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

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Vol. VIII. - No. 70.
 
  
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Talk:The Johns Hopkins Medical Journal 8 (1897)
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http://www.archive.org/details/johnshopkinsmedi08john
  
BALTIMORE, JANUARY, 1897.  
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BULLETIN OF THE JOHNS HOPKINS HOSPITAL.
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Vol. VIII. - No. 70.
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BALTIMORE, JANUARY, 1897.
  
  
Line 25: Line 41:
 
Contents
 
Contents
  
Presentation of Thorwaldsen's Statue of Christ to the Hospital, 1  
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Presentation of Thorwaldsen's Statue of Christ to the Hospital, 1
  
The Bacilhis Proteus Zenker! in an Ovarian Abscess. By  
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The Bacilhis Proteus Zenker! in an Ovarian Abscess. By Hunter Robb, M. D., and Albert A. Ghriskey, M. D., - 4
Hunter Robb, M. D., and Albert A. Ghriskey, M. D., - 4  
 
  
  
  
The Phrenology of Gall and Flechsig's Doctrine of Association Centres in the Cerebrum. By Lewellys F. Barker,  
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The Phrenology of Gall and Flechsig's Doctrine of Association Centres in the Cerebrum. By Lewellys F. Barker,
  
M. B., - - - - - 7  
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M. B., - - - - - 7
  
Notes on New Books, ......... 14,  
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Notes on New Books, ......... 14,
  
Books Received, 15  
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Books Received, 15
  
  
  
PRESENTATION OF THORWALDSEN'S STATUE OF CHRIST TO THE HOSPITAL  
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PRESENTATION OF THORWALDSEN'S STATUE OF CHRIST TO THE HOSPITAL
  
  
  
Oa Wednesday afternoon, October 14, 1896, at 3 o'clock, there  
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Oa Wednesday afternoon, October 14, 1896, at 3 o'clock, there was uuveiled in the rotunda of the Administration Building of the Jolms Hojjkins Hospital, in the presence of the trustees and officers and a large audience of invited guests. Stein's reproduction of Thorwaldsen's statue of Christ, a gift from William Wallace Spence, of Baltimore. Mr. Spence, in presenting the statue, spoke as follows:
was uuveiled in the rotunda of the Administration Building  
 
of the Jolms Hojjkins Hospital, in the presence of the trustees  
 
and officers and a large audience of invited guests. Stein's  
 
reproduction of Thorwaldsen's statue of Christ, a gift from  
 
William Wallace Spence, of Baltimore. Mr. Spence, in presenting the statue, spoke as follows:  
 
  
"I have but a few words to say on this occasion; merely to  
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"I have but a few words to say on this occasion; merely to state how it happens that this statue stands here.
state how it happens that this statue stands here.  
 
  
" On a visit to Copenhagen I saw the great work of Thorwaldsen, his ideal conception in marble, of ' Christ, the Divine  
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" On a visit to Copenhagen I saw the great work of Thorwaldsen, his ideal conception in marble, of ' Christ, the Divine Healer.' It impressed me more than did any statue I had ever seen, and I think this is the general experience of those who have the good fortune to see it. It was stated that Thorwaldsen himself said, ' I never was satisfied with any work of my own until I executed the Christ; now I am satisfied.' He felt that his genius had reached the zenith of its powers and that he could go no higher. Well might he be satisfied, for the grace, dignity and majesty of this figure have never been surpassed.
Healer.' It impressed me more than did any statue I had  
 
ever seen, and I think this is the general experience of  
 
those who have the good fortune to see it. It was stated that  
 
Thorwaldsen himself said, ' I never was satisfied with any  
 
work of my own until I executed the Christ; now I am satisfied.' He felt that his genius had reached the zenith of its  
 
powers and that he could go no higher. Well might he be  
 
satisfied, for the grace, dignity and majesty of this figure have  
 
never been surpassed.  
 
  
" Later on the thought came into my heart how eminently  
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" Later on the thought came into my heart how eminently appropriate it would be to have this ideal statue placed where it now stands, in the centre of this hall, under the lofty dome of this great hospital. To every weary sufferer entering these doors, the first object presented to him is this benign, gracious figure, looking down upon him with pitying eyes and outstretched arms, and as if it were saying to him, ' Come unto Me and I will give you rest' I thought it might help to comfort some sad and weai-y one, and lead his heart and thoughts up to the ever-living Divine Healer, who alone could give that
appropriate it would be to have this ideal statue placed where  
 
it now stands, in the centre of this hall, under the lofty dome  
 
of this great hospital. To every weary sufferer entering these  
 
doors, the first object presented to him is this benign, gracious figure, looking down upon him with pitying eyes and outstretched arms, and as if it were saying to him, ' Come unto  
 
Me and I will give you rest' I thought it might help to comfort some sad and weai-y one, and lead his heart and thoughts  
 
up to the ever-living Divine Healer, who alone could give that  
 
  
  
  
rest. With this feeling I asked permission of the trustees to  
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rest. With this feeling I asked permission of the trustees to present this statue to the hospital. It was cordially given, and at once I placed an order with Professor Stein, the eminent sculptor and Director of the Royal Academy of Art in Copenhagen, and there it stands. How well he has executed it you will judge.
present this statue to the hospital. It was cordially given,  
 
and at once I placed an order with Professor Stein, the eminent sculptor and Director of the Royal Academy of Art in  
 
Copenhagen, and there it stands. How well he has executed  
 
it you will judge.  
 
  
"A few years ago, at the formal opening of the Hospital,  
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"A few years ago, at the formal opening of the Hospital, President Gilman expressed the hope that some day it might stand there. To-day his hope is realized. And now, Mr. President, I beg to present this statue to the Johns Hopkins Hospital."
President Gilman expressed the hope that some day it might  
 
stand there. To-day his hope is realized. And now, Mr.  
 
President, I beg to present this statue to the Johns Hopkins  
 
Hospital."  
 
  
The statue was then unveiled by little Emily Riggs, an  
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The statue was then unveiled by little Emily Riggs, an infant great-granddaughter of Mr. Spence.
infant great-granddaughter of Mr. Spence.  
 
  
Mr. W. T. Dixon, the President, in behalf of the Board of  
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Mr. W. T. Dixon, the President, in behalf of the Board of Trustees of the Hospital, accepted the gift in the following words :
Trustees of the Hospital, accepted the gift in the following  
 
words :  
 
  
" Mr. Spence — It gives me very great pleasure to accept, in  
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" Mr. Spence — It gives me very great pleasure to accept, in behalf of the Board of Trustees of the Johns Hopkins Hospital, your generous gift, this beautiful and impressive statue, and to assure you of our appreciation of your motives and munificence.
behalf of the Board of Trustees of the Johns Hopkins Hospital,  
 
your generous gift, this beautiful and impressive statue, and to  
 
assure you of our appreciation of your motives and munificence.  
 
  
"These grateful feelings of the trustees, I am confident, will  
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"These grateful feelings of the trustees, I am confident, will be cordially shared by all the workers in every department of the Hospital, by our many friends throughout the country, as well as by the sick and suffering who may come under our care.
be cordially shared by all the workers in every department of  
 
the Hospital, by our many friends throughout the country, as  
 
well as by the sick and suffering who may come under our  
 
care.  
 
  
" You have most appropriately placed this ' Divine Healer '  
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" You have most appropriately placed this ' Divine Healer ' just where it can be seen by all who may enter the doors of the Hospital, thus affording them the opportunity to derive comfort, courage and hope from its contemplation. And not only are the outstretched hands of this Christus Consolator
just where it can be seen by all who may enter the doors of  
 
the Hospital, thus affording them the opportunity to derive  
 
comfort, courage and hope from its contemplation. And not  
 
only are the outstretched hands of this Christus Consolator  
 
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
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JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
[No. 70.  
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[No. 70.
  
  
  
held out to this company, this community and the people of  
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held out to this company, this community and the people of this age, but they will remain extended to tens of thousands of the generations yet to come.
this age, but they will remain extended to tens of thousands  
 
of the generations yet to come.  
 
  
" There are grave responsibilities and many discouragements  
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" There are grave responsibilities and many discouragements in maintaining and conducting a hospital, especially a hospital with the high aims and beneficent purposes of the one you are honoring to-day, and we cannot too earnestly assure you that such evidences of interest in our efforts to comfort the sick, relieve the suffering and advance knowledge, as come with your gift, are most encouraging and insj)iring to us all."
in maintaining and conducting a hospital, especially a hospital  
 
with the high aims and beneficent purposes of the one you  
 
are honoring to-day, and we cannot too earnestly assure you  
 
that such evidences of interest in our efforts to comfort the  
 
sick, relieve the suffering and advance knowledge, as come  
 
with your gift, are most encouraging and insj)iring to us all."  
 
  
The following hymn by Whittier was sung by a male  
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The following hymn by Whittier was sung by a male quartet :
quartet :  
 
  
" So stood of old the holy Christ  
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" So stood of old the holy Christ Amidst the suffering throng ; With whom his lightest touch sufficed To make the weakest strong.
Amidst the suffering throng ;  
 
With whom his lightest touch sufficed  
 
To make the weakest strong.  
 
  
That healing gift he lends to them  
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That healing gift he lends to them
  
Who use it in his name ;  
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Who use it in his name ; The power that filled his garments' hem
The power that filled his garments' hem  
 
  
Is evermore the same.  
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Is evermore the same.
  
For lo ! in human hearts unseen  
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For lo ! in human hearts unseen
  
The Healer dwelleth still,  
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The Healer dwelleth still, And they who make his temples clean
And they who make his temples clean  
 
  
The best subserve his will.  
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The best subserve his will.
  
That Good Physician liveth yet  
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That Good Physician liveth yet
  
Thy friend and guide to be ;  
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Thy friend and guide to be ; The Healer by Gennesaret
The Healer by Gennesaret  
 
  
Shall walk tlie rounds with thee."  
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Shall walk tlie rounds with thee."
  
President Gilman of the Johns Hopkins University, upon a  
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President Gilman of the Johns Hopkins University, upon a special invitation from the trustees of the Hospital, afterwards made the following address:
special invitation from the trustees of the Hospital, afterwards  
 
made the following address:  
 
  
We are assembled in the presence of one of the best works  
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We are assembled in the presence of one of the best works of modern Christian sculpture, — a transcendent theme, treated by an illustrious artist, in his noblest manner; a work, too, that has stood the test of more than seventy-five years without a word of censorious criticism. Canova saw it in Rome, while it was modeling by the artist, and praised it. The people of Copenhagen determined to have it. It was reproduced at Potsdam (Berlin) in front of the Church of Peace, near which the Emperor Frederic lies buried. A copy, in plaster, surrounded by the twelve apostles, from the same artist, was brought to New Yoi-k at least forty years ago and exhibited in what was known as the Crystal Palace or the World's Fair.
of modern Christian sculpture, — a transcendent theme, treated  
 
by an illustrious artist, in his noblest manner; a work, too,  
 
that has stood the test of more than seventy-five years without  
 
a word of censorious criticism. Canova saw it in Rome, while  
 
it was modeling by the artist, and praised it. The people of  
 
Copenhagen determined to have it. It was reproduced at  
 
Potsdam (Berlin) in front of the Church of Peace, near which  
 
the Emperor Frederic lies buried. A copy, in plaster, surrounded by the twelve apostles, from the same artist, was  
 
brought to New Yoi-k at least forty years ago and exhibited  
 
in what was known as the Crystal Palace or the World's Fair.  
 
  
But we have here, not the original cast in clay, nor a plaster  
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But we have here, not the original cast in clay, nor a plaster reproduction, nor one in galvano-plastic ; but we have a marble like that which Thorwaldsen himself touched with his chisel. The pose, the drapery, the figure, the outstretched arms, the head, the face, are reproduced for us with exactness by a living artist of Copenhagen.
reproduction, nor one in galvano-plastic ; but we have a  
 
marble like that which Thorwaldsen himself touched with  
 
his chisel. The pose, the drapery, the figure, the outstretched  
 
arms, the head, the face, are reproduced for us with exactness  
 
by a living artist of Copenhagen.  
 
  
We are greatly indebted to that honored citizen of Baltimore who has brought here a work which from so many  
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We are greatly indebted to that honored citizen of Baltimore who has brought here a work which from so many points of view delights and inspires us.
points of view delights and inspires us.  
 
  
This is not the first time that a hospital has been decorated  
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This is not the first time that a hospital has been decorated by a great work of art. If I remember rightly, Benjamin West painted the picture of " Christ Healing the Sick," for the Pennsylvania Hospital in Philadelphia; and, if I am not mistaken, in St. Luke's Hospital, New York, there is still a
by a great work of art. If I remember rightly, Benjamin  
 
West painted the picture of " Christ Healing the Sick," for the  
 
Pennsylvania Hospital in Philadelphia; and, if I am not mistaken, in St. Luke's Hospital, New York, there is still a  
 
  
  
  
famous picture by Daniel Huntington, "The Dream of  
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famous picture by Daniel Huntington, "The Dream of Mercy," based upon an incident in Buuyan's Pilgrim's Progress.
Mercy," based upon an incident in Buuyan's Pilgrim's  
 
Progress.  
 
  
Nor is this the first gift that this hospital has received. Its  
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Nor is this the first gift that this hospital has received. Its munificent endowment by Johns Hopkins has been strengthened by fuuds provided for the foundation of a school of medicine and surgery, which supplements the work of the Hospital. And minor gifts have come in. Not long ago we had a very small but noteworthy present, a likeness of Florence Nightingale. At another time a friend gave us models and pictures of various public institutions throughout the country. Again, one who loves medical biography and history has hung upon these walls a fine collection of the portraits of illustrious physicians and surgeons who in many countries and in many generations have adorned their profession. Eecently a large gift has enabled the trustees to provide better facilities for the instruction of those who are here engaged in preparing themselves for the profession of medicine or for nursing. And now we have this work of art which, perhaps, appeals to more of us than any of the other gifts, unless it be that touching memento of a departed child, the "White Eose Fund," which enables the Superintendent every year to distribute flowers to, and to provide for the entertainment of those who are convalescing in the Children's Ward.
munificent endowment by Johns Hopkins has been strengthened by fuuds provided for the foundation of a school of medicine and surgery, which supplements the work of the Hospital.  
 
And minor gifts have come in. Not long ago we had a very  
 
small but noteworthy present, a likeness of Florence Nightingale. At another time a friend gave us models and pictures  
 
of various public institutions throughout the country. Again,  
 
one who loves medical biography and history has hung upon  
 
these walls a fine collection of the portraits of illustrious physicians and surgeons who in many countries and in many  
 
generations have adorned their profession. Eecently a large  
 
gift has enabled the trustees to provide better facilities for the  
 
instruction of those who are here engaged in preparing themselves for the profession of medicine or for nursing. And now  
 
we have this work of art which, perhaps, appeals to more of  
 
us than any of the other gifts, unless it be that touching  
 
memento of a departed child, the "White Eose Fund," which  
 
enables the Superintendent every year to distribute flowers to,  
 
and to provide for the entertainment of those who are convalescing in the Children's Ward.  
 
  
Baltimore is fortunate in many ways in the gifts that are  
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Baltimore is fortunate in many ways in the gifts that are coming to it. We seem to have reached a period in the history of this city when its citizens are ready to adorn and decorate the place of their residence. Mr. Spence has presented a noble statue of William Wallace that stands in Druid Hill Park. Around the Washington Jlonument are the works of Barye, of Dubois, and of Story, and also the grand figure of Chief Justice Taney, perhaps the best portrait statue, with one or two exceptions, that has ever been produced in this country, the work of our own Rinehart. But pleasant as these tokens are, I must not dwell upon them, but must rather speak of the circumstances under which this work of Thorwaldsen was produced, and tell you some things regarding the sculptor.
coming to it. We seem to have reached a period in the history  
 
of this city when its citizens are ready to adorn and decorate  
 
the place of their residence. Mr. Spence has presented a noble  
 
statue of William Wallace that stands in Druid Hill Park.  
 
Around the Washington Jlonument are the works of Barye, of  
 
Dubois, and of Story, and also the grand figure of Chief  
 
Justice Taney, perhaps the best portrait statue, with one or  
 
two exceptions, that has ever been produced in this country,  
 
the work of our own Rinehart. But pleasant as these tokens  
 
are, I must not dwell upon them, but must rather speak of the  
 
circumstances under which this work of Thorwaldsen was  
 
produced, and tell you some things regarding the sculptor.  
 
  
The city of Copeijhagen, at the entrance to the " Sound," is  
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The city of Copeijhagen, at the entrance to the " Sound," is not a very large place; I should say not more than one-half or two-thirds the size of Baltimore (if size is measured by population) ; but it has a port, a university, a citadel, a harbor, and an academy of fine arts, the latter holding high rank among the academies of Europe. The city suffered greatly by the bombardment of 1807 during the Napoleonic wars, and it was not till some twelve or thirteen years afterward that an historic edifice, which had thus been destroyed, was reconstructed. This was the old church which bears the name of the " Frue Kirke." The sound would be more familiar to us if I called it Notre Dame, or the Church of Our Lady. Denmark, as you know, is a Protestant country, and this is a Lutheran church. I have heard it called a Presbyterian church, and I do not know that Mr. Spence will object to that. While in the process of reconstruction, the commissioners had a conference with Thorwaldsen, a native of Copenhagen, and arrangements were made by which he should model a statue of Christ. It was also agreed that the approach to the altar from the main portal should be lined with statues of the apostles, beginning with Peter and Paul. This arrangement was carried
not a very large place; I should say not more than one-half or  
 
two-thirds the size of Baltimore (if size is measured by population) ; but it has a port, a university, a citadel, a harbor,  
 
and an academy of fine arts, the latter holding high rank  
 
among the academies of Europe. The city suffered greatly  
 
by the bombardment of 1807 during the Napoleonic wars, and  
 
it was not till some twelve or thirteen years afterward that  
 
an historic edifice, which had thus been destroyed, was reconstructed. This was the old church which bears the name of  
 
the " Frue Kirke." The sound would be more familiar to us if  
 
I called it Notre Dame, or the Church of Our Lady. Denmark,  
 
as you know, is a Protestant country, and this is a Lutheran  
 
church. I have heard it called a Presbyterian church, and I  
 
do not know that Mr. Spence will object to that. While in  
 
the process of reconstruction, the commissioners had a conference with Thorwaldsen, a native of Copenhagen, and arrangements were made by which he should model a statue of Christ.  
 
It was also agreed that the approach to the altar from the  
 
main portal should be lined with statues of the apostles, beginning with Peter and Paul. This arrangement was carried  
 
  
  
  
January, 1897.]  
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January, 1897.]
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
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JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
out by the artist, then liviug in Home; and such is the origin  
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out by the artist, then liviug in Home; and such is the origin of the Christus Consolator upon which we are loolviug.
of the Christus Consolator upon which we are loolviug.  
 
  
Not far away from this church stands the Thorwaldsen  
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Not far away from this church stands the Thorwaldsen Museum, constructed by the people of Copenhagen for the reception of the casts of all or nearly all the works that Thorwaldsen made. This museum was subsequently endowed by him with a very considerable sum of money, and now constitutes his monument. In the interior court his body lies buried.
Museum, constructed by the people of Copenhagen for the  
 
reception of the casts of all or nearly all the works that Thorwaldsen made. This museum was subsequently endowed by  
 
him with a very considerable sum of money, and now constitutes his monument. In the interior court his body lies  
 
buried.  
 
  
Now perhaps you would like me to tell you regarding the  
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Now perhaps you would like me to tell you regarding the artist himself. Perhaps I may mention two or three things that will connect him with this country. Those of us who have watched the ships coming in and going out of a great harbor, as I did in my boyhood in New York, remember how common it was to see ships with carved beaks, often quite well wrought. Now Thorwaldsen commenced his sculpture by carving beaks for great ships. It is not unlikely that in some such place as the Naval Museum in Brooklyn some of those images which Thorwaldsen and his father carved are still preserved.
artist himself. Perhaps I may mention two or three things that  
 
will connect him with this country. Those of us who have  
 
watched the ships coming in and going out of a great harbor,  
 
as I did in my boyhood in New York, remember how common  
 
it was to see ships with carved beaks, often quite well wrought.  
 
Now Thorwaldsen commenced his sculpture by carving beaks  
 
for great ships. It is not unlikely that in some such place as  
 
the Naval Museum in Brooklyn some of those images which  
 
Thorwaldsen and his father carved are still preserved.  
 
  
When Thorwaldsen was beginning to acquire a reputation,  
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When Thorwaldsen was beginning to acquire a reputation, about the year 1807, the United States Consul at Leghorn negotiated with him to model a statue of Liberty to be placed in Washington. Whether it was for the summit of the capitol or to stand upon the ground, I do not know, but the life of Thorwaldsen records the fact that negotiations weut forward for the statue, and also that a proposal was made to him to make a monument t6 commemorate the American victories over the pirates of Tripoli and Tunis.
about the year 1807, the United States Consul at Leghorn  
 
negotiated with him to model a statue of Liberty to be placed  
 
in Washington. Whether it was for the summit of the capitol  
 
or to stand upon the ground, I do not know, but the life of  
 
Thorwaldsen records the fact that negotiations weut forward for  
 
the statue, and also that a proposal was made to him to make  
 
a monument t6 commemorate the American victories over the  
 
pirates of Tripoli and Tunis.  
 
  
I have come upon another incident perhaps more curious.  
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I have come upon another incident perhaps more curious. You know that when a man becomes famous all the world begins to ask " Who was his grandfather ? " and to trace his heredity as far as possible. As soon as this Danish sculptor became famous, people found out that he was descended from an old Icelandic sculptor. But they did not stop there ; they thought they found that he was a desceudant of Thor Finn. Thor Finn is the name of one of the Norsemen who is said to have crossed the Atlantic, not far from the year A. D. 1000, and is said to have skirted along the New England coast and to have established himself iu the southern part of that peninsula. A son was born to Thor Finn in what is now Rhode Island (so at least it is said), and to that man they have traced the genealogy of Thor-wald-sen, and thus they claim that Thorwaldseu is descended from the first person born of European descent in the new world.
You know that when a man becomes famous all the world  
 
begins to ask " Who was his grandfather ? " and to trace his  
 
heredity as far as possible. As soon as this Danish sculptor  
 
became famous, people found out that he was descended from  
 
an old Icelandic sculptor. But they did not stop there ; they  
 
thought they found that he was a desceudant of Thor Finn.  
 
