart. ,1. Med., Oxford, 1919, XII, 88.

88. Bradford, J. R.: Brit. M. J., Lond., 1919, I, 599.

89. Bashford, E. F.: Ibid., 1919, I, 601.

90. Bradford, J. R., Bashford. E. F., and Wilson, J. A.: Ibid.. 1919, L 127.

91. Wilson, J. A.: Ibid., 1919, I, 602.

92. Brasher, C. W. J., Caldwell, J. B., and Coombe. E. J.; Ibid., 1919, I, 733.

93. Stafford, C. M.: J. Lab. and Chn. M., St. Louis, 1919, IV, 691.

94. Morse, P. F., and Crump, E. S.: Ibid,, 1920, V, 275.

95. Strauss, I., Hirshfeld, S., and Loewe, L.: New York M. J., 1919, CIX, 772.

95. Loewe, L., Hirshfeld, S., and Strauss, I.: J. Infect. Dis., Chicago,

1919, XXV, 37S.

Loewe, L., and Strauss, I.: J. Am. M. Ass., Chicago, 1919; LXXIII, 1056; 1920, LXXIV. 1373; J. Infect. Dis., Chicago, 1920, XXVII, 250.

96. Thalheimer, W.: Arch. Neurol, and Psychiat.. Chicago, 1921, V. 113.

97. House, S, J.: J. Am. M. Ass., Chicago, 1920, LXXIV, 884.

98. Dunn, A. D., and Heagey, F. W.: Am. J. M. Sc, Phila., 1920, CLX, 568.

99. Levaditi, C, and Harvier, P.: Bull. Acad, de med.. Par., 1920. LXXXIII, 365.

Idem: Bull, et mem. Soc. med. d. hop. de Par., 1920, XLIV. 179; 1920, XLIV, 583, 1487.

Idem: Ann. de I'lnst. Pasteur, Par., 1920, XXXIV, 911. Han-ier, P.: Rev. med.. Par., 1920, XXXVII, 353.

100. Amoss, H. L.: J. Exper. M., Bait.. 1921. XXXIH, 187.

101. Oppcnheim, H.: Lehrbuch der Nervenkrankheiten. 2. Aufl.. Berlin, 1913, II, 1093.

102. Wickmaun, I.: Die akute Poliomyelitis bzw. Heine-Medinscho Krankheit, Berlin, 1911,

103. Romer, P. H.; Die epidemische Kinderlahmung, Berlin, 1911,26,

104. Peabody, F. W., Draper, G., and Dochez, A. R.: Monog. Rockefeller Inst. M. Research, N. Y., 1912, No. 4, 76.

105. Thomas, H. M.. and Blackfan, K. D.: Am. J. Dis. Child., Chicago, 1914, VIII, 377.

Blackfan, K, D.: Am. J. M. Sc, Phila., 1917, CLIII, 877.

106. Hassm, G. B., and Wien, M. S.: J. Am. M. Ass., Chicago, 1920, LXXV, 671.

107. Howell, A.: Practitioner, Lond., 1920, CIV, 290.

108. Wegeforth, P.. and Ayer, J. B.: J. Am. M. Ass., Chicago, 1919, LXXIII, 5.

109. Netter. A.: Bull. Acad, de med.. Par., 1920, LXXXIII, 303; 329. Presse med.. Par., 1920, XXVIII, 193.

110. Fourrier, M.: Soc. de therapeutique de Par., Abstr., Lancet,

1920, I, 1169.

111. Sabrazes, J., and Massias: Gaz. hebd. d. .sc. med. de Bordeaux. 1920, XLI, 86.

112. Sicard, J.: Bull, et mem. Soc. d. med. d. hop. de Par., 1920, XLIV, 207.

113. Cantieri, C, and Vegni, R.: Riforma med., Napoli, 1920, XXXVI, 525.

114. Laubie: Bull. Acad, de med.. Par., 1920, LXXXIII, 246.

115. Fendel: Mijnchen. med. Wchnschr., 1920, LXVII, 353.

116. Brill, I. C: Med. Rec, N. Y., 1920, XCVII, 1079.

117. Bourges, H. H., and Marcandier, A.: Bull, et mem. Soc. de med. de hop. de Par., 1920, XLIV, 842.

118. Hoffman, R. V.: J. Indiana M. Ass., Fort Wayne, 1920, XIII. 228.

119. Claisse, P.: Bull, et mem. Soc. d. med. d. hop. de Par., 1920, XLIV, 206.


160


JOHNS HOPKINS HOSPITAL BULLETIN


[No. 363


STUDIES ON EXPERIMENTAL RICKETS

IIL A PATHOLOGICAL CONDITION BEARING FUNDAINIENTAL RESEMBLANCES TO

RICKETS OF THE HUMAN BEING RESULTING FROIM DIETS LOW IN PHOSPHORUS

AND FAT-SOLUBLE A: THE PHOSPHATE ION IN ITS PREVENTION

By P. G. Shipley and E. A. Pakk (From the Department oj Pediatrics, The JoAji.s Hopkitis University, Baltimore)

AND

E. T. McCoLLUM and Xixa Simmonds

(From the Laboratory oj the Department oj Chemical Hygiene, School oj Hygiene and Public Health, The Johns Hopkins University,

Baltimore)


As is now well kno\N-n, Mellanby ' has reported the production of rickets in puppies by diets deficient in their content of fat-soluble A,* or an antirachitic factor having a similar distribution. Unfortunately, it has not been possible to evaluate Mellanby's results by reading his published writings, since he has never supplied objective proof of the production of rickets in the form of illustrations showing the appearance of his specimens tlirough the microscope. Tliis omission has been unfortunate, inasmuch as the diagnosis of this disease can be made with certainty only ou the evidence derived from microscopic changes in the bones. The gross deformities which characterize rickets can be simulated in other pathological conditions, as, for example, the osteoporosis which develops in growing puppies during confinement in small cages. Evidence afforded by the X-ray is not completely convincing. X-ray examination fails to disclose the exact nature of the pathological process in operation, and to differentiate rickets, as it commonly occurs in children, from related conditions such as can be produced in animals through dietetic influence.

In a previous publication' we described 11 diets, some of which produced gross deformities resembling those seen in rickets. Tlie nature of the faults of these diets was in all cases clearly pointed out. These diets included formulte for food mixtures in which there was a deficiency of but one dietary factor, i. e., calcium or fat-soluble A. The otlier diets described were faulty in tlie following respects: lack of fatsoluble A and excess of calcitun, and low calciimi and low fatsoluble A. Since tlie preparation of the earUer paper we have liad occasion to observe also the effect of changing the plane of intake of the phosphate ion on the growing bone.


"^ \\"c arc using pro\-isionally the teiin fat-soluble A, to designate the organic factor which may play a special role in bone development. In a later paper we shall present further experimental data, of a nature which will serve better than those contained in the present discussion for deciding whether the organic factor contained in codliver oil, to which that substance owes its therapeutic value in certain diseases affecting the skeleton, is identical with the factor which we here refer to as fat-soluble A.


ExPEKiMEXTS Designed to Show the Effects on the

Skeleton- of Diets Low in Theik Content

OF Fat-Soluble A and Phosphoeus

In order to bring out the effects of varj-ing the plane of the

phosphate ion in the diet on bone development, we have

employed the following food mixtures:

Diet of Lot 2667

Rolled oats 40.0

Flaxseed meal 8.3

Sodium chloride 1.0

Calcium carbonate 1.5

Dextrin 492

100 gms. of this mixture contained 0.6714 gms. of calcium and 0.2165 gms. of phosphorus.

This diet is deficient to some extent in its protein content. Tlie protein, both in aniomit and quality, is adequate, however, to induce growth, thoush at a rate distinctly below the




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1


The Curves in this Chart Illustrate the Weight Changes ia Young Rats Fe<l the Diets Described in the Text.

maximum. But no develoimient is possible on this food mixture unless it is supplemented liy some substance whicli will sene as a source of the factor, fat-soluble A. This diet, as stated, is deficient in fat-soluble A, and also contains a relatively small amount of phosphorus.

When young rats weighing from 20 to TO gms. l)etween IS and oO davs old are confined to this diet, witliout the addition


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of any substance supplying fat-soluble A, they soon cease to increase in weight and then rapidly decline (Chart I). After . an interval which varies markedly, depending principally on the age of the animal but to some extent on individual resistance, they all develop xerophthalmia. In our extensive experience no animal has ever recovered from this condition unless a substance capable of acting as a source of fat-soluble A was added to its diet. On the addition of such a substance, e. g., butter fat or cod-hver oil, animals suffering from xerophthalmia steadily improve and return to normal health. While recovery is taking place, growth is resumed. With this diet we have conducted scores of experiments; the general behavior of the animals placed upon it and the development of xerophthalmia have occurred with unvarying regularity as described.

Diet of Lot 2806

Rolled oats 40.0

Gelatin 10.0

Sodium chloride 1 .0

Calcium carbonate 1 .5

Dextrin 47.5

100 gms. of this mixture contained 0.6414 gms. of calcium and 0.1580 gms. of phosphorus.

This dieit contains protein of good quality and in sufficient amount to enable young rate to grow at a fairly rapid rate, provided the faulte in the diet are corrected by suitable additions. The principal defect in this diet is a deficiency in fatsoluble A. Without the addition of this factor no growth is possible, and severe xerophthalmia develops followed by death. A second defect in the diet sufficiently grave to interfere in a measure with growth is the lack of sufficient phosphate ion. While growth can take place on the formula tabulated above, supplemented with some substance acting as a source of fatsoluble A, it is not so satisfactory as when the sodium chloride and calcium carbonate are replaced by a salt mixture containing not only these substances Init suitable amounts of the phosphate ion as well.

Methods. — All the animals in the exiieriments were killed with ether. After careful postmortem examination I'arious bones and some of the soft tissues were saved for histological examination.

In preparing bones for micro.scopical exa*nination we have usually used the method recommended by Pommer — decalcification in MUller's fluid for periods ranging from two to fourteen days after preliminary fixation in formalin. The bones were dehydrated, embedded in celloidin and the blocks cut into sections from 10 to 60 microns thick. While we have used thionin and other dyes and have treated a large number of sections with silver nitrate after the method of Von Kossa, no staining technique has proved to be so satisfactory as that in which a combination of Ehrlich's haematoxylin with water soluble eosin is used. We have controlled the material which was partially decalcified in Midler's fluid by means of celloidin and frozen sections of undccalcified bones.

The Pathological Condition Produced in the Skeleton by the Administration of Diets Deficient in their Content of Fat-Soluble A and Phosphorus. — The diets described above (diets of lots 2667 and 2806) give rise to pathological pictures in the bone presenting a wide range of variation. At one extreme, the picture closely resembles that of rickets as that disease manifests itself in the human being, at the other extreme, osteoporosis.

The autopsy findings in the rats whose condition most closely resembled rickets, were as follows: The animals were undernourished


and under-developed. Their coats were rough and uneven. Xerophthalmia was invariably present. The teeth were loose; the incisor teeth were easily fractured or extracted. In some animals spontaneous fracture of one of the incisors had occurred. The cranial bones were soft. The costochondral junctions were enlarged and the oval swellings formed were unusually long. In some rats there was moderate displacement inwards of the middle tier of costochondral junctions. In some animals a few fractures of the ribs marked by callous formation but without deformity of the costal arch were present. The spleen was atrophic in some animals, in others more or less enlarged. The thymus was atrophic. There was little or no fat. The long bones were straight and were not factured. The ends of the long bones were greatly enlarged. The femur and tibia were easily cut and gave little evidence of the presence of calcium salts until the knife had entered well into the shaft. Gross examination of the cut surface revealed a broad zone of a pale tissue, 2-4 mm. in width, lying between the epiphyseal cartilage and the shaft (the rachitic metaphysis).

The epiphyseal cartilage in some animals was increased in width throughout the entire area of the section. It was more common, however, to find it of a nomial width or a width not greatly exceeding the normal except at the peripheiy of the bone. At the periphery prolongations of cartilage extended diaphysealwards well into the metaphysis. Higher magnification showed the matrix of the cartilage to be unusually abundant in proportion to the numbers of cells present. The undifferentiated portion of epiphyseal cartilage was represented by a thin zone in which the cells appeared to be unusually far apart. The proliferative zone contained columns of cells aggregated in bullet-shaped masses, the points of which were directed toward the undifferentiated cartilage. Each bullet-shaped mass was separated from its fellows by a broad band of matrix (Fig. 3). As the metaphysis was approached, the cells of the proliferative zone, which were small and often flattened, with lense-shaped nuclei, grew larger and assumed a nearl,y spherical form, and at the same time underwent a progressive loss of alfinity for the basic dyes. The nuclei became larger and the staining reaction approached more nearly that of the osteoid tissue in the metaphysis (Fig. 4). At the points of junction of the cartilage with the metaphysis the cartilage cells lost their columnar arrangement and became heaped together in disorderly masses. There was no evidence of calcium deposition in the zone of proliferative cartilage con-esponding to the zone of provisional calcification in the normal bone, or else the calcification was fragmentan,'. The cartilage was invaded to a considerable extent by blood vessels from the maiTOw cavity, but did not appear to be greatly disorganized. The invading vessels for the most part were slender and appeared to advance, in some instances at least, along the strands of matrix between the columns of cells.