Thor Finn is the name of one of the Norsemen who is said to  
 
have crossed the Atlantic, not far from the year A. D. 1000, and  
 
is said to have skirted along the New England coast and to have  
 
established himself iu the southern part of that peninsula. A  
 
son was born to Thor Finn in what is now Rhode Island (so at  
 
least it is said), and to that man they have traced the genealogy of Thor-wald-sen, and thus they claim that Thorwaldseu is descended from the first person born of European  
 
descent in the new world.  
 
  
The enterprising secretary of the Rhode Island Historical  
+
The enterprising secretary of the Rhode Island Historical Society took occasion to address a letter to Thorwaldsen congratulating him not only on his honors but on his origin, and Thorwaldsen replied, with a fine touch of courteous humor, "Let us admire those savants, for if it were uot for them, we should not know where we came from or whither we are going."
Society took occasion to address a letter to Thorwaldsen congratulating him not only on his honors but on his origin, and  
 
Thorwaldsen replied, with a fine touch of courteous humor,  
 
"Let us admire those savants, for if it were uot for them, we  
 
should not know where we came from or whither we are  
 
going."  
 
  
It is just one hundred years this very month, and I may  
+
It is just one hundred years this very month, and I may say this very week, since Thorwaldsen, iu a note dated October 16, 1796, states that he is on his way from his northern home, like the Norsemen of old, to establish himself in the south. He was a passenger upon a government frigate which stopped leisurely at one point and then another, so that his journey grew tiresome. At last he abandoned the man-of-war and
say this very week, since Thorwaldsen, iu a note dated October  
 
16, 1796, states that he is on his way from his northern home,  
 
like the Norsemen of old, to establish himself in the south.  
 
He was a passenger upon a government frigate which stopped  
 
leisurely at one point and then another, so that his journey  
 
grew tiresome. At last he abandoned the man-of-war and  
 
  
  
  
found other conveyances to carry him from Malta to Palermo,  
+
found other conveyances to carry him from Malta to Palermo, to Naples, and so on to Rome. There he went to work.
to Naples, and so on to Rome. There he went to work.  
 
  
But how could this boy maintain himself in Rome ? It was  
+
But how could this boy maintain himself in Rome ? It was by the aid of a scholarship provided for him by the Royal Academy of Copenhagen. He had not been a very bright boy in his ordinary school instruction. His teacher could uot make anything out of him, and the pastor who was engaged in giving him lessons for confirmation shook his head many a time at the dulness of the artist. One day in the course of these lessons he said, "Thorwaldsen, was that your brother that took the j)rize iu the Academy of Fine Arts the other day':"' " No," said the young sculptor, "it was I." "You!" said the teacher; "Mr. Thorwaldsen [with the emphasis on the title], go up to the front seat." It is not a bad thing for those of us engaged in instruction to remember that sometimes boys who are dull at books, who do uot like to receive knowledge through the printed page, may yet have talents that are worth developing. This should never be forgotten.
by the aid of a scholarship provided for him by the Royal  
 
Academy of Copenhagen. He had not been a very bright boy  
 
in his ordinary school instruction. His teacher could uot  
 
make anything out of him, and the pastor who was engaged  
 
in giving him lessons for confirmation shook his head many a  
 
time at the dulness of the artist. One day in the course of  
 
these lessons he said, "Thorwaldsen, was that your brother  
 
that took the j)rize iu the Academy of Fine Arts the other  
 
day':"' " No," said the young sculptor, "it was I." "You!"  
 
said the teacher; "Mr. Thorwaldsen [with the emphasis on  
 
the title], go up to the front seat." It is not a bad thing for  
 
those of us engaged in instruction to remember that sometimes boys who are dull at books, who do uot like to receive  
 
knowledge through the printed page, may yet have talents that  
 
are worth developing. This should never be forgotten.  
 
  
Now I want to remind you that scholarships just like that  
+
Now I want to remind you that scholarships just like that which enabled Thorwaldsen to go forward, have been established within a short time in Baltimore. Rinehart, as you know, left a considerable sum of money, which was carefully invested by Mr. Newcomer and Mr. Walters, until it reached the sum of $100,000, and it was then given to the Peabody Institute. This very week the Maryland Institute, by the aid of that fund, has instituted a school of sculpture, to bear the name of Rinehart, and besides this, Rinehart scholarships have been bestowed upon two young men, selected with great care by distinguished artists, and they are now engaged iu the prosecution of their art-studies, one in Paris and the other in Rome. I think it is not unreasonable to hope and believe that as the years roll by we shall hear something proceeding from these influences worthy to stand beside the Danish artist whom we this day commemorate, worthy likewise of Rinehart's bounty.
which enabled Thorwaldsen to go forward, have been established within a short time in Baltimore. Rinehart, as you  
 
know, left a considerable sum of money, which was carefully  
 
invested by Mr. Newcomer and Mr. Walters, until it reached  
 
the sum of $100,000, and it was then given to the Peabody  
 
Institute. This very week the Maryland Institute, by the aid  
 
of that fund, has instituted a school of sculpture, to bear the  
 
name of Rinehart, and besides this, Rinehart scholarships  
 
have been bestowed upon two young men, selected with great  
 
care by distinguished artists, and they are now engaged iu the  
 
prosecution of their art-studies, one in Paris and the other in  
 
Rome. I think it is not unreasonable to hope and believe that  
 
as the years roll by we shall hear something proceeding from  
 
these influences worthy to stand beside the Danish artist  
 
whom we this day commemorate, worthy likewise of Rinehart's  
 
bounty.  
 
  
At Rome, Thorwaldsen instantly came under the modern  
+
At Rome, Thorwaldsen instantly came under the modern influences of that day. Wiuckelmann, the well-known critic, had already called attention to the great value of the Greek art iu distinction from that of the Renaissance, and sculptors began to work iu the Hellenic spirit. You get an illustration of this movement in the Flaxman designs, as produced in England. You get another illustration in the work of Oanova, and you get an especially good illustration in the early work of Thorwaldsen.
influences of that day. Wiuckelmann, the well-known critic,  
 
had already called attention to the great value of the Greek  
 
art iu distinction from that of the Renaissance, and sculptors  
 
began to work iu the Hellenic spirit. You get an illustration  
 
of this movement in the Flaxman designs, as produced  
 
in England. You get another illustration in the work of  
 
Oanova, and you get an especially good illustration in the early  
 
work of Thorwaldsen.  
 
  
A great many illustrious people came to Rome. An amusing story is told of Sir Walter Scott. He was very desirous of  
+
A great many illustrious people came to Rome. An amusing story is told of Sir Walter Scott. He was very desirous of meeting and talking with Thorwaldsen, and they were introduced to one another; but Thorwaldsen could not speak a word of English, and Sir AValter was not at his ease in French. All that any one could hear was "plaisir," "plaisir," "connaissance," and similar nouns, expressing gratification that they had met.
meeting and talking with Thorwaldsen, and they were introduced to one another; but Thorwaldsen could not speak a  
 
word of English, and Sir AValter was not at his ease in French.  
 
All that any one could hear was "plaisir," "plaisir," "connaissance," and similar nouns, expressing gratification that  
 
they had met.  
 
  
The sculptor soon came into church circles. He was a particular friend of Cardinal Consalvi, and made his monument.  
+
The sculptor soon came into church circles. He was a particular friend of Cardinal Consalvi, and made his monument. It was through his influence, undoubtedly, that Thorwaldsen was selected to make for the Church of St. Peter the famous monument of Pius the Seventh. Some one objected that a Protestant had been selected. The Pope inquired, " Is not he the
It was through his influence, undoubtedly, that Thorwaldsen  
 
was selected to make for the Church of St. Peter the famous  
 
monument of Pius the Seventh. Some one objected that a Protestant had been selected. The Pope inquired, " Is not he the  
 
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
[No. 70.  
+
[No. 70.
  
  
  
best artist in Eome?" "Undoubtedly," was the answer.  
+
best artist in Eome?" "Undoubtedly," was the answer. "Then let him hold the place."
"Then let him hold the place."  
 
  
Thorwaldsen after a time went home, and, as I have said,  
+
Thorwaldsen after a time went home, and, as I have said, received the commission for a statue of Christ. He returned to liome, and with his helpers, it took him eight or nine years to complete the group of Christ and the Apostles.
received the commission for a statue of Christ. He returned to  
 
liome, and with his helpers, it took him eight or nine years to  
 
complete the group of Christ and the Apostles.  
 
  
You must be familiar with many of the works which he  
+
You must be familiar with many of the works which he produced meanwhile. The little medallions of Night and Day which hang in so many parlors were his. Almost every one who goes to Eurojie knows the Sleeping Lion of Lucerne and the statue of Lord Byron at Cambridge. He made many portrait busts. He worked long on mythological subjects, till finally " he turned from Jove and Mars to nobler themes."
produced meanwhile. The little medallions of Night and Day  
 
which hang in so many parlors were his. Almost every one  
 
who goes to Eurojie knows the Sleeping Lion of Lucerne and  
 
the statue of Lord Byron at Cambridge. He made many  
 
portrait busts. He worked long on mythological subjects, till  
 
finally " he turned from Jove and Mars to nobler themes."  
 
  
The story goes that he made six models of the Christ before  
+
The story goes that he made six models of the Christ before he was satisfied with the one which is here reproduced. At first he thought of giving to the figure an iiplifted hand, in the attitude of benediction. Afterwards he uplifted both arms as if in prayer. The artist was standing before his statue one day, when he said to a friend, " I am not satisfied with that." His friend replied, " What was your motive in giving that posture; what were you thinking about?" Thorwaldsen paused, and in a moment turned down the arms to the position in which you now see them, and then said, " I am satisfied now."
he was satisfied with the one which is here reproduced. At  
 
first he thought of giving to the figure an iiplifted hand, in  
 
the attitude of benediction. Afterwards he uplifted both arms  
 
as if in prayer. The artist was standing before his statue one  
 
day, when he said to a friend, " I am not satisfied with that."  
 
His friend replied, " What was your motive in giving that  
 
posture; what were you thinking about?" Thorwaldsen  
 
paused, and in a moment turned down the arms to the position  
 
in which you now see them, and then said, " I am satisfied now."  
 
  
It is worth while for me to add that between five and six  
+
It is worth while for me to add that between five and six hundred works by this artist have been catalogued — a large part of which may be seen (in the cast, if not in the original) at the Thorwaldsen Museum in Copenhagen.
hundred works by this artist have been catalogued — a large  
 
part of which may be seen (in the cast, if not in the original)  
 
at the Thorwaldsen Museum in Copenhagen.  
 
  
Now, ladies and gentlemen, it is not for me to draw the  
+
Now, ladies and gentlemen, it is not for me to draw the lesson of the statue. I suppose (to use a phrase of Coleridge) that this statue "will find each one" of us in his own mood. To some it will be a reminiscence of travel, — of a delightful day in Copenhagen. To others it will be a work that is famous in the history of modern art. To many of the anxious and suffering it will be suggestive of hope and faith and love. To each, according to the inward eye that he brings to bear upon it, will the lesson be given. I do not propose to read a homily ; but I may remind you that throughout modern literature and art this figure appears. From the Divine Comedy of Dante to the Paradise Lost of Milton, in the Saul of Browning and Tennyson's Crossing the Bar, one name
lesson of the statue. I suppose (to use a phrase of Coleridge) that this statue "will find each one" of us in his own  
 
mood. To some it will be a reminiscence of travel, — of a  
 
delightful day in Copenhagen. To others it will be a work  
 
that is famous in the history of modern art. To many of the  
 
anxious and suffering it will be suggestive of hope and faith  
 
and love. To each, according to the inward eye that he brings  
 
to bear upon it, will the lesson be given. I do not propose to  
 
read a homily ; but I may remind you that throughout modern literature and art this figure appears. From the Divine  
 
Comedy of Dante to the Paradise Lost of Milton, in the  
 
Saul of Browning and Tennyson's Crossing the Bar, one name  
 
  
  
  
is repeated. So it is in painting, from Eaphael and Leonardo to  
+
is repeated. So it is in painting, from Eaphael and Leonardo to those gifted men who are now decorating the churches in this country with the illustrations of the life of Christ. So it is in sculpture, fi'om Michael Angelo to St. Gaudens. So it is in religious meditation, from Thomas a Kempis to Phillips Brooks. Everywhere there is one Jiote prevalent, one name pre-eminent. Whatever else the founder of Christianity may have been, we cannot read the narratives of his life without a certainty that he was the Great Physician. W'hatever else may be found in this statue, however we may look at it, we must be mindful that it represents to us one who lived and walked upon this earth, and wrought more cures and more wonderful cures than any physician or surgeon that had ever lived. Thorwaldsen, better than any artist that I know, has produced this thought in marble. Li " Ecce Homo " attention is called to a fact which you will allow me to repeat — that the founder of Christianity was not only the Great Healer, but when he first organized his followers into a definite society, for the purpose of bearing glad tidings throughout the world, he sent them on their mission as physicians. " Go," he said, "and heal the sick "; and the narratives of the Evangelists and of the Book of the Acts bring out most clearly this distinctive character. Among its other lessons we shall remember that this " House of Mercy," this " Hotel-Dieu," is pervaded by the spirit which appeared upon the earth almost nineteen hundred years ago.
those gifted men who are now decorating the churches in this  
 
country with the illustrations of the life of Christ. So it is  
 
in sculpture, fi'om Michael Angelo to St. Gaudens. So it is in  
 
religious meditation, from Thomas a Kempis to Phillips  
 
Brooks. Everywhere there is one Jiote prevalent, one name  
 
pre-eminent. Whatever else the founder of Christianity may  
 
have been, we cannot read the narratives of his life without a  
 
certainty that he was the Great Physician. W'hatever else  
 
may be found in this statue, however we may look at it, we  
 
must be mindful that it represents to us one who lived and  
 
walked upon this earth, and wrought more cures and more  
 
wonderful cures than any physician or surgeon that had ever  
 
lived. Thorwaldsen, better than any artist that I know,  
 
has produced this thought in marble. Li " Ecce Homo "  
 
attention is called to a fact which you will allow me to repeat  
 
— that the founder of Christianity was not only the Great  
 
Healer, but when he first organized his followers into a definite society, for the purpose of bearing glad tidings throughout  
 
the world, he sent them on their mission as physicians. " Go,"  
 
he said, "and heal the sick "; and the narratives of the Evangelists and of the Book of the Acts bring out most clearly  
 
this distinctive character. Among its other lessons we shall  
 
remember that this " House of Mercy," this " Hotel-Dieu," is  
 
pervaded by the spirit which appeared upon the earth almost  
 
nineteen hundred years ago.  
 
  
In the presence of Mr. Spence it will not do for me to  
+
In the presence of Mr. Spence it will not do for me to recount the many good deeds which he has done for the city, the many great services, political, financial, mercantile, philanthropic, educational and religious, which he has rendered to Baltimore ; but I must be allowed to say that twice when the finances of the Johns Hopkins University have been in a critical condition, he has been the one citizen to come forward and by his example to inspire the liberality of others. He was kind enough to tell you that I had on a " wishing cap," or words to that effect, seven years ago. I am going to put on my "wishing cap" now, and I am going "to wish" that as long as Baltimore lives and flourishes it may have the presence and influence and co-operation of such men as William Wallace Spence.
recount the many good deeds which he has done for the city,  
 
the many great services, political, financial, mercantile, philanthropic, educational and religious, which he has rendered to  
 
Baltimore ; but I must be allowed to say that twice when the  
 
finances of the Johns Hopkins University have been in a critical condition, he has been the one citizen to come forward and  
 
by his example to inspire the liberality of others. He was  
 
kind enough to tell you that I had on a " wishing cap," or  
 
words to that effect, seven years ago. I am going to put on  
 
my "wishing cap" now, and I am going "to wish" that as long  
 
as Baltimore lives and flourishes it may have the presence and  
 
influence and co-operation of such men as William Wallace  
 
Spence.  
 
  
  
  
THE BACILLUS PROTEUS ZENKERl IN AN OVARIAN ABSCESS.  
+
THE BACILLUS PROTEUS ZENKERl IN AN OVARIAN ABSCESS.
  
By Hunter Robb, M. D., Professor of Gynecology, Western Reserve University, Cleveland, 0., and Albekt A. Ghriskey, M. D.,  
+
By Hunter Robb, M. D., Professor of Gynecology, Western Reserve University, Cleveland, 0., and Albekt A. Ghriskey, M. D.,
  
former Assistant Gytiecologist to the Johns Hopkins Hosjntal.  
+
former Assistant Gytiecologist to the Johns Hopkins Hosjntal.
  
  
  
Mrs. T. G. was admitted to the gynecological ward of the  
+
Mrs. T. G. was admitted to the gynecological ward of the Johns Hopkins Hospital, August 8, 1891, with the following history :
Johns Hopkins Hospital, August 8, 1891, with the following  
 
history :  
 
  
The patient was a Bohemian, 36 years of age, and had been  
+
The patient was a Bohemian, 36 years of age, and had been married seven years. She had had three children, and said that she had never miscarried. The oldest child is six and the second four years old; the third child, born in Jan., 1890, died of " summer complaint " at the age of six months. Her labors had been easy ; she remained in bed for two days after each, being attended only by a midwife. PIcr menses first appeared at 16 years of age. They were irregular, lasting usu
married seven years. She had had three children, and said  
 
that she had never miscarried. The oldest child is six and the  
 
second four years old; the third child, born in Jan., 1890,  
 
died of " summer complaint " at the age of six months. Her  
 
labors had been easy ; she remained in bed for two days after  
 
each, being attended only by a midwife. PIcr menses first  
 
appeared at 16 years of age. They were irregular, lasting usu
 
  
  
ally seven days, and were often profuse and painful; since  
+
ally seven days, and were often profuse and painful; since marriage her menses have been regular, lasting five or six days, being profuse but not painful. In May, 1890, she ceased to menstruate for two months, but in July her menses reappeared and lasted six days. At this time they were profuse and accompanied with a great deal of backache and pain in both ovarian regions. She had never had leucorrhiva; she suffered from constipation. There was no urinary difficulty. The patient remained well until April, 1891, when a hemorrhage from the vagina occurred suddenly and continued for six days. Two hours after the hemorrhage ceased she passed foul
marriage her menses have been regular, lasting five or six days,  
 
being profuse but not painful. In May, 1890, she ceased to  
 
menstruate for two months, but in July her menses reappeared  
 
and lasted six days. At this time they were profuse and  
 
accompanied with a great deal of backache and pain in both  
 
ovarian regions. She had never had leucorrhiva; she suffered  
 
from constipation. There was no urinary difficulty. The  
 
patient remained well until April, 1891, when a hemorrhage  
 
from the vagina occurred suddenly and continued for six days.  
 
Two hours after the hemorrhage ceased she passed foul
 
  
  
January, 1897.]  
+
January, 1897.]
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
smelling black clots of blood and experienced labor-like pains.  
+
smelling black clots of blood and experienced labor-like pains. During May, June and July she was free from these laborlike pains, but complained during these months of weakness, of occasional chills and fever, of pains in the lower zone of the abdomen, and backache. On admission to the hospital she was too weak to walk. The slightest touch over the region of the left ovary provoked intense pain. The temperature on admission was normal ; the jiatient weighed 123 pounds.
During May, June and July she was free from these laborlike pains, but complained during these months of weakness,  
 
of occasional chills and fever, of pains in the lower zone of the  
 
abdomen, and backache. On admission to the hospital she was  
 
too weak to walk. The slightest touch over the region of the  
 
left ovary provoked intense pain. The temperature on admission was normal ; the jiatient weighed 123 pounds.  
 
  
At the examination made August 8, 1891, under chloroform  
+
At the examination made August 8, 1891, under chloroform narcosis, the following note was made :
narcosis, the following note was made :  
 
  
Vaginal outlet moderately relaxed; vagina bathed with  
+
Vaginal outlet moderately relaxed; vagina bathed with bloody fluid ; cervix small, bilaterally lacerated, pointing upwards; uterus anteflexed, sagging in the pelvis, enlarged, soft and movable. Right broad ligament thickened. Fallopian tube and ovary not definitely palpated.
bloody fluid ; cervix small, bilaterally lacerated, pointing upwards; uterus anteflexed, sagging in the pelvis, enlarged, soft  
 
and movable. Right broad ligament thickened. Fallopian  
 
tube and ovary not definitely palpated.  
 
  
On the left side a fluctuating tumor is outlined, about the  
+
On the left side a fluctuating tumor is outlined, about the size of an orange, adherent to the uterus.
size of an orange, adherent to the uterus.  
 
  
Diagnosis. Abscess of the left ovary. Treatment advised,  
+
Diagnosis. Abscess of the left ovary. Treatment advised, coeliotomy.
coeliotomy.  
 
  
Urinary analj/sis. A voided specimen examined on August  
+
Urinary analj/sis. A voided specimen examined on August 9th was turbid, straw-colored, specific gravity 1.020, reaction acid. On standing it deposited a heavy bloody and mucous sediment. On boiling, albumen was found to be present. A large number of red blood corpuscles were revealed by the microscopical examination, as well as numerous epithelial cells both large and small.
9th was turbid, straw-colored, specific gravity 1.020, reaction  
 
acid. On standing it deposited a heavy bloody and mucous  
 
sediment. On boiling, albumen was found to be present. A  
 
large number of red blood corpuscles were revealed by the  
 
microscopical examination, as well as numerous epithelial cells  
 
both large and small.  
 