The metaphysis was composed chiefly of osteoid trabeculse but also of blood vessels canwing with them marrow elements, tongue-like bands of cartilage cells of various thicknesses continuous with the epiphyseal cartilage and of islands of cartilage cells. The trabeculjB were broad. Many of them contained central cores of uncalcified cartilage and in almost all of them single cartilage cells could be identified or small groups in various stages of transition to a state indistinguishable from the cells of the o.st.eoid itself. The trabeculae were separated from each other by wide blood channels each of which was siuroimded by a small amount of delicate connective tissue and a few marrow elements. The osteoblasts covering the trabeculae were flattened, spread out like endothelial cells and had small nuclei. The osteoid of the trabecule was for the most part laid down in the fonn of lamellae, but the lamellar arrangement could not always be made out. The bone corpuscles varied in size, but by far the majority were, to judge from their nuclei, small cells. The large prolongations of the epiphyseal cartilage into the metaphysis seemed to retain for the greater part of their extent the normal staining reaction to hjematoxyUn (Fig. 4). The smaller prolongations, those consisting of thin strands of cartilage cells, and the


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terminal portions of the large prolongations just alluded to, seemed to lose their staining reaction almost entirely. The loss of the stainmg reaction appeared to occur in the neighborhood of the blood \-essels and apparently depended on the intimacy of contact between thi cartilage cells and the vascular elements. It was most marked in the strands or groups of cartilage cells which had become incorporated in the interior of the osteoid trabeculae. As the cartilage cells came into close relationship with the marrow elements, they also appeared to undergo changes in their morphology. The cell bodies became smaller and took on a vesicular appearance. Around the cell body there de^•eloped a homogeneous material having the same staining reactions and outward appearance as the uncalcified material formed by the osteoblasts. In the osteoid trabecule removed some distance from the epiphyseal cartilage, where the change taking place in the cartilage cells appeared to be far advanced, the cartilage cells were so reduced in size that they could be distinguished from the osteoblasts only by their oval cell capsule and the vesicular appearance of the cytoplasm, or could be differentiated with the greatest difficulty or not at all. In some osteoid trabeculae cartilage cells could be found in all stages of transition to osteoblasts.* The cartilage cells embedded in the osteoid trabeculae seemed to be stimulated to reproductive activity, for areas were seen where single cells had obviously given rise to from two to five daughter cells (Fig. 5). Cell division was apparently accomphshed by amitosis. The cartilage cells composing the small islands in the metaphysis underwent the changes just enumerated. The cartilage cells composing the larger islands, however, retained their ordinary staining reactions except at the periphery where an abrupt change to osteoid took place. These large islands of cartilage cells appeared to be insulated by thin rims of osteoid. It is important to note that the tendency toward calcium deposition must have been very marked even in those animals that exhibited the pronounced changes of a rachitic nature just enumerated, for in the bones of the great majority of them linear deposits of lime salts were found which passed transversely across the metaphysis at right angles to the long axis of the bone. These deposits were sharply separated from the shaft of the bone, on the one hand, and from the proliferative zone of cartilage on the other. In some animals a single bone showed two or three of these evidences of abortive attempts at healing (Figs. 8 and 9). Such bones were striking in their resemblance to the bones of children showing the lesions of so-called " healing rickets."

In the shaft of the bones of the animals showing extreme changes of the nature just described, the formation of osteoid tissue about the trabeculae was markedly increased (Fig. 6). The small trabeculae of calcified bone were completely surrounded by broad areas of osteoid and the periosteum was widely separated from the cortex by masses of osteoid tissue (Fig. 7). New bone formation in fibrous tissue was found occasionally beneath the periosteum in the region of the metaphysis. The osteoid tissue on the periosteal side of the cortex was traversed by nimierous blood vessels. Here and there it was possible to find evidences of bone resorption. The evidences of resorptive activity in the metaphysis were very slight.

In animals at the other extreme the abnormality was of the nature of an osteoporosis. The epiphyseal cartilages were perhaps slightly irregular, but they were narrow. There was no evidence of abnormal persistence of the cartilage cells. Heavy continuous deposits of lime

♦The disappearance of the staining reaction of the cartilage cells and the morphological changes enumerated do not indicate a degenerative process. On the contrary, the existence of the cartilage cells appeared to be prolonged in a remarkable manner. As the cartilage was invaded by the capillaries, its cells became embedded in osteoid through the activity of the osteoblasts. In this envelopment of osteoid they persisted and became indistinguishable from the cells of the osteoid investment. Our experience would lead us to believe that the cartilage cells may undergo metaplasia into the cells of the osteoid.


salts were present in the diaphyseal border of the cartilage, and this latter terminated abruptly in contact with the shaft. The marrow cavity was crowded with haematopoietic cells. The cortex was thin but completely calcified. In the medullary cavities of some bones a "few very thin, completely calcified trabeculae were present, but in others the only bone to be found was the cortex of the shaft. In some of the rats showing these extreme osteoporotic changes the trabeculae were invested with fibrous tissue and around them were to be found basophile cells with single nuclei and large granules. The evidences of resorptive activity in the trabeculae were well marked. No osteoid was present anywhere. The gross autopsy findings in these animals were in accord with the picture which the microscope revealed in the sections. There were no deformities of the skeleton of any sort, but the bones were abnormally slender, a finding especially noticeable in the ribs, because of the contrast between the thin shaft and the costal cartilages. The latter appeared to be of normal size or even larger than normal. The bones gave evidence of the presence of calcium salts when an attempt was made to cut them; they were brittle and fragile, although there were no fractures to be found.

All stages of transition were found between the two extremes of the pathological process induced in the skeleton by the diets low in fatsoluble X and phosphorus, and by far the greater number of the animals examined may be said to have exhibited pathological changes of a mixed nature. In all these animals of the intermediary group the pathological picture presented had a rachitic background. The deposition of the calcium salts in the cartilages was irregular, and areas were found in the proliferative zone in which lime salt deposits were not present. The cartilages in most, of the rats were extremely irregular, and in a considerable number of animals there was persistence of the cartilage with the formation of a thick proUferative zone (Fig. 10). In this thick proliferative zone large defects were noted due to invasion of the cartilage by blood vessels. In some of the animals, although calcification of the cartilage had occurred, prolongation of the cartilage was pronounced. Other animals showed cartilage cells in calcified as well as uncalcified portions undergoing the changes already alluded to which have been probably wrongly regarded as signs of degeneration. In almost all the rats showing these mixed lesions there was a narrow metaphysis or a partial metaphysis. i. e., one extending part way across the bone. All the changes characteristic of rickets in the human being were present with the exception of the absence of calcium deposition in the proUferative cartilage. The number of trabeculae in the shaft, however, was greatly reduced and. while even broad zones of osteoid were in evidence about the trabeculae, there were many signs that the trabeculae were in process of resorption and were being removed from the meduUarv" cavity (Fig. 11). The gross changes in the skeleton consisted merely in varying degrees of enlargement of the costochondral junctions and the ends of the long bones of the extremities.

E.xPERiMEXTs Designed to Show the Effects ox the Skeleton- of Diets Low ix Their Content of FatSoluble A, But Having an Adequate Amount of Phosphorus

Diets of Lots 3120 .and 2815

Rolled oats 40.0

Gelatin 10.0

Salts (185)* 3.7

Dextrin 46.3

100 grams of this mixture contained 0.31.50 gms. of calcium, and 0.5383 gms. of phosphorus.

Composition of salt mixture 185.


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NaCl 0.173

MgSO, (anhydr) 0566

NaH:Pa + H.O 0.347

K.HPO, 0.954

CaHAPO^).. + H..0 0.540

Fe citrate 0.118

Ca lactate 1.300

Of this mixture 3.7 gms. were added to every 100 gms. of ration.

This diet, as is easily seen, contains protein of fairly satisfactory amount and quality. The properties of the mixture differ from those of the diets pf Lots 280G and 2667 in that there is contained a salt mixture having among other things the sodium, chlorine, calcium and phosphate ions in satisfactory amounts. The diets of Lots 2806 and 2667, however, lacked the phosphate ion from among the necessaiy supplements for the inorganic moiety of this diet. When young rats are restricted to this diet they soon fail to increase in weight and then slowly decline. They invariably develop xerophthalmia and die. This diet supplemented with some substance acting as a source of fat-soluble A induces growth and apparently fairly satisfactory nutrition over a considerable period.

The Pathological Coxditions Produced in the Skeletox

BY AdMIXISTKATION OF THE DiET DEFICIENT IX ITS

Content of Fat-Soluble A, but Containing ax Adequate Amouxt of Phosphorus

The eleven rats fed on this diet were all small and exceedingly mal-nourished. The eyes showed the characteristic xerophthalmia. The incisor teeth were fragile, loose in their sockets, and in some animals fractured. On removal of the skin there was a notable absence of fat. The thorax externally showed no defonnity. On opening the thorax the arch of the ribs and cartilages was normal and tliere was no deformity or enlargement of the costo-chondral junctions. The shafts of the ribs appeared extremely thin, and the costal cartilages large as compared with them. No fractures of the ribs were present. The vertebral column was not bent. Both thymus and spleen were atrophic. The fore and hind legs were slender, but presented no deformities, fractures, or enlargements of the ends of the long bones. On section of the femur and tibia the resistance was greatly diminished, but the bones grated under the knife as the latter entered the shaft. On examination of the cut .surface the cortex was found to be exceedingly thin. The marrow cavity extended close to or actually to the cartilage. There was either no sub-chondral zone of spongiosa, or an exceedingly thin one. The epiphyseal cartilage separating the large nucletis of ossification from the shaft appeared as a narrow band, the width of which was everywhere equal. By means of the binocular microscope there could be detected a continuous thin line of calciimi deposit along the diaphyseal border of the cartilage.

On microscopic examination the results of gross examination were corroborated. The band of epiphyseal csirtilage was found to be exceedingly narrow, and the columns of cartilage cells correspondingly short. Calcification of the proliferative zone lying in contact with the marrow cavity was comjilete. The character of the calcification corresponded closely to that found in the bones of animals whose growth is approaching completion, that is, each cell was completely enveloped by calcium deposit. The diap.iyseal portion of the bone also had in some respects the appearance which characterizes the bones of animals whose growth has almosf ceased, that is, there were few trabeculae immediately adjacent to the cartilage; in some of the animals there were none (Fig. 12) . When i rabeculae were present they were most numerous at the peripherj', filling in the angles between


the epiphyseal cartilage and the cortex. In the central portion of the bone in all the rats the marrow cavity was in immediate contact with the epiphyseal cartilage. The trabecute themselves were thin. In most of the rats they showed no osteoid borders anywhere. In some animals, however, the trabeculae here and there were partially covered with borders of osteoid, some of which slightly exceeded the normal in thickness. The cortex was thin, completely calcified, and solid, i. e., it did not contain spongy tissue. In the bones of the majority of the animals the signs of resorption were well marked. The trabeculae were invested with layers of fibrous tissue, and in the periphery of the trabeculae were countless numbers of rather large mononuclear cells conspicuous for the presence of basophilic granulations. These cells were thought to be connected with the resorptive process. In many trabeculae holes and cavities could be found in which osteoblasts could be identified lying free, and in other places osteoblasts could be seen lying half in the calcified part of the trabeculae and half in the osteoid border. Where osteoid borders were present, they appeared in the preparations stained with haemotoxylineosin to be exceedingly pale, almost translucent, and the cell bodies of the osteoblasts in them, ai.iparently strongly basophilic, were clearly defined in contrast. The osteoblasts themselves were large and in the trabeculae appeared unusually close together. The nuclei were large and in those cells lying in the osteoid (where the cell bodies coidd be studied) were eccentrically placed in the cell body. The cell body was not round but irregularly oval. Near the nucleus at about the center of the cell was a large, roimd area of vacuolization about the size of the nucleus. It was by means of this area of vacuolization that the osteoblasts lying free in the holes in the trabeculae or along the sides coidd be identified with such certainty. Many of the trabeculae were covered with large numbers of osteoblasts. We are inclined to believe that the osteoid borders were caused not by growth but by removal of the lime salts, i. e., halisteresis. The marrow, with the exceptions already noted, was normal. The basophilic cells which sun'ounded the trabeculae were in no instance found in the marrow cavity.

Discussiox

The first two diets used in these experiments (diets of lots 2667 and 2806) characterized by a deficiency in fat-soluble A and phosphorus, produced, as anticipated, xerophthalmia and changes in the skeleton. The xerophtJialmia, as nearly as we could judge from gross inspection of the eyas, did not vary except in degree. The changes in the skeleton, however, exhibited a wide range of variation. In the aaiimaLs at one extreme (in 13 rats) the ends of the long bones were characteristically large. The zone of proliferative cartilage in places was greatly broadened and continued in long processes toward the .shaft. The cartilage cells in these processes and those elsewhere in contact vith the marrow elements of the metaphysis exhibited the characteristic morphological changes and loss of staining properties so commonly seen in the rickets of htmian beings. The metaphysis itself was broad and composed, in addition to tlie vascular elements, almost entirely of osteoid trabeculfe. Calcification of the zone of the proliferative cartilage, corresponding to the provisional zone in the normal bone, was eitJier entirely absent or very deficient. In almost all insitances, however, there were broken linear deposits of calcitun in the metaphysis, extending acro,ss it at right angles to the long axis of the bone. The patliological condition in these animals, showing the more extreme changes, exhibited all the fimdamental characteristics of rickets, as it manifests itself in human beings, and mav be said to have


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borne a strong resemblance to a certain form of rickets occurring in the human l>eing, characterized pathologically by linear zones of lime salt deposition in the metaphysis, indicating alternate healing and exacerbation.

In tlie animals at the other extreme (in 9 rats) tlie pathological condition corresponded to what is ordinarily included under the term osteoporosis. Tlie epiphyseal cartilage was reduced to a narrow band. The transition between cartilage and shaft was abrupt. Calcification of the cartilage was regular and complete. The few thin trabecular were free from osteoid, and resorptive phenomena were abundantly in evidence. The pathological condition of the bones exliibited by the rats at this extreme of tlie series showed no evidences of rickets whatsoever, but on the contrary complete calcification of all elements both cartilage and trabeculas.

The majority of the animals on these two faulty diets (37 rats), however, showed pathological conditions in the skeleton intermediary between the two extremes ju^t briefly outlined. The trabeculse were bordered with osteoid, not tlie thin border present in growing yovmg animals, but broad zones comparable to tliose seen in the advanced rickets of children or even exceeding them in tliickness. In all there was irregularity and broadening of the epiphyseal cartilage and defects in its calcification, in some in.stances most extensive, in others small. Some animals showed short metaphyses or partial metaphyses, in which were columns or masses of cartilage in an uncalcified or in an incompletely calcified state, displaying the morphological changes and alterations in staining reactions pre\'iously enumerated. The nmnber of the trabeculfe were few, and in tlie trabeculie, in particular tliose close to tlie cartilage, there were present abundant evidences of resorptive activity. The patiiological conditions displayed in the bones of the rats sliowing tiiese intermediary changes bore a marked resemblance to tlie not verj' advanced rachitis of human beings, when tiie healing process has been well established or has progressed far toward completion. An anomalous condition was present characterized by abundant calcium deposits in the cartilage on the one hand, and borders of the trabecule still uncalcified on the other, a well recognized and characteristic intermediaiT stage in the healing of the rachitis in human beings.

It is not possible to explain why all the rats fed the diets deficient in fat-soluble A land phosphorus failed to develop exactly the same changes in tiie bone. It is possible that the diets in question were not absolutely constant in their composition, not as regards a deficiency in fat-soluble A — for all the rats without exception developed xerophthalmia — but as regards some oither substance. The stock supplies of flaxseed meal and rolled oats were replenished during the course of the experiments several times, and may have been derived from different sources.* A reason for suspecting that variations in the composition of the diets may have had some in


The content of the diets in c:\lcium and phosphorus was calculated from the average composition of rolled oats and flaxseed meal, as compiled by Forbes. Sherman and others, and from the composition of the salt mixtures employed.


fluence is that the animals which most consistently developed the marked rickets-like changes were the first animals of the series (those of the experiments completed before May 19, 1920). Another explanation, however, must be considered. As already pointed out, there were noted in all the animals, even in those sliowing the most marked racliitic-like changes, evidences of a strong tendency toward healing, manifesting itself in the deposition of calcium salts in the cartilage. In a large proportion of the animals the healing process, as measured by the extent of calcium deposition in the cartilage, appeared to be far advanced. If the composition of the diets was essentially constant, it is necessarj' to suppose that the abnoniial conditions in the body induced by them, under which lime salts could not be taken up by the cartilage and the lioiie, were not very far removed from other conditions more nearly approaching the normal under which lime salts could be taken up by the cartilage and the bone, and that the former state could be transformed into the latter by slight changes in the animals" metabolism. In other words, the particular abnormal equilibrium of the forces concerned with calcification and ossification produced by the faulty diets was unstable. With the rapid decline in the nutrition of the animals occurring during the latter part of the experiments and the corresponding loss in weight, a complete cessation, or at least a great retardation in the rate of growth of the skeleton must have occurred. There must have come about, therefore, a diminished requirement for those substances essential to ossification and calcification, which were insufficiently supplied in the diets. Moreover, it seems proljable that a supply of tho.se substances may have been liberated from the tissues of the animals themselves, for example, as the result of the resorptive processes in operation in the bones. From a theoretical standpoint, therefore, it seems possible to think that the processes in operation in the animal leading to the development of the state of extreme malnutrition may have been instrumental in restoring to the organism conditions under which calcium deposition in the skeleton again became possible. For the development of rickets growth is necessary. If the deficiencies in the diet are of sucli a nature as to render growth of the skeleton impossible, rickets cannot develop. If growth were brought to an end in an animal already rendered i-achitic through the administration of faulty diets, there is reason to expect that the rachitic lesion would disappear and a condition of osteoporosis develop. Whatever may have been the cause of the development of pathological cluniges in the skeleton, from the morphological standpoint, apparently so far removed from each other, there can be no doubt that the osteopo-osis exhibited by some of the animals of the series was closely related to the healing process in evidence in the others, and .e])resented merely the healing process in its completed state.

The pathological condition produced in tiie rat by the diet low in fat-soluble A bur, containing a coanplete salt mixture (the diet of Lots 3130 and 2185) were absolutely constant and offered no difficulties of interpretation. In the entire series of eleven animals on this diet, the band of proliferative cartilaui' was narrow, the junction between cartilage and shaft alirn|it


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PLATE XXIV



Fig. 1.



Fig. 4.


THE JOHNS HOPKINS HOSPITAL BULLETIN, MAY, 1921


PLATE XXV



Fig. 5.


Fig. 6.



Fig. 7.


Fig. S.


THE JOHNS HOPKINS HOSPITAL BULLETIN, MAY, 1921


PLATE XXVI



Fig. 11.


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and even, the calcification of the cartilage heavy and everywhere complete, the trabeculs thin ; osteoid was not present at all, or was not in greater amount than could be accounted for by the resorptive processes, obviously in operation. The pathological condition induced in the group of rats fed this diet, deficient fat-soluble A, but containing the adequate amount of phosphorus, therefore bore no resemblance whatsoever to rickets. It showed the typical picture of osteoporosis.

The experiments recorded leave no doubt that the two diets having the known deficiencies in fat-soluble A and phosphate may produce in the bone of the rat chaages having fundamental resemblance to the pathological changes in the bone wliich characterize rickets in the human being. At the same time they indicate that tlie addition of a salt mi.xture relatively high in its content of the phosphate ion coanpletely prevents the development in the bone of the rat of changes resembling rickets, though it fails to exercise any preventive influence on the development of the xerophthalmia. It seems .possible to infer from our experiments, therefore, that the! d'evelopment of rachitic-like changes in the rat induced by diets defi.cient in fat-soluble A and the phosphate ion can be prevented by the addition to the diet of phosphate-containing salts; and that conversely, for rachitic changes to develop in tlie presence of a deficiency of fat-soluble A in the diet, the diet in other respects being optimal, a low content of the phosphate ion is essential. The experiments indicate further tliat in the production of rickets-like conditions in the rat, fatsoluble A cannot be the sole factor concerned. Since tlie variable in the diets used in these experiments was certain phosphate-containing salts, it might seem possible to infer that it is necessary to consider only the inorganic content of the diet as active, and that a fat-soluble organic factor might be excluded from consideration. Even if it were granted that the induction of the rickets-like changes in the bone results from a disturbance in the level of the body's phosphate, it does not by any means follow that the inorganic ions are the only factors involved. Eecent experiments in feeding cod-liver oil, wliich is known to be high in fat-soluble A but free from phosphate, to rats already rendered rachitic by means of the diet, have proven that an organic substance (cod-liver oil) may exert, a powerful influence in causing lime salts to be deposited in the cartilage. Studies on the efl'ects of feeding cod-liver oil to rachitic children have led to similar conclusions.* iloreover, Howland and Kramer * have sho\\Ti that the blood phosphate is low in the blood plasma of rachitic children, and that the administration of cod-liver oil causes a marked rise. It seems not unlikely that a similar result may be accomplished in rats by feeding a diet high in phosphate, and from present knowledge it seems reasonable to suppose that, while the calcification of the bones of children and animals fed diets high in their content of phosphate may be dependent on the elevation of the phosphate level in the blood, the phosphate curve may also be afl'ected by the amount of the organic factor available for the body needs.


Personal communication.


Finally, our experiments show beyond doubt that the addition of certain phosphorus-containing salts to the diet low in fat-soluble A in no wise prevents the development of xerojihthalmia and indicates, as clinical observation has made it necessary to infer, tliat xerophthabiiia and rickets cannot jiossibly have an identical etiology.

C0NCLUS10X.S

1. The two diets which were low in their content of fatsoluble A and phosphorus (diets of lots 2667 and 2806) produced in the majority of the young rats placed upon them pathological conditions of the skeleton having a fundamental resemblance to rickets. The pathological conditions producedare not identical, however, with that disease as it usually manifests itself in the human being.

2. The chief difl'erence consisted in the presence of scattered or irregular deposits of calcium salts in the cartilage and metaphysis. The pictures bore a marked resemblance to those seen in rachitic children in whose bones incomplete healing has taken place.

3. "When the deficiency in phosphorus is compensated for by the addition of a complete salt mixture containing the phosphate ion (diet of Lots 3120 and 2815), the deficiency in fatsoluble A still existing, no pathological changes of a rachitic nature developed. The addition of the phosphate ion to the diets deficient in it and in the organic factor prevented, therefore, the development of any changes of a rickets-like nature.

4. The experiments reported are not sufficiently numerous or comprehensive to permit of generalizations concerning the efl^ects of a deficiencies of the fat-soluble A and phosphorus or of the fat-soluble A alone. The implication of the experiments is, however, plain.

(a) The jjhosphate ion in the diet may be a determining influence for or against the development of rickets.

(b) If the phosphate content of the diet is sufficiently high a deficiency of fat-soluble A cannot cause rickets-like changes in the skeleton.

(c) A deficiency 'in fat-soluble A cannot be the sole cause of rickets. Conversely, it is necessary that the diet be low in its content of phosphorus, all other factors, except fat-soluble A, being optimal for rickets-like conditions to develop.

5. Since the addition of the phosphate ion to the diet prevented the development of the rickets-like changes in the skeleton, but had no effect in preventing xerophthalmia, it seems permissible to infer that xerophthalmia and rickets do not have an identical etiology.

6. The above results do not in our opinion exclude the fatsoluble A from consideration as an etiological factor in the production of rickets and kindred diseases, since the level of the blood phosphate is, in all probability, determined in part by the amount of the fat-soluble A available for the needs of the organism.

BIBLIOGRAPHY

1. Mellanby, E.: The Lancet, March 15, 1919.

2. McColhnn, E. V., Simmonds. Nina, Parsons, H. T.. Shipley, P. G., and Park, E. A.: Jour. Biol. Chem., 1921. XLV. 333.


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3. Shipley, P. G., Park, E. A., McCoIlura, E. V.. Siramonds, Nina, and Parsons, H. T.: Jour. Biol. Chem., 1921. XLV, 343.

4. Howland, John, and Park, E. A.: Arch, of Pediatrics, 1920, XXXVII, 411.

DESCRIPTION OF PLATES

Fig. 1. — Microphotograph showing advanced rickets-like changes in the lower end of the left femur. The picture shows the relative positions of the epiphyseal nucleus (e. n.), cartilage (c), the metaphysis (Met.) and the diaphysis (d) of the bone. The epiphyseal cartilage is persistent at the peripherj- of the bone.

Fig. 2. — Microphotograph of the lower end of the left femur showing marked rickets-like condition.

Fig. 3. — High power photograph of the epiphyseal cartilage — extreme rickets-like lesion showing the arrangement of the cartilage cells in the matrix.

Fig. 4. — Microphotograph of the epiphyseal cartilage from a rat showing a marked rickets-like condition, to show persistence of the cartilage cells and the degenerative changes in them.

Fig. 5. — This picture shows the cell division in cartilage cells which are in contact with tissues of the metaphysis. The cell capsule (e) contains four daughter cells which have arisen by the division of the cartilage corpuscle which originally occupied the capsule.

Fig. 6. — Trabeculse in the medullary cavity of a rickets-like bone. The small spicule (o) which has undergone calcification is surrounded by a broad zone of osteoid tissue (o. s.).


Fig. 7. — This picture shows the sub-periosteal hyperplasia of the osteoid tissue — the so-called rachitic periostitis.

Fig. 8. — An abortive attempt at healing an extreme rickets-like lesion is recorded in the metaphysis of the affected bone by the linear deposit (1.) of calcium salt.

Fig. 9. — Microphotograph of a bone in which the metaphysis showed traces of three periods of calcium deposition, which are in all cases incomplete or have been partially absorbed.

Fig. 10. — This picture from a section of a bone which was in the transitional stage between the rickets-like condition and osteoporosis shows irregularit}' and prolongation of the epiphyseal cartilage, and its iiTegular calcification (cal). Broad zones of osteoid tissue (os) still persist about the trabecule.

Fig. 11. — The trabeculse shown in this figure are further along in the process of absorption than those shown in Fig. 10. Calcification o! the cartilage is incomplete in this bone. Osteoid tissue (os) is still present in the diaphysis.

Fig. 12. — Microphotograph showing the cartilage and part of the medullary canal of a bone from a rat maintained on a diet which included a complete salt mLxture (185) high in phosphorus. This bone was extremely osteoporotic. The proliferative zone of cartilage (pz) is narrow and was completely and hea\-ily calcified, as was the cortex. There were no trabeculse in the medullary cavity, and no traces of osteoid tissue to be found in the diaphysis.


GIARDIA (LAMBLIA) INTESTINALIS

A COMMON PROTOZOAN PARASITE OF CHILDREN

By Kexxeth F. Maxcy

{From the Dcpartmoit of Medical Zoology of the School oj Hygiene and Public Health, The Johns Hopkins University)


Studies of the protozoa found in the intestine of man received a great impetus during tlie war, due chiefiy to the return of large numbers of soldiers from the war area suffering from chronic diarrhoeas and dysenteries of various sorts. In investigating the underlying cause of these conditions, a surprisingly high percentage of infestations not only witli Entamceba histolytica but also with supposedly non-pathogenic protozoa was disclosed. This led to the e.xamination of non-dysenteric soldiers, of soldiers who had not been outsidd the countr)^ and, finally, of the civilian population in the community at large, with the result that approximately these same percentages were found to hold for all four groups. Pooling the results of all the recent sun-eys in England, France and the TJnited States, Hegner and Payne ^ find the percentages of infestations with the three commonest intestinal protozoa to be as follows: Entamceba coli 20 per cent, Giardia (Lamblia) intestiualis 12 per cent, and Entamoeba histolytica 9 per cent. This work has thrown an entirely different light upon the problem of amoebic dysentery and upon the so-called " flagellate " dysenteries and diarrhoeas, of which occasional mention is found in medical literature. It also suggests a reconsideration of the protozoa as intestinal parasites widely distributed in man.


' Hegner, R. W., and Payne, G. C. 47-52.


Scientific Monthly, 1921, XXI.


The frequency of Giardia is particularly striking inasmuch as this parasite of man has received little attention in the United States. Although Lambl first described it in 1859, we are really indebted to Grassi for most of our early knowledge concerning the organism. In the early eighties of the last centurj', he made a careful study of it and demonstrated its habitat to be the upper intestine, where it might be found in huge numbers perched tipon the lining epithelium, to which it adhered by means of a sort of sucking disc. He oliserved a number of individuals who harbored the parasite and thought that in certain instances it was the cause of diarrhoea.

A little later, 1892, Moritz and Holzl ' published a lengthy paper on the infestation of man with Giardia. reporting observations on six patients with diarrhoea and upon finding the organism in the duodeniun of ten patients dead of tuberculosis. They noted the frequency with which the parasite occurred in children.

Since these early studies, there have appeared in medical literature a large number of reports of the finding of Giardia in the stools of patients, with or without an accompanj-ing diarrhoea. In the United States attention was first called to it by Stiles ' in 1902, reporting the case of a patient of Dr. Hemmeter of Baltimore, a three-vear-old white child with recurring


'Moritz and Holzl: Miinch. med. Wchnschr., 1892, XXXIX. 831. = Stiles, C. W.: Washington Medical .\nnals, 1902, I, 64.


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attacks of diarrhcEa whose stool contained large numbers of the motile organism. In 1910 Allen * reported a similar condition in a five-year-old colored girl. Two years later, in an article by Dubois and Toro," we find an account of four children infested with Giardia.

Emerson," in his text-bool\, mentions a case discovered in the wards of The Johns Hopkins Hospital. In the Public Health Service Beports of 1911, Stiles' makes the statement that Giardia is by no means rare in the United States and says that he encountered it in a number of instances in the course of fecal examinations for parasitic worms in Xorth Carolina. Among 6000 admissions to the Mayo clinic, Giardia was found in 66 or a trifle over 1 per cent,' whereas among 1000 adjnissions to Augustana Hospital in Chicago it was recorded in only five instances, or 0.5 per cent.° Finally, in a very careful study of 1500 soldiers of the United States Army, 300 of whom had not been overseas, for intestinal parasites, Kofoid, Kornhauser and Plate" report 6 per cent infested with Giardia.