  
A catheterized sj3ecimen was cloudy, amber-colored, specific  
+
A catheterized sj3ecimen was cloudy, amber-colored, specific gravity 1.035, reaction acid. Albumen as in voided specimen; mucous sediment not so deeply stained with blood. The microscopical examination gave much the same results as those shown by the previous specimen.
gravity 1.035, reaction acid. Albumen as in voided specimen;  
 
mucous sediment not so deeply stained with blood. The  
 
microscopical examination gave much the same results as those  
 
shown by the previous specimen.  
 
  
Operation August 12, 1891, under chloroform narcosis.  
+
Operation August 12, 1891, under chloroform narcosis.
  
Incision 7 cm. long through thin abdominal walls. On  
+
Incision 7 cm. long through thin abdominal walls. On exploration of the pelvis, the mass previously palpated on the left side was brought into view. It was bound down to the broad ligament, uterus and pelvic walls by dense connective tissue adhesions. The tumor mass was successfully enucleated, but during its delivery a small rupture occurred at the point at which it was adherent to the fimbriated extremity of the Fallopian tube, and a small quantity of purulent fluid, having a strong foetid odor, escaped. A ligature was immediately tied about the rent, thus preventing the escape of more fluid. The remaining portion of the Fallopian tube, although not adherent, was enlarged and thickened. The tumor mass was transfixed and ligated below the round ligament, after which it was excised and the pedicle cauterized.
exploration of the pelvis, the mass previously palpated on the  
 
left side was brought into view. It was bound down to the  
 
broad ligament, uterus and pelvic walls by dense connective  
 
tissue adhesions. The tumor mass was successfully enucleated, but during its delivery a small rupture occurred at the  
 
point at which it was adherent to the fimbriated extremity of  
 
the Fallopian tube, and a small quantity of purulent fluid,  
 
having a strong foetid odor, escaped. A ligature was immediately tied about the rent, thus preventing the escape of more  
 
fluid. The remaining portion of the Fallopian tube, although  
 
not adherent, was enlarged and thickened. The tumor mass  
 
was transfixed and ligated below the round ligament, after  
 
which it was excised and the pedicle cauterized.  
 
  
The Fallopian tube and ovary of the right side being bound  
+
The Fallopian tube and ovary of the right side being bound down by only a few adhesions, were enucleated without difficulty. The fimbriated extremity of the tube was occluded, enlarged and thickened. The ovary appeared inflamed, but was not enlarged. The tube and ovary were removed by transfixion and the pedicle was cauterized. The jjelvic cavity was irrigated with three litres of a sterilized salt solution at a temperature of 112° F. and sponged dry.
down by only a few adhesions, were enucleated without difficulty. The fimbriated extremity of the tube was occluded,  
 
enlarged and thickened. The ovary appeared inflamed, but  
 
was not enlarged. The tube and ovary were removed by transfixion and the pedicle was cauterized. The jjelvic cavity was  
 
irrigated with three litres of a sterilized salt solution at a  
 
temperature of 112° F. and sponged dry.  
 
  
A drainage tube was inserted in the lower angle of the  
+
A drainage tube was inserted in the lower angle of the wound and the usual dressings applied. Time of operation, 40 minutes.
wound and the usual dressings applied. Time of operation,  
 
40 minutes.  
 
  
The specimens removed consist of the tube and ovary of the  
+
The specimens removed consist of the tube and ovary of the
  
  
  
right side, which are covered with villamentous adhesions, and  
+
right side, which are covered with villamentous adhesions, and the tube and ovary of the left side, which are encapsulated in connective tissue-like adhesions.
the tube and ovary of the left side, which are encapsulated in  
 
connective tissue-like adhesions.  
 
  
VIII-13-91. First dressing. The gauze plug in the drainage tube is thoroughly saturated with a dark bloody discharge,  
+
VIII-13-91. First dressing. The gauze plug in the drainage tube is thoroughly saturated with a dark bloody discharge, and streaked with a fluid resembling pus. Tube cleansed with 20 pledgets of cotton, the last three pledgets being but faintly stained. The discharge had a decided odor of decomposition.
and streaked with a fluid resembling pus. Tube cleansed with  
 
20 pledgets of cotton, the last three pledgets being but faintly  
 
stained. The discharge had a decided odor of decomposition.  
 
  
The cotton immediately over the drainage tube was slightly  
+
The cotton immediately over the drainage tube was slightly moistened with the same character of secretion as that seen upon the plug and upon the cotton pledgets.
moistened with the same character of secretion as that seen  
 
upon the plug and upon the cotton pledgets.  
 
  
Abdomen flat, no distension, general condition good, usual  
+
Abdomen flat, no distension, general condition good, usual cultures taken.
cultures taken.  
 
  
VIII-14-91. Second dressing. Slight amount of fluid on  
+
VIII-14-91. Second dressing. Slight amount of fluid on cotton over the drainage tube ; plug in tube moistened by a clear fluid holding a clot of blood at the lower end. On the gauze plug there are white opaque points of lymph, corresponding in position to the perforation in the drainage tube. The fluid has the same odor of decomposition. Tube cleansed with twelve pledgets of cotton, which when withdrawn were stained with a serum-like fluid, the two last being hardly soiled at all. Drainage tube removed and a plug of iodoformized gauze inserted down the track of the tube. Abdomen flat, general condition good ; usual cultures taken.
cotton over the drainage tube ; plug in tube moistened by a  
 
clear fluid holding a clot of blood at the lower end. On the  
 
gauze plug there are white opaque points of lymph, corresponding in position to the perforation in the drainage  
 
tube. The fluid has the same odor of decomposition. Tube  
 
cleansed with twelve pledgets of cotton, which when withdrawn were stained with a serum-like fluid, the two last being  
 
hardly soiled at all. Drainage tube removed and a plug of  
 
iodoformized gauze inserted down the track of the tube.  
 
Abdomen flat, general condition good ; usual cultures taken.  
 
  
VIII-15-91. Third dressing. Gauze removed from the  
+
VIII-15-91. Third dressing. Gauze removed from the tube track; moistened; not as much odor. Track of tube cleansed with peroxide of hydrogen. Abdomen flat, general condition good. Gauze reapplied to wound, but not down the track ; abdomen sensitive. Gauze impregnated with permanganate of potassium and oxalic acid applied over the protective dressing and track of the tube.
tube track; moistened; not as much odor. Track of tube  
 
cleansed with peroxide of hydrogen. Abdomen flat, general  
 
condition good. Gauze reapplied to wound, but not down  
 
the track ; abdomen sensitive. Gauze impregnated with permanganate of potassium and oxalic acid applied over the  
 
protective dressing and track of the tube.  
 
  
VIII-19-91. Fourth dressing. Stitches removed. Line of  
+
VIII-19-91. Fourth dressing. Stitches removed. Line of union good; some suppuration about the track of the tube. General condition good.
union good; some suppuration about the track of the tube.  
 
General condition good.  
 
  
VIII-26-91. Fifth dressing. Small amount of creamy  
+
VIII-26-91. Fifth dressing. Small amount of creamy fluid escaped from the track of the tube. Line of incision in good apposition and well united.
fluid escaped from the track of the tube. Line of incision  
 
in good apposition and well united.  
 
  
Analysis of temperature cliart. — The temperature was taken  
+
Analysis of temperature cliart. — The temperature was taken for ten days after the operation by the mouth, rectu m and vagina. The highest point registered was that on the fourth day, when it was 102° F. by the rectum, 101.8° F. by the vagina, and 101.2° F. by the mouth. After this it was never above 101° F. and on the 9th day registered 100.5° F.
for ten days after the operation by the mouth, rectu m and vagina.  
 
The highest point registered was that on the fourth day, when  
 
it was 102° F. by the rectum, 101.8° F. by the vagina, and  
 
101.2° F. by the mouth. After this it was never above 101° F.  
 
and on the 9th day registered 100.5° F.  
 
  
Bacteriological examination. — The following cultures were  
+
Bacteriological examination. — The following cultures were made from the left Fallopian tube and abscess cavity: Two sets of Esmarch's roll plates on agar-agar, one smear and one stab culture in the same medium ; a blood-serum tube (bullock's blood) and a litmus milk tube. From the right Fallopian tube, which was distended by a muco-purulent, rather viscid looking fluid, we only made gelatine Esmarch's roll jilates.
made from the left Fallopian tube and abscess cavity: Two  
 
sets of Esmarch's roll plates on agar-agar, one smear and one  
 
stab culture in the same medium ; a blood-serum tube (bullock's  
 
blood) and a litmus milk tube. From the right Fallopian  
 
tube, which was distended by a muco-purulent, rather viscid  
 
looking fluid, we only made gelatine Esmarch's roll jilates.  
 
  
Microscopical examination. — Cover-slips stained with gentian violet show numerous polynuclear leucocytes, with compound granular bodies, and a few cells with large round  
+
Microscopical examination. — Cover-slips stained with gentian violet show numerous polynuclear leucocytes, with compound granular bodies, and a few cells with large round nuclei resembling epithelial cells. Many bacilli were observed; they were rather faintly stained, and were seen only occasionally within the leucocytes. These bacteria were stained best with carbolic gentian violet.
nuclei resembling epithelial cells. Many bacilli were observed;  
 
they were rather faintly stained, and were seen only occasionally within the leucocytes. These bacteria were stained  
 
best with carbolic gentian violet.  
 
  
Numerous rod-shaped bacilli were found in the preparation  
+
Numerous rod-shaped bacilli were found in the preparation
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
[No. 70.  
+
[No. 70.
  
  
  
from the Fallopian tube on the right side. Though less  
+
from the Fallopian tube on the right side. Though less intensely stained, they resemble tubercle bacilli somewhat morphologically. They are, however, completely decolorized when treated after the method of staining for the latter organisms. It is to be noted that the organisms were very numerous in the specimen from the point at which the cultures were made.
intensely stained, they resemble tubercle bacilli somewhat  
 
morphologically. They are, however, completely decolorized  
 
when treated after the method of staining for the latter organisms. It is to be noted that the organisms were very numerous in the specimen from the point at which the cultures  
 
were made.  
 
  
After 48 hours in the thermostat all tubes were sterile,  
+
After 48 hours in the thermostat all tubes were sterile, except the blood serum slants, which showed an opaque, very faintly granular growth, apparently due to closely set colonies. Only the growths from the two inoculations from the abscess contents were considered reliable for study. Inoculations were made from these on the agar-agar, blood serum, potato and gelatine. Examined microscopically they proved to be pure cultures of a bacillus.
except the blood serum slants, which showed an opaque, very  
 
faintly granular growth, apparently due to closely set colonies.  
 
Only the growths from the two inoculations from the abscess  
 
contents were considered reliable for study. Inoculations were  
 
made from these on the agar-agar, blood serum, potato and  
 
gelatine. Examined microscopically they proved to be pure  
 
cultures of a bacillus.  
 
  
All these tubes showed growth after 24 hours on agar; very  
+
All these tubes showed growth after 24 hours on agar; very faintly after 48 hours on gelatine, on account of the lower temperature, but more distinctly on the latter on succeeding days. The appearance of the colonies in gelatine corresponded to that presented by the bacillus proteus, a fact suggested by Dr. Booker and confirmed by Dr. Welch. These colonies showed the typical twisted wandering offshoots (schwiirmende Colonien) characteristic of the proteus group. The gelatine was not liquefied.
faintly after 48 hours on gelatine, on account of the lower  
 
temperature, but more distinctly on the latter on succeeding  
 
days. The appearance of the colonies in gelatine corresponded  
 
to that presented by the bacillus proteus, a fact suggested by  
 
Dr. Booker and confirmed by Dr. Welch. These colonies  
 
showed the typical twisted wandering offshoots (schwiirmende  
 
Colonien) characteristic of the proteus group. The gelatine  
 
was not liquefied.  
 
  
Cultures from the Dramage Tube. — First dressing 24 hours  
+
Cultures from the Dramage Tube. — First dressing 24 hours after operation. Roll plate, agar-agar, Esmarch's tubes. The colonies on the tubes from the gauze plug were composed of the skin-coccus. Microscopical examination of stained coverglass preparations from the secretion showed a few diplococci, and numerous bacilli identical with those found in the abscess cavity. The coccus grew on potato and in bouillon with the characters of the streptococcus pyogenes albus, but liquefied gelatine, though less rapidly than this organism.
after operation. Roll plate, agar-agar, Esmarch's tubes. The  
 
colonies on the tubes from the gauze plug were composed of  
 
the skin-coccus. Microscopical examination of stained coverglass preparations from the secretion showed a few diplococci,  
 
and numerous bacilli identical with those found in the abscess  
 
cavity. The coccus grew on potato and in bouillon with the  
 
characters of the streptococcus pyogenes albus, but liquefied  
 
gelatine, though less rapidly than this organism.  
 
  
The inoculation of a guinea-pig subcutaneously in the flank  
+
The inoculation of a guinea-pig subcutaneously in the flank with the serum-like secretion from the gauze plug was without result.
with the serum-like secretion from the gauze plug was without result.  
 
  
Further inoculations from the drainage tube on bullock  
+
Further inoculations from the drainage tube on bullock serum were not made, as the supply of culture medium was exhausted.
serum were not made, as the supply of culture medium was  
 
exhausted.  
 
  
The case is of unusual interest on account of the results of  
+
The case is of unusual interest on account of the results of the bacteriological examination. The bacillus proteus vulgaris (variety Zenkeri ?) was found in cultures from the abscess cavity in the left ovary, and on cover-slips in the right Fallopian tube. In all our previous examinations of abscess cavities, cysts and Fallopian tubes, we have never met with another instance in which it was present.
the bacteriological examination. The bacillus proteus vulgaris (variety Zenkeri ?) was found in cultures from the  
 
abscess cavity in the left ovary, and on cover-slips in the right  
 
Fallopian tube. In all our previous examinations of abscess  
 
cavities, cysts and Fallopian tubes, we have never met with  
 
another instance in which it was present.  
 
  
Macroscopical and microscopical de.fcripfion of specimens from  
+
Macroscopical and microscopical de.fcripfion of specimens from the Pathological Laboratory of the Johns Ho})kins Hospital, by Dr. .T. Whitridge Williams.
the Pathological Laboratory of the Johns Ho})kins Hospital, by  
 
Dr. .T. Whitridge Williams.  
 
  
Appendages on loth sides. Left side: Tube 6 by 0.7 by  
+
Appendages on loth sides. Left side: Tube 6 by 0.7 by 1 cm. Fimbriated end thickened and adherent to ovary, but not occluded ; some portions are still bound down to the ovary, but at other places the adhesions have evidently been torn loose during the operation. On section it is seen that the mucosa is much thickened and resembles a pyogenic membrane. The characteristic folding has disappeared. Scattered through it here and there are areas which appear decidedly caseous.
1 cm. Fimbriated end thickened and adherent to ovary, but  
 
not occluded ; some portions are still bound down to the  
 
ovary, but at other places the adhesions have evidently been  
 
torn loose during the operation. On section it is seen that the  
 
mucosa is much thickened and resembles a pyogenic membrane. The characteristic folding has disappeared. Scattered  
 
through it here and there are areas which appear decidedly  
 
caseous.  
 
  
  
  
The ovary is converted into a pus sac 5.5 cm. in diameter.  
+
The ovary is converted into a pus sac 5.5 cm. in diameter. The greater part of its exterior is smooth, though signs of several dense adhesions are observed. On the surface are a few dilated follicles. The abscess wall varies from 0.5 to 1 cm. in thickness, its interior being lined by a characteristic pyogenic membrane 2 to 3 mm. thick. Externally it is glistening and presents many circular elevations, 1 to 5 mm. in diameter, which are raised only a few mm. above the general surface. These are found to be movable and to represent tags of tissue. On section, the pyogenic membrane is readily divided into two layers; the one nearer to the pus cavity being opaque, thicker, of a yellow color, and having a tuberculous aspect (?) ; the other, lying next the ovarian stroma, is lighter in color, more translucent, and considerably thinner than the inner coating.
The greater part of its exterior is smooth, though signs of  
 
several dense adhesions are observed. On the surface are a  
 
few dilated follicles. The abscess wall varies from 0.5 to 1  
 
cm. in thickness, its interior being lined by a characteristic  
 
pyogenic membrane 2 to 3 mm. thick. Externally it is glistening and presents many circular elevations, 1 to 5 mm. in  
 
diameter, which are raised only a few mm. above the general  
 
surface. These are found to be movable and to represent tags  
 
of tissue. On section, the pyogenic membrane is readily divided into two layers; the one nearer to the pus cavity being  
 
opaque, thicker, of a yellow color, and having a tuberculous  
 
aspect (?) ; the other, lying next the ovarian stroma, is lighter  
 
in color, more translucent, and considerably thinner than the  
 
inner coating.  
 
  
Cover-slips from the pus show many thick bacilli, but no  
+
Cover-slips from the pus show many thick bacilli, but no tubercle bacilli.
tubercle bacilli.  
 
  
Right side : Tube 5 by 0.4 by 1.2 cm. ; fimbriated end  
+
Right side : Tube 5 by 0.4 by 1.2 cm. ; fimbriated end occluded ; many adhesions. Ovary 3 by 3 by 1.5 cm. Many adhesions on surface. On section, the ovary is succulent and contains an oldish corpus luteum and a small corpus luteum cyst, 5 mm. in diameter, with white opaque walls 1 mm. thick and with a glistening interior. There are also several follicles with hemorrhagic contents.
occluded ; many adhesions. Ovary 3 by 3 by 1.5 cm. Many  
 
adhesions on surface. On section, the ovary is succulent and  
 
contains an oldish corpus luteum and a small corpus luteum  
 
cyst, 5 mm. in diameter, with white opaque walls 1 mm. thick  
 
and with a glistening interior. There are also several follicles with hemorrhagic contents.  
 
  
Microscopical examination. The left tube presents a marked  
+
Microscopical examination. The left tube presents a marked purulent salpingitis, the folds of its mucosa being infiltrated with leucocytes and round cells. In places the epithelium is swollen and breaking down, and in others has entirely disappeared, affording a picture which beautifully illustrates the liquefaction of tissue.
purulent salpingitis, the folds of its mucosa being infiltrated with leucocytes and round cells. In places the epithelium is swollen and breaking down, and in others has  
 
entirely disappeared, affording a picture which beautifully  
 
illustrates the liquefaction of tissue.  
 
  
There is also a marked endarteritis.  
+
There is also a marked endarteritis.
  
Sections through the wall of the ovarian abscess show that  
+
Sections through the wall of the ovarian abscess show that the jDortion adjacent to the cavity contains many newly formed blood-vessels; it is filled with leucocytes and most beautiful fibroblasts, which are rapidly proliferating, nuclear figures and cell division being well seen.
the jDortion adjacent to the cavity contains many newly formed  
 
blood-vessels; it is filled with leucocytes and most beautiful  
 
fibroblasts, which are rapidly proliferating, nuclear figures and  
 
cell division being well seen.  
 
  
In this portion the connective tissue bands are hardly visible.  
+
In this portion the connective tissue bands are hardly visible. As we recede from the abscess cavity we find fewer leucocytes, more fibroblasts and connective tissue, until we gradually approach characteristic ovarian tissue.
As we recede from the abscess cavity we find fewer leucocytes,  
 
more fibroblasts and connective tissue, until we gradually  
 
approach characteristic ovarian tissue.  
 
  
The bacillus corresponds morphologically to the bacillus  
+
The bacillus corresponds morphologically to the bacillus proteus Zenkeri, and stains well with methylene blue, and does not entirely decolorize with the Gram or Weigert stain. It may be observed in the abscess walls as a bacillus of varying lengths and in forms simulating cocci. The fibroblasts are strikingly like the large cells of the corpus luteum.
proteus Zenkeri, and stains well with methylene blue, and does  
 
not entirely decolorize with the Gram or Weigert stain. It  
 
may be observed in the abscess walls as a bacillus of varying  
 
lengths and in forms simulating cocci. The fibroblasts are  
 
strikingly like the large cells of the corpus luteum.  
 
  
In a contribution to the subject of the proteus vulgaris in  
+
In a contribution to the subject of the proteus vulgaris in abscesses, Hauser', besides the report of his own case, gives a resume of the instances previously reported by other writers. Ilauser's case is that of an adult W'ho had a series of abscesses in the hand, following an injury from one of the autopsy instruments. The pus, which was of an ichorous and stinking character, contained both the streptococcus and proteus. The suppuration was regarded as induced by the streptococci, and the peculiar character of the contents of the abscesses was attributed to the presence of the proteus.
abscesses, Hauser', besides the report of his own case, gives a  
 
resume of the instances previously reported by other writers.  
 
Ilauser's case is that of an adult W'ho had a series of abscesses  
 
in the hand, following an injury from one of the autopsy  
 
instruments. The pus, which was of an ichorous and stinking  
 
character, contained both the streptococcus and proteus. The  
 
suppuration was regarded as induced by the streptococci, and  
 
the peculiar character of the contents of the abscesses was  
 
attributed to the presence of the proteus.  
 
  
Beck'' reports several cases of puerperal endometritis in  
+
Beck reports several cases of puerperal endometritis in which the proteus vulgaris was found, and one case of puru
which the proteus vulgaris was found, and one case of puru
 
  
  
January, 1897.]  
+
January, 1897.]
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
lent peritonitis, following total extirpation of the uterus for  
+
lent peritonitis, following total extirpation of the uterus for carcinoma, in which the presence of the same organism was demonstrated.
carcinoma, in which the presence of the same organism was  
 
demonstrated.  
 
  
Finally, Dilderlein' reports that in the lochia of puerperal  
+
Finally, Dilderlein' reports that in the lochia of puerperal women he has often found bacilli which cause a rapid liquefaction of gelatine; but from his brief description one is not able to say whether or not he was dealing with the proteus.
women he has often found bacilli which cause a rapid liquefaction of gelatine; but from his brief description one is not  
 
able to say whether or not he was dealing with the proteus.  
 