It will be noted that many authors have regarded this organism as pathogenic — that is, as a cause of diarrhoea. This conclusion is usually based upon the presence in the diarrhoeic passages of a large number of motile Giardias which apparently disappear with improvement in the clinical condition. In one or two instances examination of tissues removed at operation or after death has seemed to support the contention. In areas where the surface epithelium had been denuded, these protozoa seemed to have penetrated into the wall of the intestine. On the other hand, many have denied it any pathogenic role whatsoever, contending that it was present in diseased conditions of the intestine, not as the primary pathogen, but as a secondary invader, that it deserved no more consideration than is given to EntamcBba coli, for instance.

Clinical-pathological studies so far published have, then, failed to solve the problem, and attempts have been made to attack it from the experimental side. The method has consisted mainly in inoculating rabbits," guinea-pigs," and rats," " with Giardias obtained from man. This method is complicated by the fact that these rodents are in nature infested with their o^vn species of Giardia : Giardia cuniculi in the rabbit, Giardia muris in culture mice and culture rats, and Giardia microti in the meadow mouse, etc. These species are more or less similar in appearance to that found in man and can be distinguished only after careful morphological and bio


Allen, Will.: Old Dominion Jour. Med. & Surg., 1910, X, 417. 'Dubois. E. F., and Wm. C. Toro: Proc. N. Y. Path. Soc, 1912, XII, 32.

"Emerson. C. P.: "Clinical Diagnosis," Phila., 2d ed., 1908, pp. 405-406.

'Stiles, C. W.: U. S. P. H. S. Reports, 1911, XXVI, 1347.

"Logan and Sanford: Jour. Lab. & Clin. Med., 1916-17, II, 618-621.

"Smithies, Frank: Am. Jour. Med. Sci., 1918, CLVI, 173.

"Kofoid, Kornhauser and Plate: Jour. A. M. A., June, 1919, 72: 1721.

"Perroncito: Centralblatt f. Bakt., 1887, II, 738.

"Stiles: U. S. P. H. S. Reports, Reprint No. 135, 1913, p. 89.

"Fantham and Porter: Brit. Med. Jour., 1916. 2900, II. 139-141.

"YaJcimoff: Compt. rend. Soc. biol., Paris, 1918, LXXX.


metrical study, and observations on the original habitat. If rodents are to be used in inoculation experiments, natural infestation must be carefully excluded (a feat very difficult of accomplishment), and the origin and classification of the strain of Giardia used in the experiment must have been carefully determined. These and other considerations render previous experimental work on the pathogenicity of Giardia inconclusive. For similar reasons, the statements which have crept into the literature regarding rodents as a reservoir of infection for man have not been firmly established.

To recapitulate, it may be said that previous work has demonstrated that Giardia intestinalis is a widely distributed intestinal parasite of man whose power to harm its host has been strongly suiipected but is as yet unproved. Assuming that it is capable of harm, then this should be most apparent at the age when the intestinal tract is most sensitive to disturbing influences of all kinds, — namely, in childhood. The literature lends some support to this hypothesis in so far as many of the cases of so-called " Laniblia enteritis " which have been reported have been in children. The problem fonnulated is, whether Giardia intestinalis is simply a harmless commensal in children or whether it is capaljle of causing intestinal disturbance.

As a contribution to the solution of this problem the present study was undertaken to determine the frequency of this parasite in the intestinal tract of apparently normal children in the LTnited States. It is obvious that this information is necessary before its presence in those with abnormal intestinal conditions can be properly evaluated.

Methods and Material

Protozoa are apt to be missed in the ordinary clinical laboratory examination of feces. Specimens are rarely examined immediately after passage, although it is known that the actively motile protozoa die and undergo lysis a few hours after they have left the body of the host. Again, the microscopic examination of feces is often carried out with the low power objective which gives a sufficiently high magnification for the detection of helminth ova; but the detection of the encysted forms of the protozoa require more careful examination, often of several preparations, and with the u.<e of the higher magnifications.

In pursuing the present study, attention was directed toward demonstrating only the encysted Giardia, and incidentally the other common intestinal protozoa which show encysted forms ; viz.. Entamoeba coli, Entamoeba histolytica, Endolimax nana, Chilomastix (Tetramitus) mesnili, Coccidia and Blastocystis.

The specimens were obtained for the most part without the l^revious administration of a cathartic, and were usually formed stools. Two "wet smear" preparations were made from each specimen, distilled water being used. Material for the one was scraped from the exterior of the stool, any clumps of mucus visible being included; material for the second was taken from the interior. A drop of one per cent water soluble eosin was added to the preparation. The field takes a pink stain ; the viable cysts remained unstained and stand out rather


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sharply as clearly defined, pale green, refractive ovals against the pink background. Whenever cysts were found to be present, another preparation was made and stained with iodine (iodine 1 part, potassium iodide 3 parts, distilled water 100 parts). This solution differentiates the structures a little more clearly and brings out the iodophilic inclusions.

About 15 minutes were spent iu searching through each preparation before it was discarded as negative. An 18 mm. cover-slip was used, and the field was traversed eight times in each direction, guided by a mechanical stage. The "high dry " objective (4 mm.) with a 'No. 10 B. & L. eye piece gave an approximate magnification of 450 X.

When possible each patient was examined on two occasions, at intervals of two or more days. Actually the number of examinations averaged two per case. According to Dobell." Wenyon and O'Connor" and others, this technique would reveal about two-thirds of the actually existing infestations with intestinal protozoa. This figure probably indicates the percentage of Giardia infestations detected in the present study.

The children examined were miscellaneous medical admissions to the clinic of Dr. John Howland, Harriet Lane Home, Johns Hopkins Hospital. Excepting a small group of " feeding cases," these children were admitted because of acute infectious disease, and were free from gastro-intestinal disturbance. They were fairly representative of the child population of Baltimore with the exception that the negro race was not proportionately represented (only 6 in the 89 were colored).

Eesults

Of the total of 89 children examined, IS, or 20 per cent, were found to be harboring intestinal protozoa of some type. It is noteworthy that in a group of 15 " feeding cases " under one year of age no infestations were found. The youngest positive case was a little girl 17 mouths of age whose stools showed large numbers of Entamreba coli cysts. From the second year on there was an increasing number of positive cases with advancing age, so that the group of children from 6 to 12 years old showed a decidedly higher percentage of infestations than the children between one and five.

The relative frequency of the protozoa encountered in this series and the instances of multiple infestations are shown.

Giardia intestinalis (alone) 10 cases

Giardia and Entamceba coli 1

Giardia and Blastocystis 2

Giardia, Hymenolepis nana and Oxj-uris vermicularis 1

PJntamoeba coli (alone) 4


The most interesting fact brought out by this study was the large number of children who harbor Giardia intestinalis.


If the infants under one year are excluded, then of the remaining 74 children, 14 were infested with this parasite. In other words one out of every five of the children over one year of age examined harbored Giardia. The raw data indicating the sex and age distribution of these children are given in the accompanying table. The group is in itself too small to admit

TABLE 1.— AGE .\>:D SEX DISTRIBUTIOX OF CHILDREN

FOrXD TO BE IXFESTED WITH GIARDIA (LAMBLIA)

IXTESTIXALLS


Age


Males

6S


Females 31


Tota

89


1



Non-infested 52


Infpsted


Non-infested 23


Infested S


Non-infested 75


Infested 14


0— 1


12



3



15



1— 2


10



4


1


14


1


2— 3


6


1


o



11


1


3— 4


9



2


1


11


1


4 — 5


5


Q


1


2


6


4


5— 6


2



3


1


5


1


6— 7


2



1


1


3


1


7- 8



2


1


1


1


3


S— 9


1



1


1


1


9—10

1



1



2



10—11


1 1



11—12


1


1


2



3


1


12—13


2 2




" Medical Research Committee, Xationul Health Insurance, London. 1918, Special Report Series Xos. 7 and 15; 1921, No. 59.

"Wenyon and O'Connor, J.: Royal Army Med. Corps. 1917 XXVIII, 1-24.


of conclusive analysis, but may prove of value in connection with other reports of a similar character in the literature.

The youngest instance of Giardia infestation was in a little girl 22 months old. In the group of one to five years of age, 17 per cent showed Giardia, and from 6 to 12 almost 40 per cent were positive.

The history of each one of these positive cases was obtained. Xone had suffered from chronic diarrhoea so far as could be learned. One gave a histor}- of a rather severe diarrhoea in the preceding summer, but such a history might be expected in at least one of a group of this size, and no conclusions as to its etiology could be drawn. Three of the children showed a tendency toward increased frequency of defecation — three or four times daily. This may be a significant observation, as it is what one might expect from duodenal irritation.

Case 38, a child five years old, had on admission a diarrhcea. The passages were dark brown in color and contained a large amount of yellowish mucus in which were entangled myriads of motile Giardia. The condition, however, cleared quickly and after two or three days only the encysted forms could be found in the soft, semi-formed stools, which, however, still contained some mucus at times. No history of repeated attacks of diarrhoea was obtainable in this individual.

The intermittency with which Giardia cysts are discharged was particularly well illustrated by two of the series. In case 19, examinations on January 27, 29 and 31 were negative; on February 3 and 5 large numbers of Giardia were found. In Case 37, the examination on February 24 was positive. No cysts were found on February 27, 29 and March 4. On ilarch 6 large numbers of cysts were again found and were still present at the last examination on March 11.


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Discussion

This iiitermittency emphasizes the necessity of repeated examinations for the establishment of a negative result, in order to judge of the heaviness of the infestation or the permanency of a cure. This has been pointed out by many observers. An attempt has been made to show that Giardia undergoes a regular cycle of cyst production. Porter madedaily examinations of a group of soldiers infested with Giardia and estimated the number of cysts passed in 24 hours. The number varied within wide limits, being practically nil on some days and more than 300,000 on other days. She estimated the interval between successive maxima and minima at about 14 days. Boeck, working with the Giardia microti of the meadow mouse, found a similar phenomenon but fixed the interval at seven days. Dobell," on the other hand, finds absolute irregularity in the passage of cysts, suggesting that there may be prolonged periods of complete quiescence during which no cysts can be found.

At all events, it is plainly evident that a single examination or two examinations reveals only a part of those actually parasitized. In ,the series here reported, while Giardia was actually found in one out of every five children examined, a conservative estimate would place those actually infested at close to one in four.

Eesults of British investigations '" indicate a similar high degree of incidence of Giardia in the intestinal tract of children in that country. Matthews and Smith examined 548 children in the Liverpool Eoyal Infirmary, and, based iipon a single examination per case, found 14 per cent infested with this protozoon. A. H. Campbell found 16 per cent positive in a group of 49 children under 12 years of age in the Children's Hospital, St. Michael's Hill, Bristol.

Muriel M. Nutt examined 128 children in Leeds, England. Among a group of children living in an institution (Workhouse), 48.8 per cent were found to harbor Giardia as compared with 23.9 per cent of the children in the Leeds General Infirmary. The higher incidence among inmates of an institution is a significant fact. In the Sheffield Eoyal Hospital, this same observer found 15.8 per cent of 57 children examined positive for Giardia.

Most of these figures are based upon a single examination per case. It seems to be clearly established that in England Giardia is a very common intestinal protozoon in children. Our own studies indicate that the same thing is true in the United States.

How soon the infestation is acquired is a question of considerable interest and importance. It has been noted that no cases were found among the 15 infants under one year of age examined. Matthews and Smith found none among the 50 infants which were examined by them. On the other hand.


"Porter, Annie: Lancet, London, 1916, I. 1166-69. "Boeck, Wm. C: Univ. of Cal. Pub., Berkeley, 1919, XIX, 85. "" Dobell, Clifford : Lancet, London, 1916, 11, 1053. "Medical Research Council, London, 1921, Special Report Series, No SO.


Miss Xutt found no less than 6 of the 25 children under 12 months of age examined by her to be harboring Giardia. The ages were respectively: one at three weeks, one at three months, one at nine months, one at eleven months and two at twelve months. That an infant three weeks old may become infested with Giardia is a startling fact, and indicates how soon the food of children in filthy surroundings becomes contaminated with human fecal material. However, this must certainly be an exceptional case, and infestation during the first year of life is a comparatively rare event.

Sufficient figures are not yet at hand to determine at what year of childhood the maximal incidence is foimd, but it is not unlikely that it is before the fifth year as is the case with Oxyuris vermicularis. Indeed, these two parasites may be transmitted from child to child in much the same way. Experimental work has demonstrated that Giardia cysts can remain alive outside the human host for only a few hours except under very favorable circumstances as regards moisture and absence of other deleterious influences. If allowed to dry, they perish immediately. An intermediate host has not been shown to exist nor to be necessary. The obvious inference on the basis of our present knowledge is a rather direct transference by fecal contamination of fingers and food. Without doubt it is just one more of the unwelcome guests along with the tubercle bacillus and metazoan parasites which children pick up during the " dirty age."

How long the infestation may last is as yet undetermined. This much is certain : A very much higher incidence is detected in children than in adults. The British figures are very consistent on this point. In the same population groups, the percentage of adults showing Giardia cysts, is from one-third to one-fifth that of the children. In this country, as previously mentioned, Kofoid, Kornhauser and Plate found 6 per cent of the healthy, young adult soldiers who had never been outside the United States harboring Giardia. If this figure is compared with the 20 per cent of children found infested in this investigation, the same discrepancy is apparent.

The explanation suggested is that in a certain number of children the infestation is not permanent, and that there is either a heightened immunity or lessened exposure in adult life. The same phenomenon has been noted in the protozoon infestations of certain animals, namely, that the young of the species show a far greater degree of infestation than the adults of the same species. Here the lessened exposure is not so obvious and greater emphasis must be laid upon factors of immunity. These latter may simply be changes in the bacterial flora of the intestine or in food habits. To these views Dobell "" objects that it has not yet been demonstrated in any particular instance that an individual once infested with Giardia has subsequently been ridded of the parasite. Absence of the cysts in the stools does not necessarily mean that the organism is no longer present in the intestinal tract. Cyst production may be in abeyance in adults. He has himself observed an infected individual over ten years, and although it is


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frequently impossible to find the organism in the stools the infection is still jjresent and has shown no disappearance from the bowel. Obviously it is just as wrong to generalize from this one case, and until it has been proved that Giardia is as frequent in the intestinal tract of adults as in children, it may be assumed that a certain number of children do get rid of their Giardia infestations.