  
It seems fair to assume that our patient had a puerperal  
+
It seems fair to assume that our patient had a puerperal endometritis following the abortion which occurred last April, and that the infection subsequently involved the Fallopian tube and ovary.
endometritis following the abortion which occurred last April,  
 
and that the infection subsequently involved the Fallopian  
 
tube and ovary.  
 
  
The proteus Zenkeri, which he classifies among the anaerobes of putrefaction, is described by Hauser' as follows: The  
+
The proteus Zenkeri, which he classifies among the anaerobes of putrefaction, is described by Hauser' as follows: The organisms 0.4 in bi'eadth, and of an average length of 1.65; in some instances the forms are rounder, at other times longer. After inoculation on gelatine, a layer which towards the periphery becomes thinner and has the appearance of the steps of stairs, is formed around the point of inoculation, and from the margin of this layer numerous threads and rods begin to pass out; after 24 hours we find large numbers of moving islands, composed of rods and threads presenting exactly the same appearance as in the case of proteus mirabilis. The deposit becomes gradually thicker and opaque, but no lique
organisms 0.4 in bi'eadth, and of an average length of 1.65;  
 
in some instances the forms are rounder, at other times longer.  
 
After inoculation on gelatine, a layer which towards the periphery becomes thinner and has the appearance of the steps of  
 
stairs, is formed around the point of inoculation, and from  
 
the margin of this layer numerous threads and rods begin to  
 
pass out; after 24 hours we find large numbers of moving  
 
islands, composed of rods and threads presenting exactly the  
 
same appearance as in the case of proteus mirabilis. The  
 
deposit becomes gradually thicker and opaque, but no lique
 
  
  
faction of the gelatine occurs except sometimes quite at the  
+
faction of the gelatine occurs except sometimes quite at the surface. The formation of spirilla is seldom observed. Cultures in gelatine and blood serum do not show any marked odor; meat infusion, on the other hand, is decomposed by the organism with the production of a strong smell. In its other effects the proteus Zenkeri resembles the proteus mirabilis and the proteus vulgaris, and as Hauser' has pointed out, there is probably only one species of proteus, the vulgaris, of which the other forms are to be regarded as simple physiological variations.
surface. The formation of spirilla is seldom observed. Cultures in gelatine and blood serum do not show any marked  
 
odor; meat infusion, on the other hand, is decomposed by the  
 
organism with the production of a strong smell. In its other  
 
effects the proteus Zenkeri resembles the proteus mirabilis  
 
and the proteus vulgaris, and as Hauser' has pointed out,  
 
there is probably only one species of proteus, the vulgaris, of  
 
which the other forms are to be regarded as simple physiological variations.  
 
  
Literature.  
+
Literature.
  
1. Hauser: Ueber das Vorkommen von Proteus vulgaris  
+
1. Hauser: Ueber das Vorkommen von Proteus vulgaris bei einem jauchig-phlegmonosen Eiterung. Munchener medicinische Wocheuschrift No. 7, 16 Februar, 1S92, p. 103.
bei einem jauchig-phlegmonosen Eiterung. Munchener medicinische Wocheuschrift No. 7, 16 Februar, 1S92, p. 103.  
 
  
2. Beck : Die Faulnisbachterieu der menschlichen Leiche.  
+
2. Beck : Die Faulnisbachterieu der menschlichen Leiche. Baumgarten: Arbeiten auf dem Gebiete der pathologischen Anatomie und Bacteriologie aus dem pathologisch-anatomischen Institute zu Tiibingen, Bd. I, S. 155, 1889.
Baumgarten: Arbeiten auf dem Gebiete der pathologischen  
 
Anatomie und Bacteriologie aus dem pathologisch-anatomischen Institute zu Tiibingen, Bd. I, S. 155, 1889.  
 
  
3. Doderlein : Untersuchung iiber das Vorkommen von  
+
3. Doderlein : Untersuchung iiber das Vorkommen von Spaltpilzen in den Lochien, etc. Archiv f. Gyuilkologie, 1887, Bd. 31, S. 439.
Spaltpilzen in den Lochien, etc. Archiv f. Gyuilkologie,  
 
1887, Bd. 31, S. 439.  
 
  
4. Fliigge: Die Microorganismen, 188G, p. 310.  
+
4. Fliigge: Die Microorganismen, 188G, p. 310.
  
  
  
THE PHRENOLOGY OF GALL AND FLECHSIG'S DOCTRINE OF ASSOCIATION CENTRES  
+
THE PHRENOLOGY OF GALL AND FLECHSIG'S DOCTRINE OF ASSOCIATION CENTRES
  
IN THE CEREBRUM.  
+
IN THE CEREBRUM.
  
Br Lewellts F. Barker, JI. B., Associate Professor of Anatomy in the Johns ffopki7is University and  
+
Br Lewellts F. Barker, JI. B., Associate Professor of Anatomy in the Johns ffopki7is University and Assistant Resident Pathologist to the Johns Hopkins Hospital.
Assistant Resident Pathologist to the Johns Hopkins Hospital.  
 
  
[Remarks made before the Clinical Society of Maryland, November 20, 1896.]  
+
[Remarks made before the Clinical Society of Maryland, November 20, 1896.]
  
  
  
In the history of medicine the 18th century stands out  
+
In the history of medicine the 18th century stands out prominently as a period in which flourished a whole host of so-called medical systems and theories. The animismus of Stahl and the nerve-ether theory of Hoffman had been displaced by the system of Boerhaave ; the last, in turn, being gradually supplanted by the doctrine of irritability advanced by Albrecht von Haller, who had formulated a new theory based upon his experiments in physiology. William Cullen, again, combining Hoffman's system with the doctrine of irritability of Haller, sought the cause for all pathological processes in the nervous system. Each individual attempted to subordinate the most varied phenomena met with in disease to his own particular principle, and as yet the newer studies in anatomy and physiology were not wide-reaching enough in their influence to prevent the development of the most diverse and contradictory medical theories. The " excitation theory " introduced by John Brown met with an enthusiastic reception not only in England but also on the Continent, although it was gradually undermined by the vigorous opposition of Stieglitz and of Hufeland. It was only toward the end of the 18th century and the beginning of the 19th that the investigations in the field of natural science began to affect medical ideas to any very considerable degree. The natural philosophy of Schelling, which was accepted widely by physicians, especially in Germany, benefited medicine very little, if at all.
prominently as a period in which flourished a whole host of  
 
so-called medical systems and theories. The animismus of  
 
Stahl and the nerve-ether theory of Hoffman had been displaced by the system of Boerhaave ; the last, in turn, being  
 
gradually supplanted by the doctrine of irritability advanced  
 
by Albrecht von Haller, who had formulated a new theory  
 
based upon his experiments in physiology. William Cullen,  
 
again, combining Hoffman's system with the doctrine of irritability of Haller, sought the cause for all pathological processes in the nervous system. Each individual attempted to  
 
subordinate the most varied phenomena met with in disease to  
 
his own particular principle, and as yet the newer studies in  
 
anatomy and physiology were not wide-reaching enough in  
 
their influence to prevent the development of the most diverse  
 
and contradictory medical theories. The " excitation theory "  
 
introduced by John Brown met with an enthusiastic reception  
 
not only in England but also on the Continent, although it  
 
was gradually undermined by the vigorous opposition of  
 
Stieglitz and of Hufeland. It was only toward the end of the  
 
18th century and the beginning of the 19th that the investigations in the field of natural science began to affect medical  
 
ideas to any very considerable degree. The natural philosophy of Schelling, which was accepted widely by physicians,  
 
especially in Germany, benefited medicine very little, if at all.  
 
  
  
  
Indeed, the statement has been made that the general tendency of the time to favor Schelling's philosophy did more than  
+
Indeed, the statement has been made that the general tendency of the time to favor Schelling's philosophy did more than anything else, except the curiosity of the public, to spread the three false doctrines, animal magnetism, phrenology, and homCEopathy. Animal magnetism, fathered by the shrewd Anton Mesmer, had a brilliant career until the French commission with Franklin at its head successfully demolished it. Homceopathy, founded by Christian Friedr. Samuel Hahnemann, which attempted to subordinate the whole of the healing art to an arbitrary dictum, Siinilia similibus curantur, still has many adherents, especially in America. Phrenology or cranioscopy, connected closely with the name of Franz Josef Gall, has now but few disciples, and an avowal of belief in phrenological doctrines is usually received, even by the layman, with a suppressed smile.
anything else, except the curiosity of the public, to spread the  
 
three false doctrines, animal magnetism, phrenology, and homCEopathy. Animal magnetism, fathered by the shrewd Anton  
 
Mesmer, had a brilliant career until the French commission  
 
with Franklin at its head successfully demolished it. Homceopathy, founded by Christian Friedr. Samuel Hahnemann,  
 
which attempted to subordinate the whole of the healing art  
 
to an arbitrary dictum, Siinilia similibus curantur, still has  
 
many adherents, especially in America. Phrenology or cranioscopy, connected closely with the name of Franz Josef Gall,  
 
has now but few disciples, and an avowal of belief in phrenological doctrines is usually received, even by the layman, with  
 
a suppressed smile.  
 
  
Gall was born at Tiefenbrunu, in Germany, in 1758. The  
+
Gall was born at Tiefenbrunu, in Germany, in 1758. The history of his life affords entertaining reading. He studied medicine in Strassburg and Vienna, and practiced his profession in the latter city, where he became very well known. He tells us in his books how at a very early age he noticed among his playmates the existence of definite relations between the external appearance of the head and face and certain mental characteristics. His lectures delivered in Vienna, in which his phrenological doctrines were chiefly set forth, were very popular and largely attended until 1802. when at the instance of
history of his life affords entertaining reading. He studied  
 
medicine in Strassburg and Vienna, and practiced his profession  
 
in the latter city, where he became very well known. He tells us  
 
in his books how at a very early age he noticed among his playmates the existence of definite relations between the external  
 
appearance of the head and face and certain mental characteristics. His lectures delivered in Vienna, in which his  
 
phrenological doctrines were chiefly set forth, were very popular and largely attended until 1802. when at the instance of  
 
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
[No. 70.  
+
[No. 70.
  
  
  
the ecclesiastical authorities he was commanded by the Austrian government to discontinue "his public teaching. On  
+
the ecclesiastical authorities he was commanded by the Austrian government to discontinue "his public teaching. On leaving Vienna he went to Paris, where he gathered around him many supporters and continued to lecture, investigate and publish. He died at Montrouge, near Paris, in 1828.
leaving Vienna he went to Paris, where he gathered around  
 
him many supporters and continued to lecture, investigate  
 
and publish. He died at Montrouge, near Paris, in 1828.  
 
  
It has been thought by many that Gall's statement concerning his early observations of his schoolfellows was made  
+
It has been thought by many that Gall's statement concerning his early observations of his schoolfellows was made late in his life with the object of bolstering up his claims to originality. Macal lister, in his excellent and comprehensive article on Phrenology in the Encyclopedia Britannica, points out that Prochaska, of Vienna, who had published a work on the nervous system in 1784, is really to be looked upon as the father of phrenology, inasmuch as in his volume are to be found the germs of the views propounded by Gall in the same city a few years later. Prochaska in turn was preceded, at any rate as far as the idea of connecting the anatomical diversities of the brain with intellectual peculiarities is concerned, by Metzger, who 20 years before had proposed the inauguration of a series of observations bearing upon this point. Moreover, the doctrines of localization of function in the brain are of still older date, though it must be admitted that very little positive knowledge upon this point existed before the beginning of the 19th century.
late in his life with the object of bolstering up his claims to  
 
originality. Macal lister, in his excellent and comprehensive  
 
article on Phrenology in the Encyclopedia Britannica, points  
 
out that Prochaska, of Vienna, who had published a work on  
 
the nervous system in 1784, is really to be looked upon as the  
 
father of phrenology, inasmuch as in his volume are to be  
 
found the germs of the views propounded by Gall in the same  
 
city a few years later. Prochaska in turn was preceded, at any  
 
rate as far as the idea of connecting the anatomical diversities  
 
of the brain with intellectual peculiarities is concerned, by  
 
Metzger, who 20 years before had proposed the inauguration  
 
of a series of observations bearing upon this point. Moreover,  
 
the doctrines of localization of function in the brain are of  
 
still older date, though it must be admitted that very little  
 
positive knowledge upon this point existed before the beginning of the 19th century.  
 
  
After leaving Vienna, Gall attached to himself Spurzheim,  
+
After leaving Vienna, Gall attached to himself Spurzheim, who seems to have been for some time an enthusiastic pupil, and, along with his preceptor, to have made many investigations upon the structure of the brain and the shape of the skull. Spurzheim rendered great service to the phrenological doctrines in England and America, where he lectured to large audiences and attracted many pupils, the most important one in America being perhaps George Combe. Gall and Spurzheim did not, however, remain throughout life in harmony. They separated in 1813, in the subsequent years, each preaching his own doctrine and disparaging to a certain extent, at least, the philosophical views of the other.
who seems to have been for some time an enthusiastic pupil,  
 
and, along with his preceptor, to have made many investigations upon the structure of the brain and the shape of the  
 
skull. Spurzheim rendered great service to the phrenological  
 
doctrines in England and America, where he lectured to large  
 
audiences and attracted many pupils, the most important one  
 
in America being perhaps George Combe. Gall and Spurzheim did not, however, remain throughout life in harmony.  
 
They separated in 1813, in the subsequent years, each preaching his own doctrine and disparaging to a certain extent, at  
 
least, the philosophical views of the other.  
 
  
The doctrines of the phrenologists maybe briefly summed  
+
The doctrines of the phrenologists maybe briefly summed up as follows : They believed that the brain, as a whole, is the organ of the mind, and that it is made up of multiple organs, each mental capacity displayed by an individual depending upon the development of its corresponding organ in the brain. The form of the skull was thought to depend upon its relations to the brain within it, though Gall in one of his publications vigorously opposes the appellation " cranioscopy " as descriptive of his doctrines, stating that he had always maintained that his work was directed toward the anatomy and physiology of the brain, the contributions concerning the relations of the form of the skull to the morphology of the brain being merely an appendage of the bulk of his studies.
up as follows : They believed that the brain, as a whole, is  
 
the organ of the mind, and that it is made up of multiple  
 
organs, each mental capacity displayed by an individual depending upon the development of its corresponding organ in  
 
the brain. The form of the skull was thought to depend  
 
upon its relations to the brain within it, though Gall in  
 
one of his publications vigorously opposes the appellation  
 
" cranioscopy " as descriptive of his doctrines, stating that he  
 
had always maintained that his work was directed toward the  
 
anatomy and physiology of the brain, the contributions concerning the relations of the form of the skull to the morphology of the brain being merely an appendage of the bulk  
 
of his studies.  
 
  
It is not my purpose in this brief communication to  
+
It is not my purpose in this brief communication to describe the whole list of faculties and the portion of the brain assigned to each by Gall, Spurzheim and others; phrenological diagrams are familiar to all of us, and, moreover, 'an account of the views of the various adherents and modifiers of the system is to be found in almost any encyclopedia. A glance at the loose manner in which some of the so-called organs of the mind were localized in the brain by bumps upon the skull will suffice to show the
describe the whole list of faculties and the portion of the  
 
brain assigned to each by Gall, Spurzheim and others;  
 
phrenological diagrams are familiar to all of us, and, moreover, 'an account of the views of the various adherents  
 
and modifiers of the system is to be found in almost any  
 
encyclopedia. A glance at the loose manner in which some  
 
of the so-called organs of the mind were localized in the  
 
brain by bumps upon the skull will suffice to show the  
 
  
  
  
unscientific nature of the whole system. Whereas Gall believed that there were only some 26 or 27 organs of the  
+
unscientific nature of the whole system. Whereas Gall believed that there were only some 26 or 27 organs of the brain, with some of his followers the number was increased considerably. Fowler, for example, describing as many as 43 different faculties. Spurzheim divided the different capacities of the human mind into (1) the feelings, including the propensities and sentiments, and (2) the intellechial families, including the perceptive and reflective activities. As examples of the propensities may be mentioned concentrativeness, amativeness, philoprogenitiveness, combativeness and acquisitiveness ; of the lower sentiments, self-esteem, vanity and cautiousness may be mentioned; and of the higher sentiments, benevolence, veneration and firmness. Among the perceptive faculties he included the appreciation of form, size, weight, color, locality, number, order, time and language; while the power to study causality and the ability to compare one thing with another were described as reflective faculties. Having gained an idea as to the localization of a certain faculty, Gall and his friends would examine the heads of their acquaintances and the casts of the skulls of persons who had possessed the particular mental characteristic under examination, and would seek for a distinctive feature corresponding to this particular trait. The following examples are excerpted from Macallister's article. Amfitiveness was located by Gall in the lower part of the posterior surface of the head because he found this area to be hot in an hysterical widow. He referred the faculty to the underlying cerebellum. It is amusing to learn that the adherents of phrenology explained the presence of a rudimentary cerebellum in the girl Labrosse, who had during life exhibited very marked amative tendencies, by assuming its obliteration from over-use. Destructiveness was located above the external auditory meatus, inasmuch as this is the widest part of the skulls in carnivorous animals. A marked prominence had been found in this situation on the head of a student, "so fond of torturing animals that he afterwards became a surgeon," and it was also well developed in the head of an apothecary who subsequently became an executioner. Acquixitivcness, located upon the upper edge of the anterior half of the squamous suture, was attributed to"this region because Gall had noticed it to be prominent among the pickpockets of his acquaintance. The bump of con.(riictireiiess was easily found, since it was large on the head of a milliner of very good taste and upon a skull said to have been that of Eaphael. iSi If -esteem was located over the obelion because Gall found this region prominent in a beggar who had excused his poverty on account of his pride. The lore of approbation was supposed to be situated outside the obelion, inasmuch as this part of the head was especially protuberant in a lunatic who thought herself the queen of France. Cau/ioumess was assigned its proper situation from the observation of the large size of the parietal eminences in an ecclesiastic of hesitating disposition. Veneration, located in the middle line at the bregma, was determined by Gall after visiting churches, where he found that those who prayed with the greatest fervor had distinct prominences in this region. The bump of ideality was found especially developed in the busts of poets, and was said to be the part touched by the hand when comjiosing poetry. Since the frontal eminence was prominent in llabe
brain, with some of his followers the number was increased  
 
considerably. Fowler, for example, describing as many as 43  
 
different faculties. Spurzheim divided the different capacities  
 
of the human mind into (1) the feelings, including the propensities and sentiments, and (2) the intellechial families,  
 
including the perceptive and reflective activities. As examples  
 
of the propensities may be mentioned concentrativeness, amativeness, philoprogenitiveness, combativeness and acquisitiveness ; of the lower sentiments, self-esteem, vanity and cautiousness may be mentioned; and of the higher sentiments,  
 
benevolence, veneration and firmness. Among the perceptive  
 
faculties he included the appreciation of form, size, weight,  
 
color, locality, number, order, time and language; while the  
 
power to study causality and the ability to compare one thing  
 
with another were described as reflective faculties. Having  
 
gained an idea as to the localization of a certain faculty, Gall and  
 
his friends would examine the heads of their acquaintances and  
 
the casts of the skulls of persons who had possessed the particular mental characteristic under examination, and would  
 
seek for a distinctive feature corresponding to this particular  
 
trait. The following examples are excerpted from Macallister's article. Amfitiveness was located by Gall in the lower  
 
part of the posterior surface of the head because he found this  
 
area to be hot in an hysterical widow. He referred the faculty  
 
to the underlying cerebellum. It is amusing to learn that the  
 
adherents of phrenology explained the presence of a rudimentary cerebellum in the girl Labrosse, who had during life  
 
exhibited very marked amative tendencies, by assuming its  
 
obliteration from over-use. Destructiveness was located above  
 
the external auditory meatus, inasmuch as this is the widest  
 
part of the skulls in carnivorous animals. A marked prominence had been found in this situation on the head of a  
 
student, "so fond of torturing animals that he afterwards  
 
became a surgeon," and it was also well developed in the head  
 
of an apothecary who subsequently became an executioner.  
 
Acquixitivcness, located upon the upper edge of the anterior  
 
half of the squamous suture, was attributed to"this region  
 
because Gall had noticed it to be prominent among the pickpockets of his acquaintance. The bump of con.''(riictireiiess  
 
was easily found, since it was large on the head of a milliner  
 
of very good taste and upon a skull said to have been that of  
 
Eaphael. iSi If -esteem was located over the obelion because  
 
Gall found this region prominent in a beggar who had excused  
 
his poverty on account of his pride. The lore of approbation  
 
was supposed to be situated outside the obelion, inasmuch as  
 
this part of the head was especially protuberant in a lunatic  
 
who thought herself the queen of France. Cau/ioumess was  
 
assigned its proper situation from the observation of the large  
 
size of the parietal eminences in an ecclesiastic of hesitating  
 
disposition. Veneration, located in the middle line at the  
 
bregma, was determined by Gall after visiting churches, where  
 
he found that those who prayed with the greatest fervor had  
 
distinct prominences in this region. The bump of ideality  
 
was found especially developed in the busts of poets, and was  
 
said to be the part touched by the hand when comjiosing  
 
poetry. Since the frontal eminence was prominent in llabe
 
  
  
January, 1897.]  
+
January, 1897.]
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
lais and Swift, it was believed to be the organ of the sense of  
+
lais and Swift, it was believed to be the organ of the sense of the ludicrous. The capacity for recognizing faces was supposed to depend upon the width of the interval between the eyes, inasmuch as Gall found in a squinting girl a good memory for faces. The murderer Thurtell, who had a large organ of benevolence, is said by devotees to phrenology to have been in reality generous, since it was discovered that he once gave half a guinea to a friend. Many other laughable instances might be given of these crude methods of localization and of the futile attempts of the adherents of the doctrine to bolster up their tumbling edifices.
the ludicrous. The capacity for recognizing faces was supposed to depend upon the width of the interval between the  
 
eyes, inasmuch as Gall found in a squinting girl a good  
 
memory for faces. The murderer Thurtell, who had a large  
 
organ of benevolence, is said by devotees to phrenology to have  
 
been in reality generous, since it was discovered that he once  
 
gave half a guinea to a friend. Many other laughable instances  
 
might be given of these crude methods of localization and of  
 
the futile attempts of the adherents of the doctrine to bolster  
 
up their tumbling edifices.  
 