As regards the pathogenicity of Giardia, in view of the large number of apparently normal children harboring the organism the conclusion is almost forced that in a vast majority of instances it is present merely as a harmless commensal. On the other hand, the fact that, in at least one of the 14 positive cases found in this investigation, there was evidence of an intestinal disturbance which could possibly be attributed to Giardia makes necessary guarded inferences as to its entire harmlessness in children — particularly in very young children.

There seem to be authentic instances in the literature in which individuals harboring this parasite have been suliject to recurrent attacks of diarrhoea, during which they passed large quantities of yellowish mucus in which occur the unencysted Giardia in myriads, and in whom no other explanation for the diarrhwa is obvious. As Weuyon and O'Connor ^' point out, it is difficult to explain the large quantity of mucus or the occasion of the attacks and, above all, the crowding of the mucus with flagellates, without assuming that the mucus must be produced by the intestine at the site of the Giardia infection and that the flagellates are directly responsible for its production.

Before this parasite is ruled out as of no importance to children, a larger experience is required. Its presence or absence


should be recorded in a large series of children suffering from nutritional difficulty, intestinal " indigestion," abnormal frequency of defecation, diarrhoea, etc., and compared with a like group of children, normal in these respects, and living under the same surroundings.

On the Ijasis of this recent knowledge it is evident that the mere finding of a considerable number of Giardia in the stools of a child suffering with diarrhoea and dysentery does not necessarily mean that Giardia is the cause of the condition. In fact it would be strange if a great many such eases were not found. Misdirected efforts at therapy should also be avoided. There is no evidence at the present time that any of the innumerable drugs that have been used are of the slightest value in ridding the patient permanently of his infestation.

Conclusions

1. Giardia intestinalis is present in the intestinal tract of a large percentage of apparently normal children.

2. It is rarely found before the first year.

3. The percentage of infestations appears to be much higher in childhood than in adult life.

4. The finding of a large number of motile Giardia in a diarrhoea or dysenteric stool is not sufficient evidence to establish the etiologic relationship of this parasite.

5. In certain rare instances the parasite may be responsible for some intestinal disturbance, although this point has not yet been firmly established.


^ Wenyon and O'Connor: "' Human Intestinal Protozoa in the Near East," Wellcome Bureau of Scientific Research, London, 1917.


NOTES ON NEW BOOKS


The Form and F'unctions of the Central Nervous System. An Introduction to the Study of Nervous Diseases. By Frederick TilNEY, M.D., and Henrt A. Riley, M.D. Cloth, $12.00. {.Vero York, Paul B. Hoeber, 1921.)

In one volume of a thousand pages the authors have combined the important data which are indispensable to a proper understanding of clinical neurology. No laborious attempt to correlate a mass of anatomical facts by doubtful significance has been made. The importance of phj'logenetic investigations in relation to the functions of the nervous system of man has been clearly stated.

The work is of particular value to students and clinicians, since it contains much information not available in text-book form in English. Furthermore, that information is clearly set forth in a rational manner. The microphotographs and drawings are in most instances well reproduced. A few of the former are so dark that detail is lost. Very few authors are cited in the text, but a fairly complete bibliography is appended.

The field of usefulness for the book exists and its appearance should be welcomed. V. R. M.

Physiology and Pathology of the Cerebrospinal Fluid. By William Boyd. Cloth. {New York: MacMillan Co., 1920.)

In his preface the author states that " the object of this book is to present some of the fascinating physiological problems connected with the cerebrosiunal fluid, and to show how they are related to the pathological problems which more directly concern the clinician." This object is attained. The subject is presented from a physiological


standpoint in a clear, if somewhat elementary, fashion. The more recently discovered facts pertaining to the origin and circulation of the cerebrospinal fluid, and the finer anatomical relationships of the subarachnoid space are brought together and correlated in Part I.

Part II of the book deals with the cerebrospinal fluid in special pathological conditions, and a section on therapeutics is herein included. It is to be regretted that Part I was not elaborated in more detail — to the complete exclusion of Part II from the volume. An excellent bibliography is given. H. M.

Tlie Mechanism and Graphic Registration of the Heart Beat. By TH0M.4S Lewis, M.D. Cloth, S16.00. {New York: Paul B Hoeber, 1920.)

Although advance in special methods of cardiac study has been remarkably rapid in the last few years, one cannot but feel that in a way the crest of the wave has been reached. General principles ha\-e been pretty well established, and it now remains mainly to work out the finer details of the disturbances of cardiac mechanis;n Another edition of Lewis's masterly treatise seems, therefore, most timely, bringing up to date, as it does, the whole subject. As those familiar with the previous editions know, the subject is taken u|i mainly from the standpoint of pathological physiology. The authority of the writer and the constant references to his own work do not interfere with a critical discussion of the literature in general, so that the book stands out as a storehouse of information in this large and complex domain of medical science. A. L. B.


.May, 1921]


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BOOKS RECEIVED


PUBLICATIONS



THE JOHNS HOPKINS HOSPITAL

(THE PUBLICATION OF THE MEDICAL SCHOOL AND HOSPITAL)

Vol. XXXII— No. 364

BALTIMORE, JUNE, 1921

CONTENTS

  • A Critical Analysis of Twenty-One Years' Experience With Caesarean Section. By J. WniTBiDGE Williams 173
  • Modern Methods in Handling Hospital Statistics. (Illustrated.) Bv Raymond Peakl 184
  • An Atypical Bacillus Paratyphosus B Infection. By Hugh .J. Morgan
  • Growth Requirements of Influenza Bacilli. Br T. M. Rivers and A. K. Poole
  • The Gradual Withdrawal Method of Treating Morphinism : A Mathematical Note. (Illustrated.) Bv John- Rice Miner 205
  • The Formation of Vacuoles and Neutral Red Granules in Connective-Tissue Cells and Blood Cells Observed Under Abnormal Conditions. (Illustrated.) By Rosa E. Prirosen 206
  • Notes on New Books


A CRITICAL ANALYSIS OF TWENTY-ONE YEARS' WITH CESAREAN SECTION EXPERIENCE

By J. Wjiitridge Williajis


From February 1, 1899, until the end of December, 1920, 183 Cffisarean sections were done in the Obstetrical Department of The Johns Hopkins Hospital, and I have thought that it might be interesting to follow the evolution of the operation in our sen'ice, and to learn our point of view concerning certain of its various aspects.

Feequexcy The 183 operations were done upon 145 women, 10-1 of whom had their first and only section in the service, while 41 others had one or more subsequent sections, as follows :

104 women had the first and only section in the

service 104

8 women had the first section elsewhere and the

second in the service 8

26 women had two sections in the service 52

2 women had the first section elsewhere and two

in the service 4

5 women had three sections in the service 15

145 183

Of the entire number of operations, 122 were done by me and 61 by a succession of 13 residents. Accordingly, the re

Read in abstract as the Jerome Cochran Lecture before the Medical Association of the State of Alabama, April 20, 1921.


suits obtained are composite in character, and do not represent the experience of a single, and possibly peculiarly skillful, individual.

As the 183 sections occurred in a series of approximately 20,000 deliveries, their incidence was somewhat under 1 per cent. As will be shown below, 144 of them were done on account of disproportion between the size of the child and the pelvis, and I believe that great conservatism was observed in the indications for its performance. Quite one-half of our material consists of colored women, and as the incidence of contracted pelvis is 35 and 8 per cent in the two races, respectively, this means that approximately 3500 contracted pelves were observed in our black and 800 in our white patients, or a total of over 4000 in the series. Dividing that number by 144 shows that during a period of 21 years approximately one Cesarean section was done in every 30 contracted pelves. As time has gone on, our indications have become somewhat more liberal, as is shown by the fact that only 50 sections were performed during the first 13 years of the period, as compared with 133 during the last 9 years — an average incidence of 4 and 15 sections per year, respectively.

The comparatively infrequent resort to Caesarean section during the former period is in part accounted for by the fact that between the years 1906 and 1915 we gave pubiotomy an extensive trial. Forty-three such operations were done and


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all of the patients recovered ; and, as will appear later, pubiotomy, at that time at least, constituted a very conservative procedure, no matter what one may now think of its justifiability and applicability. That many of these patients would otherwise have been delivered by Cssarean section is shown by the fact that 11 patients in the present series had been subjected to one or more pubiotomies before Csesarean section was resorted to, and that three of them required two and one three sections afterwards.

One of the striking features brought out by the consideration of our series of sections is that blacks require radical interference much more frequently than whites, our figures showing that Cfesarean section was performed upon 114 colored and 69 white women, with 57 and 14 repeated operations in the service, respectively — an incidence of 50 and 20 per cent. To particularize, it may be stated that 21 of the black women had two, and five had three repeated sections in the service ; while none of the 7 white women had a third section in the service, although one of them (8955) had two sections following a previous section elsewhere, thus making three in all. It will be noted that these figures do not tally with those given at the beginning of the article, for the reason tliat they do not include 8 patients upon whom a second section was done in the service following a first one performed elsewhere.

Considering the types of operation performed, it is found that 121 were typical conservative sections, 4 extraperitoneal sections (Ktistner), 1 postmortem section, and 57 supravaginal amputations of the uterus — the so-called Porro Ca-sarean sections. It will be noted that no cervical Cjesarean sections were done. Of the 125 conservative and extraperitoneal sections 27 were repeaters, as compared with 21 in the 57 supravaginal amputations. Moreover, the comparatively frequent employment of supravaginal amputation of the uterus following the section should lend considerable interest to our analysis, and the reasons for its frequent utilization will be considered in some detail further on.

MOKTALITT

Passing to the consideration of the mortality following Cfesarean section, it is found that 10 deaths followed the 183 operations, a gross mortality of 5.46 per cent; eight deaths occurring after the 126 conservative operations, and two after the 57 supravaginal amputations, or 6.35 per cent and 3.51 per cent, respectively. Before any deductions are made, it should be noted that the gross mortality following supravaginal amputation, which for purposes of brevity will hereafter be designated as the Porro operation, wa.s about one-half of that following the conservative operation.

Careful study of our material has convinced me that a gross mortality of 5.46 per cent gives somewhat too sombre an idea of the dangers of Cissarean section, and it will be seen that the deaths, which followed the operation in several instances, were in no way connected with it, and may be fairly deducted in determining the net mortality. For example, Case 4723, in which the patient with mitral stenosis and insufficiency was operated upon in the hope of preventing death from acute


decompensation, made a good recovery from the operation, but died at home forty days later from the original heart lesion. Likewise, in Case 5709, the woman was suffering from broken compensation due to acute ulcerative endocarditis, and was operated upon as a last resort with a pulse of 136. She died on the eighth day, but autopsy showed that death had resulted from the original endocarditis and that no signs of wound infection were present. In Case 5911 the patient was an elderly primipara, who was admitted to the service with complete placenta prsevia, a rigid cervix and advanced chronic nephritis. Death occurred on the eighth day following the section. Autopsy showed that it was due to the chronic nephritis; while negative cultures from the uterine and peritoneal cavities, as well as the absence of infiammatory lesions, demonstrated the absence of wound infection. Finally, in Case 6890, the patient was operated upon for eclampsia. Autopsy, 26 days after the section, showed that death had resulted from acute anemia following profuse gastric and intestinal hemorrhage, following the erosion of a duodenal ulcer.

Upon deducting these four deaths, which can fairly be claimed to have no connection with the operation itself, it follows that six deaths, which must be attributed to it, occurred after 179 Cfesarean sections — a corrected mortality of 3.35 per cent. Furthemiore, it is interesting to note that the net mortality following the 121 conservative and 56 Porro operations presented variations similar to those obsen'ed in the gross mortality; as five deaths occurred after the former, as compared with one after the latter — a net mortality of 4.07 and 1.82 per cent for the two operations, respectively.

A good deal of light mfiy be thrown upon the mortality, and the factors concerned in its production by considering our material from another point of view. Eegarding the first 50 operations as representing the period of learning and the remainder as the period of more ripened experience, it is found that 6 deaths occurred in the first, as compared with 4 in the succeeding period — a gross mortality of 12 and 3 per cent, respectively. Upon deducting the four deaths, which were not primarily connected with the operation, it is found that five deaths occurred in the first 49 sections, as compared with one in the succeeding 130 — a net mortality of 10 and 0.77 per cent, respectively. In other words, the net mortality was 13 times less than in the second period. Moreover, during the first period we performed 28 conservative and 22 Porro Cesarean sections, with 5 deaths in the former and 1 in the latter, a gross mortality of 18.5 and 4.5 per cent, respectively. In other words, during the period of learning the mortality was four times greater after tlie former than after the latter operation.

Eesults

It should be noted that five of the 6 deaths directly attributable to the operation were due to general peritonitis, which resulted from the extension of infection through the uterine wound, while the sixth was due to the failure of an inexperienced resident to control hfemorrhage from the uterine artery during the course of a Porro operation. As the aseptic technique was, roughly speaking, identical throughout the entire


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series, the question arises as to how the difference in the results during tlie two periods are to be exphiined, and why the mortality following the Porro operation was so much lower than after the conservative? To answer these questions, as well as to ascertain what other conclusions can be drawn from our experience, is the object of the present study.

The answer to the first question is perfectly clear, and consists in the fact that we now aim to operate before the onset of labor, or as soon afterwards as is feasible, upon patients who have not been examined vaginally for some days. During the period of learning, on the other hand, the significance of early operation was not appreciated, as it was currently taught that the ideal procedure was to allow the patient to go into the second stage, to subject her to the test of labor, and to complete delivery by Cesarean section only after a tentative attempt with high forceps had failed to draw the head into the pelvic cavity.

This lesson was in great part learned by comparison between the results following the conservative and the Porro operations. The first supravaginal amputations were undertaken for th^ purpose of sterilizing the patient, usually at the second section, or occasionally at the first, if she urgently requested it, or when she was so deformed as to become a charge upon the community. We soon became impressed by the difference in the convalescence following the two operations, and during the period of learning noted that only 41 per cent of the patients subjected to the conservative operation had normal afebrile puerperia, as contrasted with 71 per cent after the Porro operation, not to mention the difference in mortality to which reference has already been made. Moreover, we gradually learned that patients upon whom conservative sections were done late in labor or following vaginal manipulations did badly, and sometimes died ; whereas those in whom the uterus was amputated tended to have an ideal convalescence. This contrast was particularly noticeable when signs of intrapartum infection were present prior to operating.