  
It is easy to understand how a shrewd man like Gall, — and  
+
It is easy to understand how a shrewd man like Gall, — and any one who reads his books will be very ready to grant his shrewdness and intelligence, — developing with great rapidity a system full of interest for the public and stimulating their curiosity by providing them with an infallible clue to the determination of character and fitness for occupation in life, should have attained wide-spread and lucrative popularity. He soon made large amounts of money, lived in state, and numbered among his personal friends some of the first names in France. Nor was he a charlatan pure and simple; he undoubtedly had a brilliant mind, and made elaborate and careful studies of the brain and skull which resulted in discoveries of permanent value concerning the anatomy and physiology of the brain. No better proof of this statement can be obtained than by perusing the volumes which I place before you, kindly loaned by the Provost of the Peabody Library. This atlas, with its well-executed copper- plates, in particular, shows the care with which much of his work must have been done. The edition, including the atlas, sold in Paris at 1000 francs.
any one who reads his books will be very ready to grant his  
 
shrewdness and intelligence, — developing with great rapidity  
 
a system full of interest for the public and stimulating their  
 
curiosity by providing them with an infallible clue to the  
 
determination of character and fitness for occupation in life,  
 
should have attained wide-spread and lucrative popularity.  
 
He soon made large amounts of money, lived in state, and  
 
numbered among his personal friends some of the first names  
 
in France. Nor was he a charlatan pure and simple; he undoubtedly had a brilliant mind, and made elaborate and careful  
 
studies of the brain and skull which resulted in discoveries  
 
of permanent value concerning the anatomy and physiology  
 
of the brain. No better proof of this statement can be obtained than by perusing the volumes which I place before you,  
 
kindly loaned by the Provost of the Peabody Library. This  
 
atlas, with its well-executed copper- plates, in particular, shows  
 
the care with which much of his work must have been done.  
 
The edition, including the atlas, sold in Paris at 1000 francs.  
 
  
It is curious how nearly a man starting with false premises  
+
It is curious how nearly a man starting with false premises may often approach to actual conditions. 'I'he newer investigations bearing upon the architecture of the brain have thrown much unexpected light upon the origin of the phenomena of the mind; the significance of the brain for the psychic phenomena has been established upon the basis of exact scientific investigations, and we are now justified perhaps in speaking in a certain sense of a " new phrenology." It may be interesting to refer briefly to the series of investigations which have led up to our present knowledge upon this subject.
may often approach to actual conditions. 'I'he newer investigations bearing upon the architecture of the brain have thrown  
 
much unexpected light upon the origin of the phenomena of  
 
the mind; the significance of the brain for the psychic phenomena has been established upon the basis of exact scientific  
 
investigations, and we are now justified perhaps in speaking in  
 
a certain sense of a " new phrenology." It may be interesting  
 
to refer briefly to the series of investigations which have led  
 
up to our present knowledge upon this subject.  
 
  
In so far as his doctrine maintained that the convolutions  
+
In so far as his doctrine maintained that the convolutions represented the most important substratum of the mental activity, and that the single convolutions of the cerebral cortex are not of equal significance for intellectual life, Gall most certainly approached the modern theory of cerebral localization. The investigations of Flourens led him to very different conclusions, and in 1812 he published his well-known " Examen de la Phrenologie," which was thought to have demolished the phrenological doctrines. It was Flourens' idea that every portion of the substance of the cerebral cortex had precisely the same significance. He believed that the removal of any given mass of the grey matter affected all the mental functions in exactly the same way, so that visual or olfactory perceptions would not be diminished in different proportions, no matter what area was extirpated. The facts which have been discovered by pathologists and clinicians concerning aphasia were, however, in entire opposition to these ideas of Flourens. Gall and Bouillaud had recognized that circumscribed lesions
represented the most important substratum of the mental  
 
activity, and that the single convolutions of the cerebral cortex  
 
are not of equal significance for intellectual life, Gall most  
 
certainly approached the modern theory of cerebral localization. The investigations of Flourens led him to very different  
 
conclusions, and in 1812 he published his well-known " Examen de la Phrenologie," which was thought to have demolished  
 
the phrenological doctrines. It was Flourens' idea that every  
 
portion of the substance of the cerebral cortex had precisely  
 
the same significance. He believed that the removal of any  
 
given mass of the grey matter affected all the mental functions  
 
in exactly the same way, so that visual or olfactory perceptions would not be diminished in different proportions, no  
 
matter what area was extirpated. The facts which have been  
 
discovered by pathologists and clinicians concerning aphasia  
 
were, however, in entire opposition to these ideas of Flourens.  
 
Gall and Bouillaud had recognized that circumscribed lesions  
 
  
  
  
in the cerebrum, especially in the frontal region, could give  
+
in the cerebrum, especially in the frontal region, could give rise to definite disturbances in speech. Later, Marc Dax pointed out that aphasia occurred practically only when the left half of the cerebrum was diseased, and in 1863 Broca established the fact that in right-handed people the third left frontal convolution is the portion of the grey matter of the cerebral cortex which is important for articular speech. Subsequent studies upon aphasia have shown that there are several dift'erent kinds of the affection, only one variety of which depends upon disease of Broca's convolution, i. e. the one in which the capacity to speak out the word which the individual has in his consciousness is lost; the inability to understand spoken words, and the incapacity to call into consciousness the names of objects which are visible to the individual, being associated with disease of other parts. These facts alone prove that different regions of the brain are of different significance for the intellectual functions.
rise to definite disturbances in speech. Later, Marc Dax  
 
pointed out that aphasia occurred practically only when the  
 
left half of the cerebrum was diseased, and in 1863 Broca  
 
established the fact that in right-handed people the third left  
 
frontal convolution is the portion of the grey matter of the  
 
cerebral cortex which is important for articular speech. Subsequent studies upon aphasia have shown that there are several dift'erent kinds of the affection, only one variety of which  
 
depends upon disease of Broca's convolution, i. e. the one in  
 
which the capacity to speak out the word which the individual has in his consciousness is lost; the inability to understand  
 
spoken words, and the incapacity to call into consciousness the  
 
names of objects which are visible to the individual, being  
 
associated with disease of other parts. These facts alone  
 
prove that different regions of the brain are of different significance for the intellectual functions.  
 
  
In addition to the studies on aphasia there have been  
+
In addition to the studies on aphasia there have been recorded a whole series of pathological lesions which clinically were associated with definite disturbances of sensation ; thus, lesions of the occipital cortex have a tendency to affect visual sensations; lesions of certain portions of the temporal cortex interfere with hearing; the sense of smell has been shown to be connected with the under surface of the cerebrum, and the sense of touch with the upper frontal and anterior parietal regions. Physiologists by means of experiments upon animals have added most satisfactory support to these clinical and pathological observations.
recorded a whole series of pathological lesions which clinically were associated with definite disturbances of sensation ;  
 
thus, lesions of the occipital cortex have a tendency to affect  
 
visual sensations; lesions of certain portions of the temporal  
 
cortex interfere with hearing; the sense of smell has been  
 
shown to be connected with the under surface of the cerebrum, and the sense of touch with the upper frontal and  
 
anterior parietal regions. Physiologists by means of experiments upon animals have added most satisfactory support to  
 
these clinical and pathological observations.  
 
  
In 1870 Fritsch and Hitzig reported the results of their  
+
In 1870 Fritsch and Hitzig reported the results of their investigations concerning galvanic excitation of the surface of the brain of animals, in which it was shown that stimulation of definite regions calls forth movements of certain only of the parts of the body. Three years later Ferrier used faradic stimulation of the cortex and was able to elicit quite complicated movements of different parts of the body, movements which seemed to be purposeful, inasmuch as they correspond to those employed by the animal when utilizing its sense organs, that is to say, movements such as are employed in listening, touching, looking at, or smelling external objects. Munk proved fiirther that by the removal of certain convolutions it was possible to produce in animals disturbances of sensory activity quite analogous to those which had been observed in the clinical and pathological study of diseased human beings.
investigations concerning galvanic excitation of the surface of  
 
the brain of animals, in which it was shown that stimulation  
 
of definite regions calls forth movements of certain only of  
 
the parts of the body. Three years later Ferrier used faradic  
 
stimulation of the cortex and was able to elicit quite complicated movements of different parts of the body, movements  
 
which seemed to be purposeful, inasmuch as they correspond  
 
to those employed by the animal when utilizing its sense  
 
organs, that is to say, movements such as are employed in  
 
listening, touching, looking at, or smelling external objects.  
 
Munk proved fiirther that by the removal of certain convolutions it was possible to produce in animals disturbances of  
 
sensory activity quite analogous to those which had been  
 
observed in the clinical and pathological study of diseased  
 
human beings.  
 
  
The studies of Goltz upon dogs supply an exceedingly interesting link in the chain of experimentation. This investigator  
+
The studies of Goltz upon dogs supply an exceedingly interesting link in the chain of experimentation. This investigator demonstrated the possibility of keeping a dog alive for a considerable length of time in the entire absence of a cerebral cortex, and in this way was able to ascertain what faculties the animal possesses when only the lower parts of the brain are functioning uncontrolled by the cerebrum. He found that an animal without a cerebrum still possesses a very complex nerve life, a fact which is not so very surprising when one recollects the observations of comparative afiatomy. While the dog of Goltz's experiment appeared to be devoid of memory and judgment and incapable of finding out for himself among the objects outside of the body those necessary for the satisfaction of his needs, he showed himself to be by no
demonstrated the possibility of keeping a dog alive for a  
 
considerable length of time in the entire absence of a cerebral  
 
cortex, and in this way was able to ascertain what faculties  
 
the animal possesses when only the lower parts of the brain  
 
are functioning uncontrolled by the cerebrum. He found  
 
that an animal without a cerebrum still possesses a very complex nerve life, a fact which is not so very surprising when  
 
one recollects the observations of comparative afiatomy.  
 
While the dog of Goltz's experiment appeared to be devoid of  
 
memory and judgment and incapable of finding out for himself among the objects outside of the body those necessary for  
 
the satisfaction of his needs, he showed himself to be by no  
 
  
  
  
10  
+
10
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
[No. 70.  
+
[No. 70.
  
  
  
means an involuntary machine. Goltz states that he could  
+
means an involuntary machine. Goltz states that he could stand upright, could run, could be set in motion by external stimuli of various kinds, that he could show evidences of emotion, becoming angry and biting and howling under provocation. When hungry the whole body entered into lively motion, and after food had been taken the animal again became restful and showed evident signs of satisfaction. As Flechsig points out, these experiments do not permit any conclusion regarding the condition of consciousness after the loss of the cerebrum, but they do show distinctly the power and the independence of the bodily instincts, and teach us that no small part of the acts concerned in these can be set free simply through bodily influences, entirely independent of the higher mental faculties.
stand upright, could run, could be set in motion by external  
 
stimuli of various kinds, that he could show evidences of  
 
emotion, becoming angry and biting and howling under provocation. When hungry the whole body entered into lively  
 
motion, and after food had been taken the animal again became  
 
restful and showed evident signs of satisfaction. As Flechsig  
 
points out, these experiments do not permit any conclusion  
 
regarding the condition of consciousness after the loss of the  
 
cerebrum, but they do show distinctly the power and the  
 
independence of the bodily instincts, and teach us that no  
 
small part of the acts concerned in these can be set free  
 
simply through bodily influences, entirely independent of the  
 
higher mental faculties.  
 
  
The studies of His and Flechsig, which have done so much  
+
The studies of His and Flechsig, which have done so much in recent years to give us an insight into the finer organization of the nervous system, have been especially devoted to the development of the nervous system. It is to the work of Flechsig to which I wish on this occasion to especially direct your attention.* His method of outlining tracts by the observation of successive periods of myelinization is not new. His larger work, published many yeai'S ago and entitled "Die Leitungsbahnen iniGehirn und Riickenmark," is based almost entirely upon studies made after this fashion. The tracts which function first, receive their myelin sheaths before the others, and a tolerably definite idea of the physiological capacities of a develojiing animal at a given moment, up to a certain period at least, can be gained by ascertaining the number of tracts which have already been medullated. Thus the spinal cord, medulla, pons and corpora quadrigemina are almost entirely medullated at a time when the parts higher up show very little or no myelin. Even in the new-born child, Flechsig has shown that the cerebrum is almost entirely unripe, inasmuch as extremely few of the myriads of nerve fibres which it contains are at this period medullated. Man, therefore, at the beginning of his earthly experience, resembles very closely the dog of Goltz's experiments; he is practically a being without a cerebrum, and yet, as in Goltz's dog, even with the drawing of the first breath, the bodily instincts in the child demand satisfaction. The new-born infant, with satisfied impulses and unaffected by external stimuli of a disagreeable nature, shows no evidence of consciousness. H it become hungry or be exposed to cold, or if painful stimuli be applied to it, active movements of the body result.
in recent years to give us an insight into the finer organization  
 
of the nervous system, have been especially devoted to the  
 
development of the nervous system. It is to the work of  
 
Flechsig to which I wish on this occasion to especially direct  
 
your attention.* His method of outlining tracts by the observation of successive periods of myelinization is not new. His  
 
larger work, published many yeai'S ago and entitled "Die  
 
Leitungsbahnen iniGehirn und Riickenmark," is based almost  
 
entirely upon studies made after this fashion. The tracts  
 
which function first, receive their myelin sheaths before the  
 
others, and a tolerably definite idea of the physiological  
 
capacities of a develojiing animal at a given moment, up to a  
 
certain period at least, can be gained by ascertaining the number of tracts which have already been medullated. Thus the  
 
spinal cord, medulla, pons and corpora quadrigemina are  
 
almost entirely medullated at a time when the parts higher up  
 
show very little or no myelin. Even in the new-born child,  
 
Flechsig has shown that the cerebrum is almost entirely  
 
unripe, inasmuch as extremely few of the myriads of nerve  
 
fibres which it contains are at this period medullated. Man,  
 
therefore, at the beginning of his earthly experience, resembles  
 
very closely the dog of Goltz's experiments; he is practically  
 
a being without a cerebrum, and yet, as in Goltz's dog, even  
 
with the drawing of the first breath, the bodily instincts in  
 
the child demand satisfaction. The new-born infant, with  
 
satisfied impulses and unaffected by external stimuli of a  
 
disagreeable nature, shows no evidence of consciousness. H  
 
it become hungry or be exposed to cold, or if painful stimuli  
 
be applied to it, active movements of the body result.  
 
  
Flechsig has shown, in his study of the embryonal cerebrum,  
+
Flechsig has shown, in his study of the embryonal cerebrum, that it is the sensory paths which first become medullated.
that it is the sensory paths which first become medullated.  
 
  
*I have thought it best at this time to present, in as clear and  
+
I have thought it best at this time to present, in as clear and
brief a manner as possible and without discussion, the main tenets  
+
brief a manner as possible and without discussion, the main tenets of Flechsig with regard to the structure and function of the brain. While in such a short communication it is impossible to do justice to so broad a subject, it is to be hoped that it may be possible to show at least the trend of his views. The anatomical basis for his studies is given at some length in the voluminous notes appended to his "Gehirn und S'eele " (Leipzig, Veit. Co., 189(>). An idea of some of the criticisms which may be made of his doctrines can be gained by a perusal of the discussion of the address delivered by Flechsig at the Versammlung deutscher Naturforscher und Aerzte, Frankfurt, September, lS9()(cf. Centralbl. f. Nervenheilkunde und Psychiatric, October, ISOO).
of Flechsig with regard to the structure and function of the brain.  
 
While in such a short communication it is impossible to do justice  
 
to so broad a subject, it is to be hoped that it may be possible to  
 
show at least the trend of his views. The anatomical basis for his  
 
studies is given at some length in the voluminous notes appended  
 
to his "Gehirn und S'eele " (Leipzig, Veit. Co., 189(>). An idea of  
 
some of the criticisms which may be made of his doctrines can be  
 
gained by a perusal of the discussion of the address delivered by  
 
Flechsig at the Versammlung deutscher Naturforscher und Aerzte,  
 
Frankfurt, September, lS9()(cf. Centralbl. f. Nervenheilkunde und  
 
Psychiatric, October, ISOO).  
 
  
  
  
Gradually the individual fibres of one sensory path after  
+
Gradually the individual fibres of one sensory path after another, beginning with that concerned in the sense of smell and ending with that by which are carried auditory impulses, passing from the sense organs of the body toward the cerebral cortex, gain their myelin sheaths. Each sensory path includes a very large number of nerve fibres containing the axones of neurones whose cell bodies are situated lower down. Following the different sensory paths to their cortical termination, it is easy to show in these early stages, in which very little of the brain is medullated, that the individual sensory paths terminate in tolerably sharply circumscribed cortical regions, for the most part widely removed from one another, being separated by masses of cortical sitbstauce which remain for a considerable period entirely unripe. Indeed, the cortical terminations of the individual sense paths correspond entirely to those regions of the surface of the brain which pathological observation has shown to stand in relation to the different qualities of sensation. It is the destruction of these internal sense organs which results in cortical blindness, cortical deafness, etc.
another, beginning with that concerned in the sense of smell  
 
and ending with that by which are carried auditory impulses,  
 
passing from the sense organs of the body toward the cerebral  
 
cortex, gain their myelin sheaths. Each sensory path includes  
 
a very large number of nerve fibres containing the axones of  
 
neurones whose cell bodies are situated lower down. Following the different sensory paths to their cortical termination, it  
 
is easy to show in these early stages, in which very little of  
 
the brain is medullated, that the individual sensory paths  
 
terminate in tolerably sharply circumscribed cortical regions,  
 
for the most part widely removed from one another, being  
 
separated by masses of cortical sitbstauce which remain for a  
 
considerable period entirely unripe. Indeed, the cortical  
 
terminations of the individual sense paths correspond entirely  
 
to those regions of the surface of the brain which pathological  
 
observation has shown to stand in relation to the different  
 
qualities of sensation. It is the destruction of these internal  
 
sense organs which results in cortical blindness, cortical deafness, etc.  
 
  
After these sensory paths in the child's brain have become  
+
After these sensory paths in the child's brain have become medullated, new paths begin to develop from the points where the sense fibres terminate — paths which go in the opposite direction. These fibres as they become medullated can be traced passing downwards to the medulla and the spinal cord, to the nuclei of origin of the motor nerves, and connecting in this way the sensory regions on the surface of the cerebrum with the motor apparatus. The area of the cortex concerned in the sense of touch has an especially well developed bundle of these motor fibres, the fasciculus cerebro-spinalis or so-called pyramidal tract, which consists of more than 100,000 fibres on each side, an arrangement which permits the carrying out of very delicate movements, especially of the parts of the body concerned in the sense of touch. Connections between the cortical sensory areas and the lower centres which appear to be concerned more directly with the bodily instincts, have already been made out. It is clear, therefore, that bodily instincts and external sense impressions may reciprocally influence one another. According to Flechsig, the sense of smell is moat intimately connected, the sense of hearing least associated with the centres concerned in the exercise of the lower instincts, a fact which, if confirmed, might account for the more ideal character of auditory impressions.
medullated, new paths begin to develop from the points where  
 
the sense fibres terminate — paths which go in the opposite  
 
direction. These fibres as they become medullated can be  
 
traced passing downwards to the medulla and the spinal cord,  
 
to the nuclei of origin of the motor nerves, and connecting in  
 
this way the sensory regions on the surface of the cerebrum  
 
with the motor apparatus. The area of the cortex concerned  
 
in the sense of touch has an especially well developed bundle  
 
of these motor fibres, the fasciculus cerebro-spinalis or so-called  
 
pyramidal tract, which consists of more than 100,000 fibres on  
 
each side, an arrangement which permits the carrying out of  
 
very delicate movements, especially of the parts of the body  
 
concerned in the sense of touch. Connections between the  
 
cortical sensory areas and the lower centres which appear to be  
 
concerned more directly with the bodily instincts, have already  
 
been made out. It is clear, therefore, that bodily instincts  
 
and external sense impressions may reciprocally influence one  
 
another. According to Flechsig, the sense of smell is moat  
 
intimately connected, the sense of hearing least associated  
 
with the centres concerned in the exercise of the lower  
 
instincts, a fact which, if confirmed, might account for the  
 
more ideal character of auditory impressions.  
 
  
In the diagram before you, the localization of these various  
+
In the diagram before you, the localization of these various sense areas in the brain, according to the newest investigations of Flechsig, has been pictured. It will be seen that they are very sharply circumscribed, although at the peripheries of the areas the fibres do not terminate so close together as in the central parts. The large region, the sonifesthetic area, occupying the whole domain between the fossa sylvii up to the corpus callosum, including the gyri centrales and the feet of the frontal convolutions, together with the lobulus paracentralis and the middle third of the gyrus fornicatus, represents the cortical field in which terminate on either side those of the 200,000 fibres of the medial lemniscus which do not stop at the basal ganglia. These fibres, together with those relaid in the thalamus, it is believed, carry to the cortex the impulses which are concerned in the projection
sense areas in the brain, according to the newest investigations  
 
of Flechsig, has been pictured. It will be seen that they are  
 
very sharply circumscribed, although at the peripheries of  
 
the areas the fibres do not terminate so close together as in the  
 
central parts. The large region, the sonifesthetic area, occupying the whole domain between the fossa sylvii up to the  
 
corpus callosum, including the gyri centrales and the feet of  
 
the frontal convolutions, together with the lobulus paracentralis and the middle third of the gyrus fornicatus,  
 
represents the cortical field in which terminate on either side  
 
those of the 200,000 fibres of the medial lemniscus which  
 
do not stop at the basal ganglia. These fibres, together with  
 
those relaid in the thalamus, it is believed, carry to the  
 
cortex the impulses which are concerned in the projection  
 
  
  
  
Gyru.cm,.r..l,{J»«;r;;p,S<,m»»>.l,.tlo.,„.  
+
Gyru.cm,.r..l,{J»«;r;;p,S<,m»»>.l,.tlo.,„.
  
  
  
Corpus cAllonnn  
+
Corpus cAllonnn
  
Porulx louguti,  
+
Porulx louguti,
  
(Septum pellucW,  
+
(Septum pellucW,
  
  
  
  
"^ti^^i^r^^^j^  
+
"^ti^^i^r^^^j^
  
  
  
^^^  
+
^^^
  
  
  
Oolliculiia superior (corp. quad.)  
+
Oolliculiia superior (corp. quad.) . Hnin nucleus of tliaUmua.
. Hnin nucleus of tliaUmua.  
 
  
  
  
  
Fig-. 6.  
+
Fig-. 6.
  
  
  
Soraae»tUetic  
+
Soraae»tUetic
  
  
  
  
Gynm hippocampi.  
+
Gynm hippocampi.
  
  
  
Fig. +.  
+
Fig. +.
  
  
Line 1,303: Line 513:
  
  
LEGENDS.  
+
LEGENDS.
  
Fig. 1. Sagittal section through brain of a child one month old stained by the  
+
Fig. 1. Sagittal section through brain of a child one month old stained by the Weigert-Pal method. lAfter FUchsig.)
Weigert-Pal method. lAfter FUchsig.)  
 
  
a. Taenia thalaini optici iretiex path tor the transference of olfactory  
+
a. Taenia thalaini optici iretiex path tor the transference of olfactory
  
impressions to the centres governing the movements of the  
+
impressions to the centres governing the movements of the head ?).
head ?).  
 
  
b. White matter of septum pellucidum (in part running between the  
+
b. White matter of septum pellucidum (in part running between the
  
olfactory area and the gyrus hippocampi).  
+
olfactory area and the gyrus hippocampi).
  
c. Corpus callosum corresponding to the somiesthetic area.  
+
c. Corpus callosum corresponding to the somiesthetic area. D. Superior I
D. Superior I  
 
  
h. Inferior jcolliculus of corpora cjuadrigemina, cut near the middle  
+
h. Inferior jcolliculus of corpora cjuadrigemina, cut near the middle line : here very few meduUated fibres are present; sections lateral to this show many, r. Red nucleus of the tegmentum ; below this is seen the decussatio brachii conjunctiva (In this and succeeding plates I have translated Flechsig's terms as tar as possible into the nomenclature of the Anatomical Society. For his sense-centres and association-centres English terms which seemed most suitable have been employed For the suggestion of the name " soma-sthetic area" as a translation of the German KorperfuhUplKire I am indebted to Prof. B. L. Gildersleeve.— L. F. B.)
line : here very few meduUated fibres are present; sections lateral  
 
to this show many,  
 
r. Red nucleus of the tegmentum ; below this is seen the decussatio  
 
brachii conjunctiva  
 
(In this and succeeding plates I have translated Flechsig's terms as tar as possible into the nomenclature of the Anatomical Society. For his sense-centres and  
 
association-centres English terms which seemed most suitable have been employed  
 
For the suggestion of the name " soma-sthetic area" as a translation of the German  
 
KorperfuhUplKire I am indebted to Prof. B. L. Gildersleeve.— L. F. B.)  
 
  
Fio. 2. Horizontal section through the brain of a child aged 3 months. (AHer  
+
Fio. 2. Horizontal section through the brain of a child aged 3 months. (AHer Flechstg.) \ j'-'»
Flechstg.) \ j'-'»  
 
  
II. Tractus opticus.  
+
II. Tractus opticus.
  
H. Association system (cross-section) in the g. hippocampi, connecting  
+
H. Association system (cross-section) in the g. hippocampi, connecting the olfactory cortex of the uncus with Ammon's horn, going over into the alveus. M. Nucleus amygdalae. P. Pyramidal tract in cross-section. p'. Temporal cerebro-pontal path. p'. Frontal cerebro-pontal path. The decussation of the nervus trochlearis is shown. The projection fibres of the olfactory sense area and of the g. hippocampi are completely medullated. At the tip of the frontal lobe and at the junction of the superior and middle temporal gyri myelin is as yet entirely absent. In many other parts (darker in tint) corresponding to the advanced age, association fibres are already medullated.
the olfactory cortex of the uncus with Ammon's horn, going  
 
over into the alveus.  
 
M. Nucleus amygdalae.  
 
P. Pyramidal tract in cross-section.  
 
p'. Temporal cerebro-pontal path.  
 
p'. Frontal cerebro-pontal path.  
 
The decussation of the nervus trochlearis is shown. The projection fibres of the  
 
olfactory sense area and of the g. hippocampi are completely medullated. At the  
 
tip of the frontal lobe and at the junction of the superior and middle temporal gyri  
 
myelin is as yet entirely absent. In many other parts (darker in tint) corresponding  
 
to the advanced age, association fibres are already medullated.  
 
  
Fio. 3. Horizontal section from the brain of a child a little over a week old.  
+
Fio. 3. Horizontal section from the brain of a child a little over a week old. {After Flcchxig.)
{After Flcchxig.)  
 
  
C. Nucleus oaudatus.  
+
C. Nucleus oaudatus. P. Putamen of the nucleus lenticularis. gp. Globus pallidus of the nucleus lenticularis. The optic radiation is well medullated ; the auditory path is not yet medullated as far as the cortex.
P. Putamen of the nucleus lenticularis.  
 
gp. Globus pallidus of the nucleus lenticularis.  
 
The optic radiation is well medullated ; the auditory path is not yet medullated  
 
as far as the cortex.  
 
  
Fig. 4. Sagittal section through the brain of a child said to have died in the  
+
Fig. 4. Sagittal section through the brain of a child said to have died in the fifth month of life. (The child was probably some months older.) (After Fleclmii.) All parts of the white substance medullated, only in places still mixed with non-medullated fibres.
fifth month of life. (The child was probably some months older.) (After Fleclmii.)  
 
All parts of the white substance medullated, only in places still mixed with  
 
non-medullated fibres.  
 
  
C, P. (IP, as in Fig. 3.  
+
C, P. (IP, as in Fig. 3. T. Thalamus (lateral nucleus). II. External geniculate body.
T. Thalamus (lateral nucleus).  
 
II. External geniculate body.  
 
  
X. Substantia iiinominata Rei! (gray substance between the n. lenticularis and the n. amygdalse).  
+
X. Substantia iiinominata Rei! (gray substance between the n. lenticularis and the n. amygdalse). M. Nucleus amygdalir.
M. Nucleus amygdalir.  
 
  
x—y. Projection fibres of the anterior upper and inner part of the  
+
x—y. Projection fibres of the anterior upper and inner part of the somiEsthetic area (KOrperfiihlsphiire); these run from the internal capsule (between P and C) forwards and bend around at an acute angle at x to pass upwards and inwards. V. Lateral ventricle.
somiEsthetic area (KOrperfiihlsphiire); these run from the  
 
internal capsule (between P and C) forwards and bend around  
 
at an acute angle at x to pass upwards and inwards.  
 
V. Lateral ventricle.  
 
  
Fig. .5. External view of right cerebral hemisphere, showing sense-centres and  
+
Fig. .5. External view of right cerebral hemisphere, showing sense-centres and association-centres. (After Fle.chxig.) The more closely dotted areas show the regions in which the majority of the sensory projection fibres terminate. The large areas between the dotted areas represent the association centres.
association-centres. (After Fle.chxig.) The more closely dotted areas show the regions  
 
in which the majority of the sensory projection fibres terminate. The large areas  
 
between the dotted areas represent the association centres.  
 
  
Fio. 6. Internal view of left cerebral hemisphere. (After FUchHg.)  
+
Fio. 6. Internal view of left cerebral hemisphere. (After FUchHg.)
  
1. Corpus mammillare.  
+
1. Corpus mammillare.
  
2. Median section of optic chiasm.  
+
2. Median section of optic chiasm.
  
3. Cross-section of anterior commissure.  
+
3. Cross-section of anterior commissure.
  
4. Superior colliculus of corpora i|uadrigemina.  
+
4. Superior colliculus of corpora i|uadrigemina. .5, Corpus callosum (cross-section).
.5, Corpus callosum (cross-section).  
 
  
6 Fornix.  
+
6 Fornix.
  
7. Septum pellucidum.  
+
7. Septum pellucidum. z. Pineal gland. H.S. Tegmentum. T. Basis pedunculi.
z. Pineal gland.  
 
H.S. Tegmentum.  
 
T. Basis pedunculi.  
 
  
  
  
January, 1897.]  
+
January, 1897.]
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
11  
+
11
  
  
  
into consciousness of sensations of touch, pain, temperature,  
+
into consciousness of sensations of touch, pain, temperature, muscle and tendon sense, thirst, hunger and equilibrium, as well as sexual sensations, that is to say, the sensations which tell us of the condition of our bodies rather than that of external objects. It is obvious that this area must represent a complex mass of sense centres rather than a single sensory area ; indeed, we already have evidence from the pathological side indicating very different functions to the several parts of the somssthetic area, although the localization here, as might be expected, concerns that of groups of elementary rather than of single sensations. This is the area in which the body in its whole extent can be reflected in consciousness. It is possible that a similar mirroring of somatic sensations occurs in the cerebellar cortex.
muscle and tendon sense, thirst, hunger and equilibrium, as  
 
well as sexual sensations, that is to say, the sensations which  
 
tell us of the condition of our bodies rather than that of  
 
external objects. It is obvious that this area must represent  
 
a complex mass of sense centres rather than a single sensory  
 
area ; indeed, we already have evidence from the pathological  
 
side indicating very different functions to the several parts of  
 
the somssthetic area, although the localization here, as might  
 
be expected, concerns that of groups of elementary rather than  
 
of single sensations. This is the area in which the body in its  
 
whole extent can be reflected in consciousness. It is possible  
 
that a similar mirroring of somatic sensations occurs in the  
 
cerebellar cortex.  
 
  
Besides being a sensory field, the soma3sthetic area is also  
+
Besides being a sensory field, the soma3sthetic area is also the great motor region whence nearly all the movements serving for the voh;ntary satisfaction of the bodily instincts appear to start. When a man voluntarily swallows, chews, breathes or seizes an external object, it is this area which is active.
the great motor region whence nearly all the movements  
 
serving for the voh;ntary satisfaction of the bodily instincts  
 
appear to start. When a man voluntarily swallows, chews,  
 
breathes or seizes an external object, it is this area which is  
 
active.  
 
  
The nerve fibres conducting the impulses concerned in olfactory sensations terminate, according to Flechsig, mainly in the  
+
The nerve fibres conducting the impulses concerned in olfactory sensations terminate, according to Flechsig, mainly in the gyrus unciuatus where it touches the island of Keil, although many of them end in the frontal lobe.
gyrus unciuatus where it touches the island of Keil, although  
 
many of them end in the frontal lobe.  
 
  
The fibres concerned in visual sensation, passing from the  
+
The fibres concerned in visual sensation, passing from the lateral geniculate body, the thalamus and the superior colliculus of the corpora quadrigemina, follow a direct course to terminate in the immediate neighborhood of the calcarine fissure, although subsequently fibres run out from this tract into adjacent areas, ending, however, only in that part of the cortex of the occipital lobe which shows the well known macroscopic stripe of Vicq d'Azyr. It is interesting to note that fibres from the fovea centralis are believed to go to the cortex of both cerebral hemispheres. Such a distribution would help to account for the incomplete blindness from unilateral cortical lesions.
lateral geniculate body, the thalamus and the superior colliculus of the corpora quadrigemina, follow a direct course to  
 
terminate in the immediate neighborhood of the calcarine  
 
fissure, although subsequently fibres run out from this tract  
 
into adjacent areas, ending, however, only in that part of the  
 
cortex of the occipital lobe which shows the well known  
 
macroscopic stripe of Vicq d'Azyr. It is interesting to note  
 
that fibres from the fovea centralis are believed to go to the  
 
cortex of both cerebral hemispheres. Such a distribution  
 
would help to account for the incomplete blindness from  
 
unilateral cortical lesions.  
 
  
The fibres communicating auditory impulses to the cerebral  
+
The fibres communicating auditory impulses to the cerebral cortex form the lateral lemniscus in the pons and are connected particularly with the median geniculate body; they run out into the temporal lobe to terminate mainly in the transverse temporal gyri, especially in the anterior one. It is obvious, therefore, that the main portion of the auditory area of the cortex is hidden in the wall of the fossa sylvii, appearing on the external surface of the hemisphere only in the middle third of the superior temporal gyrus, /. e. in that part of it which is in contact with the transverse gyri.
cortex form the lateral lemniscus in the pons and are connected particularly with the median geniculate body; they  
 
run out into the temporal lobe to terminate mainly in the  
 
transverse temporal gyri, especially in the anterior one. It is  
 
obvious, therefore, that the main portion of the auditory area  
 
of the cortex is hidden in the wall of the fossa sylvii, appearing on the external surface of the hemisphere only in the  
 
middle third of the superior temporal gyrus, /. e. in that part  
 
of it which is in contact with the transverse gyri.  
 
  
When all these sense centres have become ripe, that is, when  
+
When all these sense centres have become ripe, that is, when the fibres going to them and the motor fibres passing from them to become connected with the lower motor centres, are medullated, only about one-third of the whole area of the cortical surface has been concerned. This means that approximately only one-third of the human cerebral cortex is directly connected with the paths which bring sensory impressions from the periphery into consciousness, or carry motor impressions to the periphery causing muscular contractions. Twothirds of the whole cortex appears to have nothing directly to do with the periphery, but to be reserved for another and apparently a higher work. These other areas which are left
the fibres going to them and the motor fibres passing from  
 
them to become connected with the lower motor centres, are  
 
medullated, only about one-third of the whole area of the cortical surface has been concerned. This means that approximately only one-third of the human cerebral cortex is directly  
 
connected with the paths which bring sensory impressions  
 
from the periphery into consciousness, or carry motor impressions to the periphery causing muscular contractions. Twothirds of the whole cortex appears to have nothing directly to  
 
do with the periphery, but to be reserved for another and  
 
apparently a higher work. These other areas which are left  
 
  
  
  
uncolored in the diagram are the so-called association centres  
+
uncolored in the diagram are the so-called association centres of Flechsig. They make up the main portion of the frontal lobe, a large part of the temporal and occipital lobes, the island of Eeil, and occupy a large area in the posterior parietal region of the brain. For a whole month after birth these portions of the cortex remain uuripe and are entirely devoid of myelin. But after the development of the sense areas of the cortex, Flechsig has been able to follow baud after band of nerve fibres passing from the different sense areas into these other immature portions of the cerebral cortex, and ending there close beside one another, thus forming true centres of association between the different sense centres. And it is his belief that these association centres represent arrangements which unite the activities of the central internal sense organs and build them up to higher units. Sensory impressions of different qualities, visual, auditory, tactile, olfactory and gustatory, are united, or at any rate the anatomical mechanism is afforded for their union. The association centres have an entirely different microscopic structure from that to be made out in the sense centres, a topic into which, however, I cannot now enter.
of Flechsig. They make up the main portion of the frontal  
 
lobe, a large part of the temporal and occipital lobes, the  
 
island of Eeil, and occupy a large area in the posterior parietal region of the brain. For a whole month after birth these  
 
portions of the cortex remain uuripe and are entirely devoid  
 
of myelin. But after the development of the sense areas of the  
 
cortex, Flechsig has been able to follow baud after band of  
 
nerve fibres passing from the different sense areas into these  
 
other immature portions of the cerebral cortex, and ending  
 
there close beside one another, thus forming true centres of  
 
association between the different sense centres. And it is his  
 
belief that these association centres represent arrangements  
 
which unite the activities of the central internal sense organs  
 
and build them up to higher units. Sensory impressions of  
 
different qualities, visual, auditory, tactile, olfactory and gustatory, are united, or at any rate the anatomical mechanism is  
 
afforded for their union. The association centres have an  
 
entirely different microscopic structure from that to be made  
 
out in the sense centres, a topic into which, however, I cannot now enter.  
 
  
Flechsig believes, therefore, that these association centres  
+
Flechsig believes, therefore, that these association centres are the portions of the cerebral cortex which above all others are concerned in the higher intellectual manifestations, in memory, judgment and reflection. If his theory be right, the study of the association centres should be the especial object of research for the neurologist and jisychologist. That they really are of definite importance for the intellectual activities has been shown by these anatomical studies, which might of themselves be deemed conclusive. But it must be conceded that clinical experience has also afforded a large mass of evidence in favor of the view. In certain of the diseases of the mind marked disorganization of the association centres has been noted, the microscope permitting the recognition in them of the destruction of many cells and fibres. In such cases, during life, iustead of a connected train of thought, the mental processes may be confused and tangled. New mental pictures entirely foreign to the normal intelligence may appear, the capacity for using past experiences may be lost and the knowledge of the results of certain acts be gone. It is in the study of general paresis that the most convincing clinical proof of Fiechsig's doctrine of association centres is to be found, and from a consideration of the varying symptomatology of this disease, taken together with the pathological lesions which have been proven to exist in such cases, some clues have already been gained towards the explanation of differences in function in the different parts of the association areas in the cortex. Flechsig in the first edition of his "Gehirn und Seele" stated that the anatomically demonstrable alterations of the brainsubstance in general paresis were often limited to the intellectual domains. He refers in the second edition particularly to the monograph of Tuczek upon dementia paralytica published in 1884, and recommends strongly the study of this paper in connection with his own classification of the different regions of the cortex.
are the portions of the cerebral cortex which above all others  
 
are concerned in the higher intellectual manifestations, in  
 
memory, judgment and reflection. If his theory be right, the  
 
study of the association centres should be the especial object  
 
of research for the neurologist and jisychologist. That they  
 
really are of definite importance for the intellectual activities  
 
has been shown by these anatomical studies, which might of  
 
themselves be deemed conclusive. But it must be conceded  
 
that clinical experience has also afforded a large mass of evidence in favor of the view. In certain of the diseases of the  
 
mind marked disorganization of the association centres has  
 
been noted, the microscope permitting the recognition in them  
 
of the destruction of many cells and fibres. In such cases,  
 
during life, iustead of a connected train of thought, the mental  
 
processes may be confused and tangled. New mental pictures  
 
entirely foreign to the normal intelligence may appear, the  
 
capacity for using past experiences may be lost and the knowledge of the results of certain acts be gone. It is in the study  
 
of general paresis that the most convincing clinical proof of  
 
Fiechsig's doctrine of association centres is to be found, and  
 
from a consideration of the varying symptomatology of this  
 
disease, taken together with the pathological lesions which have  
 
been proven to exist in such cases, some clues have already  
 
been gained towards the explanation of differences in function  
 
in the different parts of the association areas in the cortex.  
 
Flechsig in the first edition of his "Gehirn und Seele" stated  
 
that the anatomically demonstrable alterations of the brainsubstance in general paresis were often limited to the intellectual domains. He refers in the second edition particularly  
 
to the monograph of Tuczek upon dementia paralytica published in 1884, and recommends strongly the study of this  
 
paper in connection with his own classification of the different  
 
regions of the cortex.  
 
  
It seems likely from Fiechsig's studies of the brain lesions  
+
It seems likely from Fiechsig's studies of the brain lesions in general paresis, that this disease more than any other will afford the key for the deduction of psychic disturbances from
in general paresis, that this disease more than any other will  
 
afford the key for the deduction of psychic disturbances from  
 
  
  
  
12  
+
12
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
pfo. 70.  
+
pfo. 70.
  
  
  
alterations in the cerebral substance. In cases of the disease  
+
alterations in the cerebral substance. In cases of the disease in which the lesions are widely diffused over very many different areas of the cortex, no reliable conclusions can be drawn regarding the significance of the association centres ; but occasionally the disappearance of nerve fibres is limited almost entirely to the association centres, and in some instances especially favorable for the study of function, the frontal association centre alone or the large posterior parietal association centre alone is chiefly diseased.
in which the lesions are widely diffused over very many different areas of the cortex, no reliable conclusions can be drawn  
 
regarding the significance of the association centres ; but occasionally the disappearance of nerve fibres is limited almost  
 
entirely to the association centres, and in some instances  
 
especially favorable for the study of function, the frontal association centre alone or the large posterior parietal association  
 
centre alone is chiefly diseased.  
 
  
The study of such lesions and of the symptoms manifested  
+
The study of such lesions and of the symptoms manifested by the patients during life, has not yet gone far enough to justify many positive assertions regarding the specific function of the different association centres; but enough has been done to warrant the consideration of certain statements which possess some degree of probability. Thus, where there has been bilateral disease of the frontal lobes, that is, of the anterior association centre, there has been observed in the individual during life an alteration or loss of ideas regarding his own personality and his relations to what is taking place inside and outside his body — symptoms which are quite in accord with those observed in higher apes by Bianchi after extirpation of the frontal lobes. The phenomena vary of course according to the irritative or destructive nature of the lesion. The individual may in his mind connect his personality with mental pictures which have in reality nothing to do with himself; thus he may think himself of enormous dignity, or that he is possessed of great wealth or that he is a genius. In other cases he fails to connect his own person in any way by means of association with external perceptions, so that he may forget himself or may fail altogether to observe his surroundings. Still in possession of numerous ideas, he may speak in an orderly fashion, although he appears unable to distinguish the true from the false and the imagined from the experienced. Besides these logical defects he may show a diminution of his capacity for ethical and esthetic judgment, so that he will perform acts entirely irreconcilable with his character as manifested earlier in his life. Even in the absence of emotion he may appear to be devoid of his normal self-command; but when subjected to unaccustomed stimuli, especially to sexual excitement, anger or vexation, he may lose all control of his movements and acts, so that some simple influence may lead him to try to satisfy his desires without any regard to custom or good taste. In late stages of the disease imbecility may appear, with entire loss of the mental pictures regarding his personality.
by the patients during life, has not yet gone far enough to  
 
justify many positive assertions regarding the specific function  
 
of the different association centres; but enough has been done  
 
to warrant the consideration of certain statements which possess some degree of probability. Thus, where there has been  
 
bilateral disease of the frontal lobes, that is, of the anterior  
 
association centre, there has been observed in the individual  
 
during life an alteration or loss of ideas regarding his own  
 
personality and his relations to what is taking place inside  
 
and outside his body — symptoms which are quite in accord  
 
with those observed in higher apes by Bianchi after extirpation of the frontal lobes. The phenomena vary of course  
 
according to the irritative or destructive nature of the lesion.  
 