The more favorable results following the Porro operation were at first attributed to the lessened resist<ance to infection of the incised involuting uterus, and seemed explicable in the same manner as the simple convalescence following the treatment of uterine myomata by supravaginal hysterectomy as compared with the more stormy one following myomectomy. Later, however, it was found that this was not the whole story ; for when we came to examine microscopically uteri that had been amputated following Caesarean section, particularly when the operation had been undertaken late in labor, it was noted in many instances that the decidua lining the lower uterine segment presented pronounced leukocytic infiltration and other signs of inflammation, which were usually lacking in the upper part of the uterus. Moreover, when such sections were treated with appropriate stains, streptococci and other bacteria could be demonstrated in the tissues. Such observations led us to conclude that the infection was due to an ascending process, which had not given rise to clinical symptoms at the time of operation. Thus, in 14 instances in which the uterus had been amputated late in labor, microscopic study conclusively


demonstrated the existence of an ascending infection. In two instances the patients had presented signs of intrapartum infection, but in the other 13 the pulse and temperature were normal at the time of operation, and no signs were present which might lead one to suppose that infection had already occurred. The evidence thus adduced is so clear that it is now realized that whenever a considerable time has elapsed between the onset of labor and the performance of Caesarean section, we must reckon with the probable existence of latent infection. In this event, it would appear that the involuting uterus is unable to offer a sufficient resistance to the spread of the infection, with the result that the process extends through the uterine incision to the peritoneum, giving rise to a general peritonitis to which the patient almost always succumbs. Since the probability of latent infection in prolonged labor has been recognized and our procedure modified accordingly, the results following conseri'ative Caesarean section have become highly satisfactory.

The difference between the two operations can be still further demonstrated by comparing the clinical course of the puerperium. Upon designating as febrile all patients in whom the temperature reaches 100.5° F. on one occasion or more, the convalescence was found to be afebrile in 43.9 and 59.6 per cent following the conservative and Porro sections, respectively. Furthermore, the comparison becomes even more striking when the cases are arranged in groups according as the operation was done before the beginning of labor or at varying periods after its onset.

TABLE I. SHOWING INCIDENCE OF NORMAL PUERPERIA ACCORDING TO TIME AT WHICH SECTION WAS DONE



Conservati


ve


Porro



Normal


Febrile


Per ct.


Normal


Febrile


Per ct.


Before onset of labor


25


21


54.4


10


4


71.4


1 to 6 hours after onset. . . .


2.5


28


47.2


7


5


58.3


6 to 12 hours after onset. . .


1


6


14.3


1



100


12 to 24 hours after onset. .


2


8


20


4


3


57.1


Over 24 hours after onset. .


1


6


14.2


12


11


52.2



54 69


43.9


34


23


59.6



123



57



This table shows .that there was a progressive and rapid diminution in the number of afebrile puerperia according as conservative section was done before the onset of labor or after the lapse of 24 hours — 54.4 per cent as compared with 14.2 per cent. After the Porro operation, on the other hand, it is noted that afebrile puerperia are much more frequent, and while their incidence tends to decrease as the operation is performed late, it is nevertheless practically the same when the Porro operation is done after 24 hours of labor as when the conservative section is done before the onset of labor. Such observations clearly indicate that the involuting uterus


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represents a locus minoris resisteritia, and that its removal does away with a considerable danger of infection.

The difference in results following early and late operation on the one hand, and the conservative and Porro operation on the other, can likewise be demonstrated by considering the mode of healing of the abdominal incision.

Upon arranging our cases in four groups according as the operation was done before labor, one to twelve hours after the onset of labor, late in labor, and after the appearance of clinical signs indicating the existence of intrapartum infection, respectively, (as in Table II), it is noted that following the conservative section there is a progressive increase in the incidence of stitch abscess and actual infection of the wound, which occur three times more frequently when the operation is done late in labor than at its onset. In the corresponding groups following the Porro section, no such change can be noted, and in the 48 operations comprised in the first three groups the incidence of defective wound healing was only 4.17 per cent as compared with 13.44 per cent following the conservative operation.

Moreover, when the patients were operated upon in the presence of intrapartum infection still more striking differences were noted. Thus, in the two instances in which the conservative operation was done, both patients died before the end of the first week and were not included in the table, while of the eight in which the operation was ended by amputation of the uterus none died, but in 37.5 per cent of them the convalescence was disturbed by widespread infection of the abdominal wound.

TABLE II. SHOWING HEALING OF ABDOMINAL WOUND

ACCORDING TO TIME AT WHICH CESAREAN

SECTION WAS DONE



Conservative


Porro


Time of operation


5

45 62 12


"a

41 53 9


3 5 2


6.67 8.06 16.67


|i 1

4 1


c

a.

2.2 6.45 8.33



o

13 15 20 8

56


12

15 19 5

51


•=1



1


1


0,


5


1.78


1


3

4


i

7.6

a

37.6 7.14


.i. •

|li


Before onset

1 to labours

Late in labor

Intrapart. infec...


8.9 14.5 25.


7.6

6 37.5



119


103


10


8.40


6


5.4


13.44


8 93




(Does not include 7 patients who died within week of operation— 6 conservatives and one Porro.)

It cannot be stated precisely why defective wound healing occurs so much more frequently following the conservative operation at the several periods, although it may be assumed that latent infection is more probably present in patients operated upon late, and, if so, it may result in soiling and subsequent infection of the abdominal wound Nvithout causing a fatal peritonitis. In the presence of intrapartum infection, on the other hand, the patients usually die from infection following the conservative operation be^fore local signs appear in the abdominal wound; whereas after the Porro operation the


peritoneum is able to take care of the infecting agents in the absence of the involuting uterus, while localized infectious processes tend to develop in the abdominal wound.

We now turn to the consideration of the factors concerned in the causation of death following Csesarean section. As reference has already been made to the four deaths which I do not believe should be attributed to the operation itself, six others remain for consideration. One of these occurred during the course of a Porro section, while the other five followed conservative sections. The fijst death (1548) was due to hgomorrhage, the patient succumbing on the table as the result of failure of an inexperienced resident to control the bleeding from one of the uterine arteries. The other five were due to infection. In two the fatal outcome was due to unavoidable accidents. Thus, in Case 4116, the patient, who had had two preceding pubiotomies, was operated upon at an appointed time before the onset of labor and died five days later from general peritonitis. Afterwards, it was found that owing to a defect in the autoclave all of the dressings had been imperfectly sterilized. In Case 8826, death after the third section was due to infection following the imperfect repair of a loop of bowel, which was adherent to the abdominal cicatrix and which was wounded when the abdomen was opened.

The other three deaths, on the other hand, were due to errors in judgment and, vnth our present knowledge, should have been avoided. Thus, in Case 1256, a conservative section was done late in labor upon a patient with normal pulse and temperature. In Case 1611a repeated conservative section was done 12 hours after the onset of labor upon a patient who presented signs of intrapartum infection with a temperature of 100.8°; and finally, in Case 2158, the patient was given a test of labor in the second stage and had a pulse of 116 and a temperature of 101° when operated upon.

Pelvic Indications

As has already been mentioned, 144 of tlje 183 sections were done an account of disproportion between the size of the child and the pelvis, while the other 39 were necessitated by nonpelvic indications, an incidence of 78 and 22 per cent, respectively.

Table III gives an idea of the various indications, and illustrates very clearly the great differences which prevail in white and colored patients, as seen in Baltimore, the pelvic indication being present in somewhat less than six-tentl)s of the former, as contrasted with nine-tenths of the latter. Furthermore, it is seen that in the colored women the various types of rhachitic pelvis afforded the predominant indication, as they made up 98 of the 103 contracted pelves requiring Cesarean section in that race; while in the white women, on the other hand, only 10 of the 41 abnormal pelves were rhachitic in origin. Or, taking the entire number of sections into consideration, rhachitic pelves offered the indication for 86 per cent of the operations in the blacks as compared with 14.5 per cent in the whites. Consequently, if the application of suitable dietetic and hygienic measures should eventually lead to the


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disappearance of rickets, Cffisarean section would be very rarely indicated in the black race.

In the whites, on the other hand, the most usual pelvic indication was afforded by the simple flat pelvis, which was

TABLE III. SHOWING INDICATIONS FOR 183 CESAREAN SECTIONS


Pelvic indications


Other indications


Type of pelvis


1


'.S


s


Condition


H


Si

5 R


^ S


Generally contracted rhachitlc.


86 IS


3 15


83



9

K


4


Heart


9.


Flat rhachitic


13


6


7


Atresia of cervix


4


4



Scolio-rhachitic


8


1


7


Ovarian cysts


3


3



Kvpho - scolio- rhachitic. Generally contracted.


1 6 6 4


4 5 4


1 2

1


Neglected transverse. .

Premature separation

of placenta. Nephritic toxemia. . .


3 2

2


3 1 2



Achondropla^ic

Kyphotic funnel



2


1


1


Ventral fixation



1




1 1


1


1


Pregnancy in rudimentary horn. Hour-glass contraction.





Hypoplastic dwarf...



Oblique (luxation) . . .


1


1



Placenta prsevia

E.xcessive size of child. Carcinoma of cervix. .



1 1

1




144


41 103


39


28 11




144




39


noted in 15 instances; while not a feingle pelvis of that type necessitated interference in colored women. Indeed, the simple flat pelvis is the most important variety of pelvic contraction in white women, as it frequently happens that such pelves presenting so relatively long a diagonal conjugate as 10 to 10.5 cm. sometimes give rise to serious dystocia and lead to the birth of a number of dead children before the patient comes into the hands of a competent obstetrician. Furthermore, it is interesting to note that the various types of contracted pelvis, due to factors other than rickets, were observed much more commonly in the white women, notably the generally contracted, funnel, and chondrodystrophic pelves.

Non-Pelvic Indications

Passing to the non-pelvic conditions, it will be seen that eclampsia offered the indication for section in 9 instances, and was of approximately equal frequency in the two races. This is neither the time nor the place to consider the justifiability of the treatment of eclampsia by tliis means, although I may say briefly that it is exactly in connection with this indication that the operation is being greatly abused, and that I expect to employ it much less frequently in the future than I


have in the past. With my present experience I hold that Csesarean section is indicated in the treatment of eclampsia only when the cervix is rigid and undilated and the patient has failed to show any improvement after venesection.

The next most common indication was afforded by heart disease, which was present in eight instances — in six whites and two blacks. In each instance the patients were suffering from marked decompensation, which had failed to yield to medicinal treatment, so that the operation was undertaken as a last resort and in the hope that by avoiding the strain of the second stage of labor the life of the patient might be preserved. As in most of these cases the lesion was a mitral stenosis, which might be expected to become worse with succeeding pregnancies, it was felt that such a possibility should be obviated by a sterilizing procedure, and consequently the operation was usually terminated by amputation of the uterus or by some operation upon the tubes.

The mere enumeration of the other non-pelvic indications in the table suffices to indicate that they were of such character as not to require extended comment, except in the case of the three sections for neglected transverse presentations and the one for placenta praevia. Generally speaking, it may be said that Csesarean section is not indicated in the former condition unless such a degree of pelvic deformity is present as to render version and extraction out of the question. Is the three cases here mentioned, however, quite different conditions obtained. In each instance the patient was a multipara with a normal pelvis who had previously had a number of normal spontaneous labors, but who had been so neglected that after a long labor she had been admitted to the service with an arm protruding from the vulva, the uterus tetanically contracted, but with the child in excellent condition. Under such circumstances version and extraction were out of the question, and the alternative lay between decapitation of the Uve child and Csesarean section. Furthermore, owing to the fact that the patients had been repeatedly examined by ignorant physicians or midwives, it was felt that the probability of infection was so great that if a section were done the uterus must be sacrificed. Accordingly in each instance a Porro Csesarean section was performed and the patient made an uninterrupted recovery.

The single case of placenta prsevia also deserves mention, especially as the patient is the only one in my experience who has seemed to justify the employment of Ceesarean section in connection with this complication. Of coiirse, I have realized for years that in rare instances, when the cervix is rigid and undilated and the bleeding profuse, Csesarean section will offer the most favorable prospect for safe delivery in complete placenta praevia. The rarity of such a combination of circumstances is shown by the fact that in the 66 cases of placenta praevia observed in the service, this was the only one in which Cfesarean section appeared indicated, and strange to say, the death which followed it constitutes one of the few fatalities associated with that complication. In this instance the patient was a very anaemic elderly primipara vrith advanced chronic nephritis, and, as has already been indi


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cated, died on the eighth day following the operation, the autopsy showing that death had resulted from the underlying chronic nephritis rather than from infection or loss of blood. Generally speaking, I believe that Caesarean section should play only a very minor part in the treatment of placenta praevia in the hands of competent obstetricians, and I contend that the use of the rubber bag will give almost ideal results. That this has been the case in our hands, is shown by the fact that only one maternal death occurred in the last 40 cases treated by that method.

POREO CESAREAN SECTION

Reverting to the consideration of the Porro Cesarean section, it will be noticed that the operation has been employed relatively frequently, and constitutes nearly one-third of our total number of sections (57 out of 183). Its frequent utilization has been in great part due to one of two factors. First, that it has been followed by uniformly good results, particularly in the presence of manifest or latent infection, and second, that we have regarded it as the most efficient and safest means of effecting sterilization, more particularly as a large nvunber of our patients are colored women of relatively low intelligence in whom we have felt that an unlimited number of repeated Cesarean sections was not justifiable.

In considering the 57 Porro sections in greater detail, it is found that in 36 instances the uterus was removed as a primary procedure following the delivery of the child, while in 21 it was removed at a second or third Caesarean section. The following table gives the indications for the primary operations :

Cases

Late second stage, or manifest intrapartum infection. . .9

Sterilization 6

Heart disease 5

Atresia of cenix 4

Transverse presentation 3

Uncontrollable haemorrhage 2

Rupture of uterus in service 2

Dystocia following ventral fixation 1

Pregnancy in rudimentary horn of uterus 1

Hour-glass contraction of uterus 1

Myoma of cervix 1

Apoplexy of uterus incident to premature separation

of placenta 1

Total 36

I shall discuss each group as briefly as possible. In view of what has already been said, the nine cases in which the operation was performed late in the second stage of labor need little consideration, as it has already been demonstrated that in such circumstances the operation may be regarded as a lifesaver. Seven of the nine uteri in this group were examined microscopically after amputation, and four of them presented positive evidence of ascending infection, so that, had the uterus been retained, the probabilities are that many of the patients would have died from infection by the end of the first week.


In the six instances in which the uterus was removed for the purpose of sterilizing the patient, the indication was offered either by the direct request of the patient or by the existence of such deformity or so low a grade of intelligence that I felt that it was a service to the state to prevent further pregnancies.

Serious cardiac decompensation was the indication for five operations (5709, 5773, 6753, 7705 and 7832). In each instance the condition of the patient was so serious that the operation was undertaken from a double point of view: first, to carry her over the present emergency, and second, to prevent the exacerbation which must inevitably occur in future pregnancies.

In four instances (1788, 2757, 5381 and 6801) the indication for amputation of the uterus was afforded by pronounced atresia of the cervix. In three patients the condition had followed g}Tiecological operations upon the cervix which had been performed elsewhere, while in the remaining patient no clue to the etiology of the condition could be elicited. In each instance there was no visible opening in the cervical region, which might serve as a basis for a vaginal operation, but the main indication for the radical procedure was afforded by the fact that all of the women presented signs of intrauterine infection upon admission to the service, which was afterwards confirmed by histological examination, so that it was felt that a conservative section would have seriously compromised the chances of recovery.

The three cases of neglected transverse presentation, in which the uterus was amputated in preference to decapitating a live child, have already been considered and call for no further comment (5238, 5418, 6708).

In two instances the uterus was removed on account of atony which did not yield to the ordinary methods of treatment (5051, 7072). In both patients it was intended to do a conservative section, and the uterine incision was closed in the usual manner in spite of more than the usual amount of bleeding. The uterus, however, remained so flabby and atonic, notwithstanding several injections of pituitrin and ergot, as well as vigorous mechanical stimulation, that it was felt imperative to remove it. In a third patient the uterus was amputated on account of the hemorrhagic disassociation of the uterine muscle following premature separation of the normally implanted placenta (7190). In this instance the uterus absolutely failed to contract and presented the consistency of wet chamois-skin, so that we were compelled to remove it from the primiparous patient after all the sutures had been laid.

It will be noted that we have classed as Porro sections two cases in which intrapartimi rupture of the uterus occurred in the service, and in which immediate operation was performed (6838 and 7692). In one of these rupture occtirred five hours after the onset of labor in a secundipara -^vith a slightly contracted pelvis, whose previous labor had ended spontaneously. The second rupture resulted from the impaction of an ovarian cyst in the pelvic cavity in a multiparous woman. In both instances the uterine wounds were so exten


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sive and complicated that amputation of the uterus seemed to afford the most appropriate means of meeting the situation. The two cases in which the uterus was amputated on account of a full-term pregnancy in the rudimentary horn of a bicornate uterus (2823), and on account of a large myoma of the cervix, which completely blocked the pelvic canal and rendered spontaneous labor impossible (6384), need no justification.

In another instance the uterus was removed in order to overcome the dystocia resulting from ventral fixation (Case 2479). This patient had a normal pelvis and had previously given birth spontaneously. The existence of dystocia was not recognized until late in labor, when examination showed that the anterior wall of the uterus had become " buckled " in such a manner as to prevent engagement of the head, while at the same time the uterine cavity had become divided into two compartments, the anterior of which was occupied by tlie feet of the child, which were in such a position as to be just beyond the reach of the hand of the operator so that version could not be effected. The uterus was amputated, on account of the extensive manipulation, and microscopic examination demonstrated that it was a wise decision, inasmuch as definite evidences of ascending infection existed.

The last primary Porro Cesarean was indicated by the rare condition of hour-glass contraction of the uterus (Case 10840). In this instance a bag had been introduced for the purpose of inducing labor in a patient who had gone some days beyond term. After its expulsion, labor came to a standstill, and signs of intrapartum infection developed. The half dilated cervix presented swollen and cedematous margins, so that prompt delivery seemed indicated. The resident obstetrician introduced his hand into the uterus with the intention of completing manually the cervical dilatation, but found that the contraction ring was so tightly clamped about the neck of the child that it seemed unlikely that it could be delivered even after the cervix had been dilated. In view of these conditions, Caesarean section seemed imperative, and on account of the existing infection, as well as the extensive manipulation to which the patient had been subjected, removal of tlie uterus appeared to be the only procedure justifiable. A live child was obtained and the patient made an ideal recovery.

The following list gives an idea of the indications for the Porro operation in the 21 cases in wliich the uterus was amputated at a repeated section :


Late second stage 4

Sterilization 1

Impetuosity of operator

Tearing of uterine incision

Rupture of scar of previous section

Fear of rupture of scar of previous section

Extensive raw area up on anterior wall of uterus. . . . Blocking of vulva by condylomata


Total 21

These cases can be disposed of briefly. In the first group, the operation was fully justified by the microscopic demon


stration of an ascending infection in each of the amputated uteri. Of the 11 cases in which sterilization was the indication for the operation, the histories show that in seven the uterus was amputated at the repeated section at the direct request of the patient; wliile in the other four sterilization was effected at the third section upon my own initiative, as I felt that women who have had three sections had fulfilled their reasonable duty to the state.

In the case designated as " impetuosity of operator " (1548), the uterus was amputated by a former resident during my absence. The operation was performed before the onset of labor, and a small child was delivered, which might have been born spontaneously. It is interesting to note that this is the case in which the patient died from haemorrhage on the operating table, and represents the only death in the entire series attributable to the Porro operation.

In Case 6939 the indication for removing the uterus at the second section was accidental, as we had expected to do a conservative section, but in extracting the child the lower end of the uterine incision tore downward beneath the peritonemn of the broad ligament, and so complicated a wound resulted that it seemed more conservative to remove the uterus than to attempt to repair it.

In Case 7570 the uterus was removed on account of rupture of the scar of the previous section during the eighth month of pregnancy. The details of this accident will be described by Thomas 0. Gamble in an article on the " Behavior of the Uterine Cicatrix following Cesarean section" which will shortly appear, and is of interest from two points of view — first, that it is the only occurrence of the kind in 48 women upon whom repeated sections have been done in the service, as well as in 12 other women who were delivered by the natural passages subsequent to " a preceding section, and secondly, on account of the comparatively trifling symptoms associated with the accident.

In Case 8697 the uterus was removed through an excess of caution, but also at the expressed desire of the patient. In this instance infection followed the first section, wliich had been done elsewhere, and resulted in the formation of an extensive utero-abdominal fistula. This was eventually repaired, and necessitated an extensive resection of the uterine wall which was closed with silk sutures. The patient soon afterwards became pregnant and came to us for a second section at which we amputated the uterus with the idea that the cicatrix of the former operation might be a source of danger in future pregnancies, but when the specimen was examined microscopically no trace of tlie cicatrix could be found, except a fine linear scar upon its anterior wall. This specimen also will be described by Dr. Gamble.

In another instance (10758) the indication for operation was afforded by the fact that following the first section such intimate and extensive adhesions had developed between the uterine wall and the intestines that, after they had been freed, a raw area the size of the pahn of one's hand remained upon the anterior surface of the uterus. As it could not be covered with peritoneum, it was felt that still more extensive adhe


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sions would result if the uterus were retained, and consequently it was amputated.

Finally, in the last case of the series (9323) the uterus was removed on account of fear of infection at the second section. In this instance the vulva was entirely occluded by large condylomatous masses bathed by purulent secretion, and it was felt that the chances of infection would be excessive if the uterus were retained.

Upon considering these various indications in a critical spirit, it may be admitted that we have perhaps employed the radical operation too freely as a means of effecting sterilization, and within the last few years we have attempted to restrict its emplojonent for tliat purpose by resecting the tubes and retaining the uterus. We now ask women who request sterilization, or whom we feel should be sterilized, whether they wish to continue to menstruate or not after the last section. It they reply in the affirmative, sterilization is effected by doubly Hgating the tubes and burying their uterine ends between the folds of the corresponding broad ligament ; but, if they reply in the negative, I still continue to remove the uterus as the safest and most efficient method of relieving the existing situation and of effecting definitive sterilityv

Possibly, a similar criticism may be made concerning certain of the cases in which the patient was steriUzed on account of broken compensation. It may, however, be stated that in such cases haste is imperative, and we are able to amputate the uterus in a shorter time than is required for a conservative Caesarean section followed by a sterilizing operation upon the tubes. Likewise, certain of the operations which were done for some of the less common indications may be open to criticism, but each such case must be judged upon its own merits, and the justifiability of the procedure must depend upon the personal judgment and experience of the operator. In general I feel, notwithstanding certain very manifest limitations, that the Porro Caesarean section still remains tlie safest means of delivering the patient, and I must confess that I perform it whenever a suitable opportunity presents. It should, however, be realized that its prime indication is when Caesarean section is required late ia labor and particularly when signs of intrapartum infection are present. In such circumstances, it is universally admitted that the mortality following the typical conservative section is too high for it to be considered a justifiable procedure, and we then have to decide whether it is better to remove the uterus and thereby do away with the possibility of future pregnancies, or to perform craniotomy upon a live child. Doubtless, such a problem will be approached differently according to one's own experience and predilections, and it must be admitted that in the future such a choice may not be necessary, particularly if the claims of the advocates of the several varieties of so-called extra-peritoneal Csesarean section are borne out; but, until they are, I shall continue to do the Porro operation in the type of cases under consideration. From my experience with the typical extraperitoneal Caesarean section, I should certainly hesitate to resort to that complicated procedure in any instance in wliich the patient is presumably already infected.


as I cannot conceive of more favorable conditions for the spread of infection than the extensive broad ligament wounds which are made in the course of that operation.

EVISCERATION OF THE UtEEDS

In studying critically the convalescence following our series of Caesarean sections, a number of factors have been encountered which may influence its course. The first which may be mentioned is the effect upon the course of the puerperium of the old practice of eviscerating the uterus before incising it. It will be recalled that during evolution of the modern Caesarean section the possibility of severe, or even fatal, haemorrhage from the incised uterus was constantly in mind. For this reason it was originally the practice to attempt to control haemorrhage by applying a constricting rubber ligature about the cervix before opening the uterus. This, of course, necessitated eviscerating the undelivered organ througli a long abdominal incision. After experience had taught tliat the application of the ligature was not necessary, the practice of eviscerating the uterus was continued for a time so that an assistant could compress the lower segment manually, and thereby control the flow of blood through the uterine arteries when necessary.

Upon studying the histories of our patients we find that the uterus was eviscerated in 26 conservative sections prior to 1911. After that date a smaller abdominal incision was made, and the uterus was incised in situ and not delivered until after the cliild had been extracted. Upon comparing the convalescence following the two procedures, it was found that the puerperium was afebrile in 31.8 per cent of the former as compared with 51.6 per cent of the lattcB. Wliether evisceration of the uterus ever led to the death of a patient it is impossible to state, but it is readily understood how it favored the possibility of infection, as the bulky imemptied uterus inevitably came into intimate contact with the external abdominal wall, and was likewise handled more extensively than when it is incised in situ. At present we eviscerate the uterus only in patients showing signs of intrapartum infection in whom the organ is to be amputated after the deUvery of the child. In such cases the abdominal wound is brought together by clamps above the cervix, and by the use of gauze packs the peritoneal cavity is still further protected against contamination by the infected liquor amnii.

Since abandoning the practice of evisceration a much smaller abdominal incision has been necessary, and I usually prefer to make it below the umbilicus. My preference for this low incision, rather than for the high one advocated by Asa B. Davis or for one extending midway above and below the umbilicus as advocated by others, is that it is sufficiently large for the extraction of the child, and at the same time permits accurate exploration of the pelvic contents, as well as amputation of the uterus should an unexpected necessity for a radical operation arise. Wliereas, with the high and midumbilical incisions the abdominal wound must be extended downward before the pelvic contents become accessible.


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Suture of Uteeine Incision Passing to the method of suturing the uterine incision, it is found that considerable divergence in practice prevailed during the early and later periods of the series. In the early eases the uterine incision was closed with deep, interrupted silk sutures, which passed down to but did not include the decidua. After a wliile we began to use fine interrupted silk sutures between the deep sutures, in order to secure better approximation of the peritoneal layer ; a little later catgut was substituted for silk, and finally, the method was evolved which is now employed. For years we have laid the greatest stress upon the manner in which the uterus is sutured and are well satisfied with the following procedure: As many deep interrupted chromic catgut sutures as necessary are laid. These extend through the bulk of the muscle, but do not include its superficial layer or the peritoneal covering. If, after they are tied and cut, there is any gaping of the muscle between the sutures, a continuous catgut suture brings together the gaping points; and finally, the peritoneum and superficial muscle are brought together with a single continuous catgut suture, which completely buries the knots of the deep sutures and brings the peritoneal edges into the closest approximation.

Our records show that the uterine incision was closed with silk in 20 and with catgut in 106 conservative sections. As witli but few exceptions, silk sutures were employed at the same time as evisceration was practised, it is impossible to draw definite conclusions as to whether the employment of the former had any influence upon the course of the puerperium, or whether the comparatively poor results obtained at that time was associated with the evisceration of the organ, and particularly with the selection of patients for operation.

Rupture of Cicatrix in Subsequent Pregnancy Closely alhed with the question of suturing the uterus is the consideration of how the resulting scar will stand the distention incident to subsequent pregnancies. A voluminous literature has accumulated upon the subject, and it is generally believed that the scar yields in from 3 to 5 per cent of subsequent pregnancies, when the uterine contents are extruded into the abdominal cavity with the result that the child is inevitably lost and the mother perishes from infection or hEemorrhage unless promptly operated upon. Of course, this accident depends in part upon the manner in which the uterus was orginally sutured, and particularly whether its healing was complicated by infection. The possibility of its occurrence has been so emphasized that the dictum " once a Caesarean, always a Caesarean " has obtained very general acceptance. In our experience, however, the danger of subsequent rupture has proved to be less than is generally believed, and we attribute its relatively infrequent occurrence to the care with which we have closed the uterine incision. Rupture occurred but once in 48 women who had repeated sections in the service, as well as in 12 others who were delivered by the natural passages following a previous section.


An interesting point in this connection is that in many of the repeated sections no trace of the cicatrix of the previous section could be noted on inspecting the unopened uterus at the second or third operation; while in other instances the only evidence of it consisted in adhesions over the anterior surface of the uterus, which apparently involved the old scar. So far as I can recall, with the exception of the actual case of rupture, signs of stretching of the cicatrix were noted in only a single uterus before it was incised at the subsequent section. On the other hand, when we came to study the conditions obtaining in the 21 uteri which were amputated at a final section, we found a varying condition of afEairs. In many instances no trace of the cicatrix could be observed; in others the site of the previous incision was marked by a shallov? depression upon the inner or outer surface of the uterus ; while in a still smaller number a longitudinal depression upon both its outer and inner surfaces marked its site, and had led to a greater thinning of the uterine wall there than elsewhere. Microscopic examination, however, showed that, irrespective of the gross appearance of the cicatrix, no trace of scar tissue remained, and that the muscle fibers crossed the site of the original incision as if it had never been made. I shall not enter into details concerning this subject, for the reason that my assistant. Dr. Thomas 0. Gamble, is now engaged in an extended study of all of its phases.