The individual may in his mind connect his personality with  
 
mental pictures which have in reality nothing to do with  
 
himself; thus he may think himself of enormous dignity, or  
 
that he is possessed of great wealth or that he is a genius. In  
 
other cases he fails to connect his own person in any way by  
 
means of association with external perceptions, so that he  
 
may forget himself or may fail altogether to observe his surroundings. Still in possession of numerous ideas, he may  
 
speak in an orderly fashion, although he appears unable to  
 
distinguish the true from the false and the imagined from  
 
the experienced. Besides these logical defects he may show  
 
a diminution of his capacity for ethical and esthetic judgment, so that he will perform acts entirely irreconcilable with  
 
his character as manifested earlier in his life. Even in the  
 
absence of emotion he may appear to be devoid of his normal  
 
self-command; but when subjected to unaccustomed stimuli,  
 
especially to sexual excitement, anger or vexation, he may  
 
lose all control of his movements and acts, so that some simple  
 
influence may lead him to try to satisfy his desires without  
 
any regard to custom or good taste. In late stages of the  
 
disease imbecility may appear, with entire loss of the mental  
 
pictures regarding his personality.  
 
  
The mental phenomena displayed in connection with disease  
+
The mental phenomena displayed in connection with disease of the posterior parietal association centres appear to stand in marked contrast to those just outlined. They have been studied in cases of general jjaresis, but better opportunities for the observation of such phenomena are often afforded where there has been focal softening of the cortex due to vascular disease. Here the individual may be incapable of naming correctly objects outside his body which he can touch and see ; and if this centre on both sides be widely diseased, he may not recognize at all the nature of these objects, so that he loses the power of forming intelligent conceptions of the external world. On the contrary, he may be entirely clear as regards his own personality; he may appear to possess his
of the posterior parietal association centres appear to stand in  
 
marked contrast to those just outlined. They have been  
 
studied in cases of general jjaresis, but better opportunities for  
 
the observation of such phenomena are often afforded where  
 
there has been focal softening of the cortex due to vascular  
 
disease. Here the individual may be incapable of naming  
 
correctly objects outside his body which he can touch and  
 
see ; and if this centre on both sides be widely diseased, he  
 
may not recognize at all the nature of these objects, so that he  
 
loses the power of forming intelligent conceptions of the  
 
external world. On the contrary, he may be entirely clear as  
 
regards his own personality; he may appear to possess his  
 
  
  
  
self-control, and may show deep perversity of feeling or of the  
+
self-control, and may show deep perversity of feeling or of the will, the specific character of the disease-picture consisting in his inability to recognize external objects, that is, to associate external sensory impressions with the memories of those of his previous experiences. On this account he may use external objects falsely ; he may confuse persons ; he has no certain ideas as regards space and time. His mental conceptions of the external world, the knowledge of these which he can put into words, and the power of interpretation of external impressions as the result of experience, are lost to him. He is in severe cases almost bankrupt in ideas, although his regard for himself and for those who are dear to him may be unaffected.
will, the specific character of the disease-picture consisting in  
 
his inability to recognize external objects, that is, to associate  
 
external sensory impressions with the memories of those of  
 
his previous experiences. On this account he may use external objects falsely ; he may confuse persons ; he has no certain  
 
ideas as regards space and time. His mental conceptions of  
 
the external world, the knowledge of these which he can put  
 
into words, and the power of interpretation of external impressions as the result of experience, are lost to him. He is in  
 
severe cases almost bankrupt in ideas, although his regard for  
 
himself and for those who are dear to him may be unaffected.  
 
  
If one of the sense areas of the cortex alone be diseased, the  
+
If one of the sense areas of the cortex alone be diseased, the clinical picture is entirely different from that presented by these purely intellectual disturbances. Here again we may have to do either with phenomena of absence or phenomena of irritation. A tumor pressing upon the auditory area may give rise to noises and other subjective perceptions of sound. Pressure upon the posterior central gyrus may lead the individual to believe that he experiences movements of his thumb, although his eyes convince him that it remains station.'fl-y. Again, a tumor pressing upon the uncinate gyrus has been known to give rise to subjective odors; while a cysticercus cyst pressing upon the visual area of the occipital lobe has caused the arrival into consciousness of mental pictures of colored figures and the like. Destructive lesions of the sense centres may prevent the external sense impressions from entering into consciousness at all. There may be entire absence of mental confusion in such instances; the patient recognizes the subjective character of the hallucinations, and so is not actually mentally diseased in the ordinary sense, but if focal disease affect along with one sense centre several of the others, or the posterior large association centre, the picture of hallucinatory confusion is prominent.
clinical picture is entirely different from that presented by  
 
these purely intellectual disturbances. Here again we may  
 
have to do either with phenomena of absence or phenomena of irritation. A tumor pressing upon the auditory area may give rise to noises and other subjective perceptions of sound. Pressure upon the posterior central gyrus  
 
may lead the individual to believe that he experiences movements of his thumb, although his eyes convince him that it  
 
remains station.'fl-y. Again, a tumor pressing upon the uncinate gyrus has been known to give rise to subjective odors;  
 
while a cysticercus cyst pressing upon the visual area of the  
 
occipital lobe has caused the arrival into consciousness of  
 
mental pictures of colored figures and the like. Destructive  
 
lesions of the sense centres may prevent the external sense  
 
impressions from entering into consciousness at all. There  
 
may be entire absence of mental confusion in such instances;  
 
the patient recognizes the subjective character of the  
 
hallucinations, and so is not actually mentally diseased in the  
 
ordinary sense, but if focal disease affect along with one sense  
 
centre several of the others, or the posterior large association centre, the picture of hallucinatory confusion is prominent.  
 
  
Time will not permit me to discuss the so-called functional  
+
Time will not permit me to discuss the so-called functional disturbances ascribable to conditions of exhaustion of different cortical areas dependent upon prolonged and violent emotion, various intoxications, impoverishment of the blood, and other causes. Suffice it to say that, on theoretical grounds at least, more or less sharp criteria can be mentioned for the participation in the process of the different centres, especially the somresthetic area, the frontal lobes and the posterior large association centres. In many instances, however, the phenomena presented show, what we a priori might expect, that several of the sense areas and association centres are diseased at once. The various permutations and combinations possible will doubtless account for the manifold symptomatology of the great group of nervous and mental diseases, a symptomatology which as yet is in almost hopeless confusion and which calls urgently for an ordering hand. It will be the task of psychology and neurology in the future to analyse the specific activities of the various regions of the cortex, and to correlate these with the mental phenomena of human beings in health and disease.
disturbances ascribable to conditions of exhaustion of different cortical areas dependent upon prolonged and violent  
 
emotion, various intoxications, impoverishment of the blood,  
 
and other causes. Suffice it to say that, on theoretical grounds  
 
at least, more or less sharp criteria can be mentioned for the  
 
participation in the process of the different centres, especially  
 
the somresthetic area, the frontal lobes and the posterior large  
 
association centres. In many instances, however, the phenomena presented show, what we a priori might expect, that  
 
several of the sense areas and association centres are diseased  
 
at once. The various permutations and combinations possible will doubtless account for the manifold symptomatology  
 
of the great group of nervous and mental diseases, a symptomatology which as yet is in almost hopeless confusion and  
 
which calls urgently for an ordering hand. It will be the  
 
task of psychology and neurology in the future to analyse  
 
the specific activities of the various regions of the cortex, and  
 
to correlate these with the mental phenomena of human beings  
 
in health and disease.  
 
  
Flechsig's researches have established the fact that the  
+
Flechsig's researches have established the fact that the human cerebral cortex is made up of at least seven anatomically more or less well separated areas. As the phrenologists
human cerebral cortex is made up of at least seven anatomically more or less well separated areas. As the phrenologists  
 
  
  
  
January, 1897.]  
+
January, 1897.]
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
13  
+
13
  
  
  
thought, the brain is the organ of the mind, and the whole  
+
thought, the brain is the organ of the mind, and the whole is in reality made up of multiple organs. But instead of calling these, as did the old phrenology, after certain qualities, friendship, good-nature, wit, firmness, and the like, thanks to Flechsig's studies we can now adopt a more rational nomenclature. We can now speak of sense centres and of association centres in the cerebral cortex. The sense centres may be roughly grouped as the somssthetic area, the visual sense area, the olfactory sense area and the auditory sense area ; the association centres for the present have to be designated according to their position as frontal or anterior, insular or middle, and parieto-occipital or posterior. Thus a distinct advance has already been made, and it is hardly too much to expect that further study will permit of much more complete differentiation and more definite localization of both kinds of areas.
is in reality made up of multiple organs. But instead of calling  
 
these, as did the old phrenology, after certain qualities, friendship, good-nature, wit, firmness, and the like, thanks to  
 
Flechsig's studies we can now adopt a more rational nomenclature. We can now speak of sense centres and of association centres in the cerebral cortex. The sense centres may  
 
be roughly grouped as the somssthetic area, the visual sense  
 
area, the olfactory sense area and the auditory sense area ; the  
 
association centres for the present have to be designated  
 
according to their position as frontal or anterior, insular or  
 
middle, and parieto-occipital or posterior. Thus a distinct  
 
advance has already been made, and it is hardly too much to  
 
expect that further study will permit of much more complete  
 
differentiation and more definite localization of both kinds of  
 
areas.  
 
  
It is not stating too much to affirm that advances in true  
+
It is not stating too much to affirm that advances in true psychology are to be mainly hoped for from strictly scientific investigations into the structure and function of the nervous system. Pure philosophical psychology has advanced but little beyond the concepts of Aristotle and the other ancients, and as Flechsig says, " Medicine at all periods has been nearer the ideas believed in to-day mainly on account of the fact that the physician has had ever before him as the special object of his observations the human individual, presenting healthy or diseased conditions, in life and in death."
psychology are to be mainly hoped for from strictly scientific  
 
investigations into the structure and function of the nervous  
 
system. Pure philosophical psychology has advanced but  
 
little beyond the concepts of Aristotle and the other ancients,  
 
and as Flechsig says, " Medicine at all periods has been nearer  
 
the ideas believed in to-day mainly on account of the fact that  
 
the physician has had ever before him as the special object of  
 
his observations the human individual, presenting healthy or  
 
diseased conditions, in life and in death."  
 
  
It would take too long to give even a brief resume at this  
+
It would take too long to give even a brief resume at this time of the insight into psychological processes which are afforded by Flechsig's work. His recent publications speak for themselves, and his treatment of the subject cannot fail to prove interesting to the reader. Doubtless many of the theories which he has advanced as a result of his anatomical studies will not stand the test of time. But we owe to him a deep debt of gratitude for supplying us with a large mass of entirely new knowledge, from which further investigations may start.* The relative 2'ositions of the individual sense centres to the association centres are, as can be seen from the diagram, very peculiar. The posterior association centre is situated among the visual, auditory and somajsthetic areas of the cortex; while the anterior association centre is related, in gross at least, only to the somajsthetic area and to the olfactory sense area. The middle association centre has adjacent to it the auditory, olfactory and somaesthetic areas. When one remembers that the association centres receive bands of fibres which run into them from the adjacent sense areas, the remarks made before concerning the specific functions of the different association centres will perhaps be more easily appreciated.
time of the insight into psychological processes which are  
 
afforded by Flechsig's work. His recent publications speak  
 
for themselves, and his treatment of the subject cannot fail  
 
to prove interesting to the reader. Doubtless many of the  
 
theories which he has advanced as a result of his anatomical  
 
studies will not stand the test of time. But we owe to him a  
 
deep debt of gratitude for supplying us with a large mass of  
 
entirely new knowledge, from which further investigations  
 
may start.* The relative 2'ositions of the individual sense  
 
centres to the association centres are, as can be seen from the  
 
diagram, very peculiar. The posterior association centre is  
 
situated among the visual, auditory and somajsthetic areas of  
 
the cortex; while the anterior association centre is related, in  
 
gross at least, only to the somajsthetic area and to the olfactory  
 
sense area. The middle association centre has adjacent to it  
 
the auditory, olfactory and somaesthetic areas. When one  
 
remembers that the association centres receive bands of fibres  
 
which run into them from the adjacent sense areas, the remarks  
 
made before concerning the specific functions of the different  
 
association centres will perhaps be more easily appreciated.  
 
  
Flechsig in his " Kectoratsrede," as well as in his later  
+
Flechsig in his " Kectoratsrede," as well as in his later
  
  
  
* We should be particularly grateful for the deflnitiveness of the  
+
We should be particularly grateful for the deflnitiveness of the
concepts of brain structure which Flechsig has afforded us. In  
+
concepts of brain structure which Flechsig has afforded us. In this embryological self-analysis of the cerebral tracts, the bands of medullated libres, stained by the method of Weigert, stand out as clear-cut on the yellow background of non-medullated nervous tissue as the lines of a diagram. The illustrations of sections in Flechsig's book are by no means fanciful. In his regular lectures during the spring semester of 1895, Flechsig showed us a large number of his preparations which bear out fully his anatomical statements and illustrations.
this embryological self-analysis of the cerebral tracts, the bands of  
 
medullated libres, stained by the method of Weigert, stand out as  
 
clear-cut on the yellow background of non-medullated nervous  
 
tissue as the lines of a diagram. The illustrations of sections in  
 
Flechsig's book are by no means fanciful. In his regular lectures  
 
during the spring semester of 1895, Flechsig showed us a large  
 
number of his preparations which bear out fully his anatomical  
 
statements and illustrations.  
 
  
  
  
address upon the " Border-lands of mental health and disease,"  
+
address upon the " Border-lands of mental health and disease," has laid especial emphasis upon the significance of the somajsthetic area. Assuming it to be the portion of the cerebral cortex where impressions regarding the body enter into consciousness, the centre which appears to have to do with the bodily emotions and bodily needs, and upon the excitability of which the crudity or delicacy of the instincts which enter into consciousness depends, as well as the centre whence start nearly all motor impulses which are concerned in conduct, be they those leading to the closure of the fist, the pressure of the hand, or the most delicate embrace, Flechsig believes that this somsesthetic area is to be looked upon as the main organ of character. This cortical area, connected as it is on the one side directly with the peripheral sensory and motor apparatus of the body, and on the other with the higher association centres in the cortex, stands, as it were, like a buffer intercalated between the organs of the body and the organs of the intellect. The character of the activities manifested by these complex cortical centres of which the somfesthetic area is made up, may thus be influenced from either of the two sides. As Flechsig says, it represents a sort of arena in which, at least in the more nobly endowed natures, the lower inpnlses struggle for the mastery with the higher feelings and ideas. To follow this struggle between the reciprocal influences of the body and the intellect will form one of the most stimulating problems of brain investigation, especially when it is remembered that the subject is of eminently practical significance. In the investigation of the brain it will be necessary to study the conditions which lead to an ennobling of the sensual instincts, whether it come immediately through bodily influences or from the other side through the intellect. Since, further, in these studies the presumptive existence of an ennobling of the intellect through refinement of the sensual instincts must be kept in view, the new brain anatomy and physiology is brought into contact with the fundamental problems of all scientific pedagogy and the aims of all true culture. The old a priori ideas concerning the antitheses of sensuality and reason, and of the " heart " and the " brain," would seem to find some actual confirmation in recent anatomical discoveries.
has laid especial emphasis upon the significance of the somajsthetic area. Assuming it to be the portion of the cerebral  
 
cortex where impressions regarding the body enter into consciousness, the centre which appears to have to do with the  
 
bodily emotions and bodily needs, and upon the excitability  
 
of which the crudity or delicacy of the instincts which enter  
 
into consciousness depends, as well as the centre whence start  
 
nearly all motor impulses which are concerned in conduct, be  
 
they those leading to the closure of the fist, the pressure of the  
 
hand, or the most delicate embrace, Flechsig believes that this  
 
somsesthetic area is to be looked upon as the main organ of  
 
character. This cortical area, connected as it is on the one  
 
side directly with the peripheral sensory and motor apparatus  
 
of the body, and on the other with the higher association  
 
centres in the cortex, stands, as it were, like a buffer intercalated between the organs of the body and the organs of the  
 
intellect. The character of the activities manifested by these  
 
complex cortical centres of which the somfesthetic area is  
 
made up, may thus be influenced from either of the two sides.  
 
As Flechsig says, it represents a sort of arena in which, at  
 
least in the more nobly endowed natures, the lower inpnlses  
 
struggle for the mastery with the higher feelings and ideas.  
 
To follow this struggle between the reciprocal influences of the  
 
body and the intellect will form one of the most stimulating  
 
problems of brain investigation, especially when it is remembered that the subject is of eminently practical significance.  
 
In the investigation of the brain it will be necessary to study  
 
the conditions which lead to an ennobling of the sensual  
 
instincts, whether it come immediately through bodily influences or from the other side through the intellect. Since,  
 
further, in these studies the presumptive existence of an  
 
ennobling of the intellect through refinement of the sensual instincts must be kept in view, the new brain anatomy  
 
and physiology is brought into contact with the fundamental  
 
problems of all scientific pedagogy and the aims of all true  
 
culture. The old a priori ideas concerning the antitheses of  
 
sensuality and reason, and of the " heart " and the " brain,"  
 
would seem to find some actual confirmation in recent anatomical discoveries.  
 
  
Furthermore, Flechsig sees in these newer studies the essential preparation for a physiological basis of ethics, so much  
+
Furthermore, Flechsig sees in these newer studies the essential preparation for a physiological basis of ethics, so much desired by some of the writers of the last century. Inasmuch as the health of the cerebrum is essential for the control of the lower centres concerned with the instincts and emotions, as is proven by the cessation of the struggle between the instincts and the ethical feelings where the intellectual centres are paralyzed, and inasmuch as we now know some of the causes of the diseases of the sense centres and of the association centres, and are convinced that many of these causes are removable or avoidable, the etliical significance of these studies becomes manifest.
desired by some of the writers of the last century. Inasmuch  
 
as the health of the cerebrum is essential for the control of  
 
the lower centres concerned with the instincts and emotions,  
 
as is proven by the cessation of the struggle between the instincts and the ethical feelings where the intellectual centres are  
 
paralyzed, and inasmuch as we now know some of the causes  
 
of the diseases of the sense centres and of the association centres,  
 
and are convinced that many of these causes are removable or  
 
avoidable, the etliical significance of these studies becomes  
 
manifest.  
 
  
It must be the aim of educators to enlighten the people concerning the hygiene of the body and especially of the brain.  
+
It must be the aim of educators to enlighten the people concerning the hygiene of the body and especially of the brain. We must not fear to teach the intimate interdependence of bodily conditions and mental phenomena, or hesitate to let the masses know that the abuse of alcohol, the over-indulgence of the passions, and mental and physical excesses of all descrip
We must not fear to teach the intimate interdependence of  
 
bodily conditions and mental phenomena, or hesitate to let the  
 
masses know that the abuse of alcohol, the over-indulgence of  
 
the passions, and mental and physical excesses of all descrip
 
  
  
14  
+
14
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
[No. 70.  
+
[No. 70.
  
  
  
tions, can lead to i-esults of a most serious nature. Only by  
+
tions, can lead to i-esults of a most serious nature. Only by increasing knowledge, general and special, can we hope in coming generations to strengthen and make solid the foundations of the higher ethical feelings. All will agree that for the advancement of the race we must presuppose a social arrangement which will subordinate the blind instincts of the morally and intellectually deficient to the control of the deeper insight and the better will of an intellectual ethical aristocracy. If it is in the main the remarkable development of his association centres which has raised man so far above the level of all other living creatures, it is also by virtue of the function of these same association centres that man is to be elevated in the future beyond his present status. Flechsig at the close of his " Rectoratsrede " makes brief reference to the aims other than practical of these newer studies. "Just as by means of one of the noblest faculties of our natures, namely, the thirst for knowledge, an instinct conferred upon human beings with the development of their association centres, we are forced to study the natural laws involved even in the domain of the mind, so the actual advances of our knowledge, even in this field of investigation, lead with the forcible necessity of a natural law to an ideal philosophy. The more the enormous potencies embodied in an intelligent individual become unveiled to our questioning reason, the more clearly must we feel that behind the world of phenomena there are controlling forces with which human knowledge scarcely dare lay claim to be compared."
increasing knowledge, general and special, can we hope in  
 
coming generations to strengthen and make solid the foundations of the higher ethical feelings. All will agree that for  
 
the advancement of the race we must presuppose a social  
 
arrangement which will subordinate the blind instincts of the  
 
morally and intellectually deficient to the control of the deeper  
 
insight and the better will of an intellectual ethical aristocracy. If it is in the main the remarkable development of his  
 
association centres which has raised man so far above the  
 
level of all other living creatures, it is also by virtue of the  
 
function of these same association centres that man is to be  
 
elevated in the future beyond his present status. Flechsig at  
 
the close of his " Rectoratsrede " makes brief reference to the  
 
aims other than practical of these newer studies. "Just as  
 
by means of one of the noblest faculties of our natures, namely,  
 
the thirst for knowledge, an instinct conferred upon human  
 
beings with the development of their association centres, we  
 
are forced to study the natural laws involved even in the  
 
domain of the mind, so the actual advances of our knowledge,  
 
even in this field of investigation, lead with the forcible necessity of a natural law to an ideal philosophy. The more the  
 
enormous potencies embodied in an intelligent individual  
 
become unveiled to our questioning reason, the more clearly  
 
must we feel that behind the world of phenomena there are  
 
controlling forces with which human knowledge scarcely  
 
dare lay claim to be compared."  
 