Site of Placental Implantation Many writers upon Cesarean section advise that every effort should be made to locate the situation of the placenta in order that the uterine incision may be made in such a location as not to involve it. Although for years we have made it a rule to attempt to locate before operation the situation of the placenta by determining the course of the round Ligaments, and still continue to do so as a matter of diagnostic interest, we make no attempt to avoid the placental site, and as a matter of routine incise the uterus in the midline of the lower part of its anterior wall, except in the rare instances in which it is so pendulous that its posterior wall lies in contact with the anterior abdominal wall.

At the same time, figures concerning the location of the placenta may be of interest, and analysis of the notes which were available in 157 operations gives the following results: posterior implantation, 94, anterior implantation, 62, placenta prffivia, 1. In other words, anterior implantation was observed in 38 per cent of tlie cases ; and, consequently, if the anterior wall be incised as a matter of routine, the placenta will be involved in two cases out of five.

As has been indicated above, we regard this as a matter of indifference, so that when the placenta lies anteriorly we cut through it and deliver the child through the wound, and the only difference which we have noted is that in such cases there is a profuse preliminary gush of blood, which ceases as soon as the child is extracted and the uterus begins to retract. So far as the convalescence is concerned, our notes show no difference between the cases in which the placenta was incised and those in which it was not.


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Use of Pituitary Extract For many years it was our habit, as soon as the abdominal wall was incised, but before opening the uterus, to inject two barrels of ergotol into the arm or thigh of the patient for the purpose of stimulating the retraction of the uterus and thus preventing bleeding. When pituitary extract came into use we employed it in preference to ergotol. In several instances, however, in which it was necessary to free dense adhesions the action of the drug became manifest before we were ready to incise the uterus, with the result that it became tetanically contracted, and seemed to interfere with the placental function. While this had no serious consequences, we thought it safer to defer employing it until the uterus had been incised, and we then developed the custom of injecting 2 c. c. directly into the uterine substance whenever the uterus did not contract satisfactorily or if the haemorrhage were excessive. Thus far no deleterious effects have been observed, but in view of the fact that apparently aseptic abscesses sometimes follow the injection of pituitary extract into the muscles of the tlugh, it must be assmned tliat sooner or later such an accident will happen when it is injected into the uterus, when, of course, its consequences may be serious. For this reason we have recently abandoned the practice and now inject the medicament into the muscles of the thigh as a routine procedure as soon as we are ready to incise the uterus.

CoNDiTiox OF Child It is usually stated that the Cassarean section child is born in an apnceic condition and sometimes is deeply asphyxiated. This is believed to be due in part to the transmission of the anaesthetic agent through the placental circulation, and in part to the lack of friction which is normally associated with birth through the natural passages. Upon analyzing our histories I was surprised to find that such conditions were encountered less frequently than is ordinarily stated, and from the 145 histories which contained notes concerning the estabUslmient of respiration in the child, we have collected the following figures:

Cried at once 75 cases (51.7%)

Slightly asphyxiated 60 " (41.4%)

Deeply asphyxiated 10 " ( 6.9%)

In 16 other cases the child was born dead, but in no instance could its death be attributed to the operation, as in all such cases the section was undertaken for the sake of the mother and quite irrespective of the condition of the child. Consequently, it appears permissible to conclude that if the child is aUve and in good condition when the operation is begun, it will be born aUve, after which its chances for prolonged life will be the same as after normal delivery.

Formation of Adhesions

Another point in connection with the convalescence from Csesarean section is the occurrence of adhesions between the uterine wound and other structures. In the old days, before aseptic technique had been developed and when the retraction


of the uterus was relied upon to check haemorrhage without the application of sutures, the formation of dense adhesions between the uterus and anterior abdominal wall was the rule. At that time this was so much the case that one expected in subsequent operations to deliver the child through a uteroabdominal fistula without opening the peritoneum.

So far as I can ascertain, no figures are available concerning the incidence of such adhesions following the modern technique, and although it is often possible by examination of the living woman to determine their existence, no accurate statement can be made as to their frequency. On the other hand, when repeated sections are done, definite conclusions can be drawn by noting the condition of affairs at the time of operation. Thus, upon analyzing the 48 such cases in our series we find the following :

Caaed

No note 2

No adhesions 12

Slight adhesions 10

Omental adhesions only 6

Broad adhesions 7

Dense adhesions 11

In other words, adhesions were absent in one-fourth, while broad or dense adliesions were present in one-third of the cases.

It is interesting to attempt to determine what relation, if any, the character of the convalescence bears to their formation, and whether a febrile puerperium favors their development. As in 10 instances the preceding section was done elsewhere, it is impossible to make any statement concerning the convalescence following it; but in 37 cases we have notes concerning the previous convalescence and the accompanying table summarizes the findings :

Convalescence, Normal Febrile

No adhesions 4 7

Slight adhesions 3 7

Omental adhesions 2 3

Broad adhesions 3 2

Dense adhesions 2 4

14 23

In other words, the puerperium was normal in 38 and febrile in 62 per cent of the eases, and adhesions of the various types occurred after each, but were nearly twice as frequent after a febrile convalescence. It is, therefore, apparent that while a febrile puerperium appears to favor their formation, an afebrile puerperium does not necessarily insure their absence. This being the case, it seems justifiable to inf»r that the occurrence of adhesions is not always the result of actual infection, but may quite as well be associated with the presence of raw surfaces resulting from defective methods of suturing the uterus, or from other traimiatic factors. Such a conclusion is only hypothetical, but a certain degree of probability is lent to it upon considering the differences observed according as the first section was done elsewliere or in our service, as it may be assumed that it is possible that other operators sutured tlie uterus less carefully than we. Thus, broad or dense adhesions were noted in seven out of the nine


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operations done elsewhere, as compared with 11 in the 37 cases done here. In other words marked adhesions developed in 76 and 30 per cent of the two groups respectively.

Corpus Luteum and Sex of Child From the time of Hippocrates to Rumley Dawson, many writers have believed that boys are derived from ova originating in the right and girls from those in the left ovary. Since our attention had been directed to this point, we have made it a practice at Caesarean section to examine the ovaries carefully, and to note whether the corpus luteum was visible, and, if so, in which ovary it was situated. Notes to tliat eflEect were made at 99 operations, and upon analyzing them it was found that no corpus luteum was discoverable in one-third of the cases, while it was present in the other two-tliirds.

When the corpus luteum was present in the right ovary 23 boys and 13 girls were noted, as compared with 16 boys and 12 girls when it was situated in the left ovary. In other words, in our experience, more boys than girls were obtained, irrespective of whether the corpus luteum was in the right or in the left ovary, and thus convincing evidence is adduced against the correctness of the theory that boys are derived from one and girls from the other ovary^

An interesting point in connection with these figures is that they demonstrate very clearly the fallacy of attempting to draw conclusions from too small a number of cases. For example, in the 64 cases in which the corpus luteum was present and the sex of the child was noted there were 25 girls and 39 boys, a ratio of 100 to 158, as compared with the normal of 100 to 106. With such figures at hand, an incautious person might be tempted to draw various erroneous conclusions, as for example that the existence of contracted pelvis or of some other condition which necessitates Caesarean section may lead to a predominance of boys. That such a conclusion is unjustifiable, is shown by the fact that when the entire number of sections was considered the ratio of girls to boys was 100 to 107, which closely approaches the normal, and indicates that the former abnormal ratio was entirely accidental and of no particular significance.

Conclusions

1. This analysis is based upon 183 Cssarean sections performed upon 145 women up to December 31, 1920.

2. The operations were done in a series of approximately 20,000 deliveries, and comprise 104 single, and 79 repeated sections. The latter were done upon 41 women, 34 of whom had two, and 7 three sections each.

3. Although the number of white and black patients in the service was approximately identical, many more Cesarean sections were done upon the latter — 114 to 69, while 30 to 11 required repeated sections.

4. The following types of operation were done :

121 typical conservative sections. 4 extraperitoneal sections. 1 postmortem section. 57 Porro sections.


5,. The gross mortality was 5.46 per cent, but, upon deducting the cases in wliich death was not attributable to the operation, the net mortality was 3.45 per cent; or 4.07 per cent in the conservative and 1.82 per cent in the Porro sections.

All deaths, except one from htemorrhage were due to infection.

6. The mortality was 13 times greater in the first 50 than in the last 133 cases — 10 to 0.77 per cent. This remarkable diminution was not due to changes in operative technique, but to the avoidance of ascending infection by operating before the onset of or during the first hours of labor.

7. The conservative section late in labor is always dangerous, even if vaginal examinations have not been made ; while the Porro section is relatively safe. The most important means of lowering the mortality of conservative Cesarean section due to disproportion is by learning to determine before the onset of labor whether operation will be required or not.

8. Tlie Porro operation is relatively safe even in infected or exhausted patients, as the absence of the involuting uterus hinders the spread of infection.

9. Disproportion due to contracted pelvis was the indication for interference in nine-tenths of the black, and in six-tenths of the white patients.

10. The several varieties of rachitic pelvis afl'orded the predominant indication in the blacks, as compared with the simple flat pelvis in the whites.

11. The most frequent non-pelvic indications were eclampsia and serious cardiac decompensation.

12. Cesarean section is not the ideal treatment for eclampsia, and is indicated only in the rare instances in which the cervix is rigid and undilated and venesection has not led to improvement.

13. It is likewise only rarely indicated in placenta previa. We have done but one section in 66 eases, and regard the rubber balloon as the best treatment.

14. Generally speaking the patient should be sterilized at the third section, either by amputating the uterus or by an operation upon the tubes.

15. We make the abdominal incision below the imibilicus, as it permits amputation of the uterus or operations upon the appendages, when necessarj', without extending tlie incision.

16. The uterus should be incised in situ, and eviscerated before incision only in the presence of infection. Our experience indicates that in normal cases the latter procedure increases the incidence of infectioru

17. The uterine incision should be sutured in layers, and the greatest care taken to insure the closest approximation of the peritoneal margins.

18. The uterine cicatrix ruptured once in 48 women with repeated sections, as well as in 12 deliveries through the natural passages subsequent to section. The frequency of its occurrence is probably exaggerated, so that the dictum " once a Caesarean always a Caesarean " is not necessarily correct.


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On the other hand, the possibility of rupture must always be faced and constitutes the strongest argument against the unnecessary employment of Cassarean section for non-pelvic indications.

19. The placenta was inserted upon the anterior wall of the uterus in two out of every five of our cases. Consequently, it is frequently involved in the uterine incision. This has no other significance than a momentary gush of blood.

20. The delivery of an asphyxiated child occurs less frequently than is generally believed. Somewhat over one-half of our children cried immediately after delivery, and only 7 per cent were deeply asphyxiated.

21. Notwithstanding the extraordinary value of pituitary extract in stimulating uterine contraction, pronounced atony with danger of death from hsmorrhage is stiU to be reckoned with, and necessitated amputation of the uterus in two of our patients.

22. Uterine adliesions were absent in one-quarter of our repeated sections, and were extensive in one-third of them. They are not necessarily the result of infection, as the puerperium was normal in 36 per cent of the cases in which they developed. In many instances they appear to be associated


with imperfect approximation of the uterine wound or with other traumatic factors.

23. The old superstition that boys originate from the right and girls from the left ovary can be definitely discarded. In two-thirds of our patients the corpus luteum persisted until the end of pregnancy, and its location bore no relation to the sex of the child.

24. Finally it should be remembered that Csesarean section is not devoid of danger, and is relatively safe only when done under appropriate conditions before the onset or during the first hours of labor.

As the uterine cicatrix constitutes a loctis minoris resistenti(B in subsequent pregnancies Csesarean section for other than pelvic indications should be performed only when absolutely necessary.

It is my conviction that the operation is being abused throughout the country, and if accurate statistics as to its results were available that it would be found to be accountable for many unnecessary maternal deaths.

It should be recognized that, although -it is frequently the easiest manner of delivering the patient in the presence of various abnormalities, it is not always the safest, and that ideal results are obtained in only a few clinics.


MODERN METHODS IN HANDLING HOSPITAL STATISTICS'


By Raymond Pearl,

Statistician to The Johns Hopkins Hospital


I. Introduction

To an ever-increasing degree modern science is becoming quantitative in its methods of thought and activity. The history of science from the beginning shows that the earliest development of any discipline is purely qualitative and that only as it emerges from this state and passes over into the quantitative phase, in greater or less degree, does it begin to take an assured place in the hierarchy of the established sciences. Recent examples of this change from a qualitative point of view are found in psychology and sociology. With the development of knowledge and of an appropriate technique eventually any natural phenomenon which can be observed can also be quantitatively measured. The entire history of medicine shows that there has been almost from the first an earnest desire and efl'ort, on the part of some of its leaders, to develop quantitative modes of thought and methods of work. The large measure of progress which has been made in this direction is sufficiently evidenced by the number of items of diagnostic and clinical significance wliich are measured and recorded in quantitative terms.

The analytical treatment of the quantitative data of medicine has developed far more slowly than the appreciation and collecting of the data themselves. This fact is neitlier surprising nor peculiar to medicine. Only in the last decade of

'Papers from the Statistical Department of The Johns Hopkins Hospital, No. 1.


the nineteenth century with the pioneer work of Galton, Weldon and Pearson, did there begin the application of really adequate statistical methods to any sort of biological problem. Since that time the development has been very rapid in many of the fields of general biology. In medicine there have been differences of opinion, as would be expected, between leaders, as to the significance and importance of a really scientific statistical calculus in the field of medicine. The reactionary and the progressive viewpoints in this regard cannot be better set forth than in the following quotations from two clinicians of the foremost rank. In 1912 Sir Almroth AVright, in discussing the statistical method, said: '

These general considerations have prepared the way for bringing forward the suggestion that the ordeal ot minutely accurate quantitative statement which is always floating before the vision of the statistician should in the field of clinical medicine be frankly abandoned. This would mean recognizing that it is, in medicine, impossible by the method of cumulative experiments either (a) to detect minute differences, or (b) to arrive in any case at an accurate

quantitative conclusion Where there is a conflict of opinions

between observers the proper course to pursue is to appraise the relative weight of the authorities who are ranged over against each other.'


^Wright, A., and others. Observations on the pharmaco-therapy of pneumococcus infection. Lancet, 1912, (2), pp. 1701 and 1704.

^ It should be pointe