  
  
  
NOTES ON NEW BOOKS.  
+
NOTES ON NEW BOOKS.
  
Practical Points in Nursing, for Nurses in Private Practice, with an  
+
Practical Points in Nursing, for Nurses in Private Practice, with an Appendix. By Emily A. M. Stoney, Superintendent of Training School for Nurses, Carney Hospital, Boston. Illustrated with 73 engravings and 9 colored and half-tone plates. {Philadelphia: W. B. Saunders, 1896.)
Appendix. By Emily A. M. Stoney, Superintendent of Training  
 
School for Nurses, Carney Hospital, Boston. Illustrated with 73  
 
engravings and 9 colored and half-tone plates. {Philadelphia:  
 
W. B. Saunders, 1896.)  
 
  
This little book is primarily designed for the instruction of  
+
This little book is primarily designed for the instruction of private nurses, and as such it will undoubtedly serve a useful purpose. It is to be regretted, however, that it is also intended to be used for the instruction of classes, and for the home nurse, for which purposes it seems very inadequate. It may help those who are already instructed and who require a book of reference, but it presupposes a degree of previous knowledge on the part of the student which pupil nurses and home nurses do not possess.
private nurses, and as such it will undoubtedly serve a useful purpose. It is to be regretted, however, that it is also intended to be  
 
used for the instruction of classes, and for the home nurse, for  
 
which purposes it seems very inadequate. It may help those who  
 
are already instructed and who require a book of reference, but it  
 
presupposes a degree of previous knowledge on the part of the  
 
student which pupil nurses and home nurses do not possess.  
 
  
The chapters on physiology and descriptive anatomy are of the  
+
The chapters on physiology and descriptive anatomy are of the most elementary character and are couched in such terms as to convey no adequate idea of the subjects treated. Witness the following: "The parotid gland is situated below and toward the front of the ear. It secretes saliva, and it is inflammation of this gland that causes mumps." — or " The skull is a box of bone containing the brain, which is a soft pulpy substance, and is the chief organ of the nervous system." Coulil tlie modicum of technical knowledge be made any smaller? The book ought to be very popular fur the instruction of nurses among those who are apprehensive of the over-education of nurses and are fearful that they will make thirdclass physicians.
most elementary character and are couched in such terms as to  
 
convey no adequate idea of the subjects treated. Witness the  
 
following: "The parotid gland is situated below and toward the  
 
front of the ear. It secretes saliva, and it is inflammation of this  
 
gland that causes mumps." — or " The skull is a box of bone containing  
 
the brain, which is a soft pulpy substance, and is the chief organ of  
 
the nervous system." Coulil tlie modicum of technical knowledge  
 
be made any smaller? The book ought to be very popular fur the  
 
instruction of nurses among those who are apprehensive of the  
 
over-education of nurses and are fearful that they will make thirdclass physicians.  
 
  
The definitions are very imperfect and are evidently written by  
+
The definitions are very imperfect and are evidently written by one who is not accustomed to use language accurately. "A lotion is a medicinal application, and may be evaporating or non-evaporating." " Worms, which are of three kinds — tapeworm, tliread worms and round worms — are caused by impure drinking water and food, and also bi/ feeding food that is not properly cooked." "Oph
one who is not accustomed to use language accurately. "A lotion  
 
is a medicinal application, and may be evaporating or non-evaporating." " Worms, which are of three kinds — tapeworm, tliread  
 
worms and round worms — are caused by impure drinking water and  
 
food, and also bi/ feeding food that is not properly cooked." "Oph
 
  
  
thalmia neonatorum is inflammation of the conjunctiva, which is  
+
thalmia neonatorum is inflammation of the conjunctiva, which is one of the coats of the eyeball. Its causes are numerous, but in the newborn it is generally caused by infection during birth from the urethral or vaginal discharges of the mother."
one of the coats of the eyeball. Its causes are numerous, but in  
 
the newborn it is generally caused by infection during birth from  
 
the urethral or vaginal discharges of the mother."  
 
  
The chapter in which directions are given to nurses as to their  
+
The chapter in which directions are given to nurses as to their conduct is clearly and judiciously written. Some nurses would doubtless take exceptions to the author's declaration that " it is not degrading to the nurse to assist in tlie kitchen when emergencies arise ; it shows the true spirit of a nurse, and the kindness is not lost." Tlie chapters also on the Sick Room, of the Patient, and Accidents and Emergencies, are to be commended. The book is well printed and illustrated, and has a good index.
conduct is clearly and judiciously written. Some nurses would  
 
doubtless take exceptions to the author's declaration that " it is  
 
not degrading to the nurse to assist in tlie kitchen when emergencies arise ; it shows the true spirit of a nurse, and the kindness  
 
is not lost." Tlie chapters also on the Sick Room, of the Patient,  
 
and Accidents and Emergencies, are to be commended. The  
 
book is well printed and illustrated, and has a good index.  
 
  
Practical Notes on Urinary Analysis. By W. B. Caxfield, M. D.  
+
Practical Notes on Urinary Analysis. By W. B. Caxfield, M. D.
  
{Published by Oeorge 8. Davis, Detroit, 1896.3  
+
{Published by Oeorge 8. Davis, Detroit, 1896.3
  
The second edition of this little work has recently appeared as one  
+
The second edition of this little work has recently appeared as one of the numbers of The Physician's Leisure Library. It is essentially practical, as most of the tests given are such as can be used at the bedside by the general practitioner. Although the subject is treated as briefly as possible, yet we think that if practitioners were fully conversant with the various tests described, and with the precautions to be observed in performing them, many errors in diagnosis would be prevented and much valuable assistance in the treatment of diseases affordeil. Many of the higher organic compounds found normally in the urine are, however, not even mentioned. In fact, no constituents of the urine, normal or abnormal, are treated of that cannot be tested for with the simplest apparatus and reagents. Thus, the use of the polariscope in diabetes and the influence of diabetic urine on polarized liglit, one of the most reliable tests, is entirely overlooked. Such statements as the diagnosis of typhoid fever is now made almost certain by the diazo-reaction of Ehrlich" should certainly be qualified, as it is well known that this reaction is very frequently obtained in tuberculosis and not infrequently in other febrile conditions : the test is merely an aid to diagnosis. One can hardly see how the practitioner is to be aided in recognizing leucin and tyrosin in the urine, by the author's statement that "leucin and tyrosin are found in the urine in certain abnormal conditions of the liver. They are easily recognized in the sediment, or may be found on evaporating the urine." It is only justice to say that a diagram of the leucin spherules and tyrosin crystals is given in the plate of urinary sediments, from which alone it would be unsafe to make a diagnosis, however. While the author's book serves a useful purpose, no general practitioner should be without a larger work on urinary analysis, for purposes of reference.
of the numbers of The Physician's Leisure Library. It is essentially  
 
practical, as most of the tests given are such as can be used at the  
 
bedside by the general practitioner. Although the subject is treated  
 
as briefly as possible, yet we think that if practitioners were fully conversant with the various tests described, and with the precautions to  
 
be observed in performing them, many errors in diagnosis would  
 
be prevented and much valuable assistance in the treatment of  
 
diseases affordeil. Many of the higher organic compounds found  
 
normally in the urine are, however, not even mentioned. In fact,  
 
no constituents of the urine, normal or abnormal, are treated of  
 
that cannot be tested for with the simplest apparatus and reagents.  
 
Thus, the use of the polariscope in diabetes and the influence of  
 
diabetic urine on polarized liglit, one of the most reliable tests, is  
 
entirely overlooked. Such statements as ''the diagnosis of typhoid  
 
fever is now made almost certain by the diazo-reaction of Ehrlich" should certainly be qualified, as it is well known that  
 
this reaction is very frequently obtained in tuberculosis and  
 
not infrequently in other febrile conditions : the test is merely  
 
an aid to diagnosis. One can hardly see how the practitioner  
 
is to be aided in recognizing leucin and tyrosin in the urine, by  
 
the author's statement that "leucin and tyrosin are found in the  
 
urine in certain abnormal conditions of the liver. They are  
 
easily recognized in the sediment, or may be found on evaporating the urine." It is only justice to say that a diagram of the  
 
leucin spherules and tyrosin crystals is given in the plate of urinary  
 
sediments, from which alone it would be unsafe to make a diagnosis, however. While the author's book serves a useful purpose, no general practitioner should be without a larger work on  
 
urinary analysis, for purposes of reference.  
 
  
Diseases of the Eye. A [Hand-book of Ophthalmic Practice for  
+
Diseases of the Eye. A [Hand-book of Ophthalmic Practice for Students and Practitioners. By G. E. deSchweinitz, A. M., M. D., Professor of Ophthalmology in Jefferson Medical College, etc. With 256 illustrations and 2 chromo-lithographic plates. Second edition, thoroughly revised. {Philadelphia : W. B. Saunders, 1896.)
Students and Practitioners. By G. E. deSchweinitz, A. M., M. D.,  
 
Professor of Ophthalmology in Jefferson Medical College, etc.  
 
With 256 illustrations and 2 chromo-lithographic plates. Second  
 
edition, thoroughly revised. {Philadelphia : W. B. Saunders,  
 
1896.)  
 
  
This admirable textbook of ophthalmology is so well and so  
+
This admirable textbook of ophthalmology is so well and so favorably known, and so short a time has elapsed since the appearance of the first edition (1892), that an extended notice seems scarcely called for at this time. In the preface to the present eilition the author states that the entire book has been thoroughly revised, and that in addition to this general revision, new paragraphs have been addeii upon Filamentous Keratitis, Blood-staining of the Cornea, Essential Phthisis Bulbi, Foreign Bodies in the Lens, Circinate Retinitis, Symmetrical Changes at the Macula Lutea in Infancy, Hyaline Bodies (Drusen) in the Papilla, Jlonocular Diplopia, Subconjunctival Injection of Germicides, InfiltrationAnaisthesia, and Sterilization of CoUyria.
favorably known, and so short a time has elapsed since the appearance of the first edition (1892), that an extended notice seems  
 
scarcely called for at this time. In the preface to the present  
 
eilition the author states that the entire book has been thoroughly  
 
revised, and that in addition to this general revision, new paragraphs have been addeii upon Filamentous Keratitis, Blood-staining of the Cornea, Essential Phthisis Bulbi, Foreign Bodies in the  
 
Lens, Circinate Retinitis, Symmetrical Changes at the Macula Lutea  
 
in Infancy, Hyaline Bodies (Drusen) in the Papilla, Jlonocular  
 
Diplopia, Subconjunctival Injection of Germicides, InfiltrationAnaisthesia, and Sterilization of CoUyria.  
 
  
For the bibliography of tlie first edition an appendix containing  
+
For the bibliography of tlie first edition an appendix containing a description of the method of using the ophthalmometer of Javal & Schiotz and the tropometer of Stevens has been substituted. The
a description of the method of using the ophthalmometer of Javal  
 
& Schiotz and the tropometer of Stevens has been substituted. The  
 
  
  
  
January, 1897.]  
+
January, 1897.]
  
  
  
JOHNS HOPKINS HOSPITA.L BULLETIN.  
+
JOHNS HOPKINS HOSPITA.L BULLETIN.
  
  
  
15  
+
15
  
  
  
chapter on operations has been enlarged and rewritten, and those  
+
chapter on operations has been enlarged and rewritten, and those on General Optical Principles and on Abnormal Refraction, which were contributed to the first edition by Dr. James Wallace, have been revised by Dr. Edward Jackson, who has also recast the section written by himself upon Eetinoscopy.
on General Optical Principles and on Abnormal Refraction, which  
 
were contributed to the first edition by Dr. James Wallace, have  
 
been revised by Dr. Edward Jackson, who has also recast the  
 
section written by himself upon Eetinoscopy.  
 
  
Dr. Jackson's revision of these chapters has evidently been carefully done, and we note a number of instances, as, for example, in  
+
Dr. Jackson's revision of these chapters has evidently been carefully done, and we note a number of instances, as, for example, in the definition of emmetropia and of ametropia (p. 140), and in the description of the refraction of light by an astigmatic eye (p. 163), in which it has resulted in the elimination of errors, some of which had previously arrested our attention in the perusal of the first edition. It is perhaps not to be wondered at that he has not, in every instance, succeeded in noting and correcting these faults. The description of the "seat of astigmatism" on p. 161, which, in the new edition as in the old, seems to warrant the inference that lenticular astigmatism is due always to an oblique position of the lens, it would appear, might easily have been improved upon. So, too, as to the description given of the well-known illustration (p. 163) of the refraction of a pencil of light in regular astigmatism. It is certainly not correct to speak of the different sections of the pencil there shown, as representing the "retinal images of a point" in compound hypermetropic astigmatism, simple hypermetropic astigmatism, mixed astigmatism, etc., unless absence of accommodative power in the eye be presupposed.
the definition of emmetropia and of ametropia (p. 140), and in the  
 
description of the refraction of light by an astigmatic eye (p. 163),  
 
in which it has resulted in the elimination of errors, some of  
 
which had previously arrested our attention in the perusal of the  
 
first edition. It is perhaps not to be wondered at that he has not,  
 
in every instance, succeeded in noting and correcting these faults.  
 
The description of the "seat of astigmatism" on p. 161, which,  
 
in the new edition as in the old, seems to warrant the inference  
 
that lenticular astigmatism is due always to an oblique position of the  
 
lens, it would appear, might easily have been improved upon. So,  
 
too, as to the description given of the well-known illustration (p.  
 
163) of the refraction of a pencil of light in regular astigmatism. It  
 
is certainly not correct to speak of the different sections of the pencil there shown, as representing the "retinal images of a point"  
 
in compound hypermetropic astigmatism, simple hypermetropic  
 
astigmatism, mixed astigmatism, etc., unless absence of accommodative power in the eye be presupposed.  
 
  
The author tells us in his preface that the book has been enriched  
+
The author tells us in his preface that the book has been enriched with forty additional illustrations, but he does nottell us how much more effective many of the illustrations have been made by the substitution of well-executed photo-engravings for the woodcuts of the first edition. The illustrations of congenital ptosis and of epicanthus and congenital ptosis on p. 200, and of rodentulcerof theorbit (p. 203), are striking examples of the effectiveness of this method of representation. Having said this much in praise of the illustrations, perhaps we shall be pardoned for finding fault with the legend descriptive of Fig. 90, on p. 254 — " lipomatous dermoid of the conjunctiva."
with forty additional illustrations, but he does nottell us how much  
 
more effective many of the illustrations have been made by the substitution of well-executed photo-engravings for the woodcuts of the  
 
first edition. The illustrations of congenital ptosis and of epicanthus and congenital ptosis on p. 200, and of rodentulcerof theorbit  
 
(p. 203), are striking examples of the effectiveness of this method  
 
of representation. Having said this much in praise of the illustrations, perhaps we shall be pardoned for finding fault with the  
 
legend descriptive of Fig. 90, on p. 254 — " lipomatous dermoid of  
 
the conjunctiva."  
 
  
The publisher has performed his part of the work ip a manner  
+
The publisher has performed his part of the work ip a manner worthy of especial commendation. S. T.
worthy of especial commendation. S. T.  
 
  
A Manual of Obstetrics. By W. A. Newman Dorland, A. M., M. D.  
+
A Manual of Obstetrics. By W. A. Newman Dorland, A. M., M. D. With 163 illustrations in the text and 6 full-page plates. (Philadelphia: W. B. Saunders, 1896.)
With 163 illustrations in the text and 6 full-page plates. (Philadelphia: W. B. Saunders, 1896.)  
 
  
This well-printed and fully illustrated volume seems a happy  
+
This well-printed and fully illustrated volume seems a happy mean between the more ambitious and encyclopedic works upon obstetrics and the quiz-compends, and is clearly and systematically arranged for the use of students. Although lacking the details and references of larger works, it is clearly and carefully written and will be a safe guide. There is really little to criticise.
mean between the more ambitious and encyclopedic works upon  
 
obstetrics and the quiz-compends, and is clearly and systematically  
 
arranged for the use of students. Although lacking the details and  
 
references of larger works, it is clearly and carefully written and  
 
will be a safe guide. There is really little to criticise.  
 
  
The directions given for the disinfection of the accoucheur and  
+
The directions given for the disinfection of the accoucheur and of the patient are admirable and explicit. The recommendation to use a creolin douche after the expulsion of the placenta, as a matter of routine, cannot be endorsed, because it would do harm rather than good in the majority of cases. Vaginal douches should notbe given after the second stage of labor, unless they are clearly and definitely indicated. The employment of a pad above the fundus uteri and the use of am abdominal binder tightened daily for six weeks or three months are recommendations which do not seem free from danger.
of the patient are admirable and explicit. The recommendation to  
 
use a creolin douche after the expulsion of the placenta, as a matter  
 
of routine, cannot be endorsed, because it would do harm rather  
 
than good in the majority of cases. Vaginal douches should notbe  
 
given after the second stage of labor, unless they are clearly and  
 
definitely indicated. The employment of a pad above the fundus  
 
uteri and the use of am abdominal binder tightened daily for six  
 
weeks or three months are recommendations which do not seem  
 
free from danger.  
 
  
Water and Water Supplies. By John C. Thrush, Medical OflBcer of  
+
Water and Water Supplies. By John C. Thrush, Medical OflBcer of
  
Health to the Essex Co. Council, etc. (London : The Rebman  
+
Health to the Essex Co. Council, etc. (London : The Rebman
  
Publiahing Co., L'i'd. Philadelphia : W. B. Saunders, 1896.)  
+
Publiahing Co., L'i'd. Philadelphia : W. B. Saunders, 1896.)
  
This excellent little book can be commended unreservedly as  
+
This excellent little book can be commended unreservedly as
  
probably the best short treatise on Water and Water Supplies in the  
+
probably the best short treatise on Water and Water Supplies in the
  
English language. The information contained in it is concise and  
+
English language. The information contained in it is concise and
  
the whole book is thoroughly modern. It is gratifying to observe  
+
the whole book is thoroughly modern. It is gratifying to observe
  
that the author shares the opinion of Koch that the best of all  
+
that the author shares the opinion of Koch that the best of all
  
  
  
water supplies for a city is that obtained from deep wells. The  
+
water supplies for a city is that obtained from deep wells. The sourcesof water pollution are clearly described and well illustrated. We are pleased to see that careful directions are given for the filtration of water, and the dangers which lurk in improper filtration are distinctly stated. If the book could be in the hands of every householder, the preventable causes of water-borne disease would unquestionably be mucli better understood. The book is well printed and sensibly illustrated, and deserves a large sale.
sourcesof water pollution are clearly described and well illustrated.  
 
We are pleased to see that careful directions are given for the  
 
filtration of water, and the dangers which lurk in improper filtration are distinctly stated. If the book could be in the hands of  
 
every householder, the preventable causes of water-borne disease  
 
would unquestionably be mucli better understood. The book is  
 
well printed and sensibly illustrated, and deserves a large sale.  
 
  
  
  
BOOKS RECEIVED,  
+
BOOKS RECEIVED,
  
  
  
Transactions of the Association of American Physicians. Eleventh  
+
Transactions of the Association of American Physicians. Eleventh Session held at Washington, D. C, April 30 and May 1 and 2, 1896. Vol. XI. 8vo. 1896. 453 pages. Printed for the Association. Philadelphia.
Session held at Washington, D. C, April 30 and May 1 and 2,  
 
1896. Vol. XI. 8vo. 1896. 453 pages. Printed for the Association. Philadelphia.  
 
  
Transactions of the Medical Society of the State of Pennsylvania.  
+
Transactions of the Medical Society of the State of Pennsylvania. Forty-sixth Annual Session, held at Harrisburg, 1896. Vol. XXVII. 8vo, 499 pages. Published by the Society. The Edwards & Docker Co., printers, Philadelphia.
Forty-sixth Annual Session, held at Harrisburg, 1896. Vol.  
 
XXVII. 8vo, 499 pages. Published by the Society. The Edwards & Docker Co., printers, Philadelphia.  
 
  
An American Text Book of Applied Therapeutics. For the use of  
+
An American Text Book of Applied Therapeutics. For the use of practitioners and students. Edited by J. C. Wilson, M. D., assisted by Augustus A. Eshner, M. D. 1896. 4to, 1326 pages. W. B. Saunders, Philadelphia.
practitioners and students. Edited by J. C. Wilson, M. D.,  
 
assisted by Augustus A. Eshner, M. D. 1896. 4to, 1326 pages.  
 
W. B. Saunders, Philadelphia.  
 
  
An American Text-book of Physiology . Edited by William H. Howell,  
+
An American Text-book of Physiology . Edited by William H. Howell, Ph. D., M. D. 1896. 4to, 1052 pages. W. B. Saunders, Philadelphia.
Ph. D., M. D. 1896. 4to, 1052 pages. W. B. Saunders, Philadelphia.  
 
  
A Te.vt-book of Histology, Descriptive and Practical. For the use of  
+
A Te.vt-book of Histology, Descriptive and Practical. For the use of students. By Arthur Clarkson, M. B., C. M. Edin. 1896. 8vo, 554 pages. W. B. Saunders, Philadelphia.
students. By Arthur Clarkson, M. B., C. M. Edin. 1896. 8vo,  
 
554 pages. W. B. Saunders, Philadelphia.  
 
  
Diseases of the Eye. A hand-book of ophthalmic practice for students  
+
Diseases of the Eye. A hand-book of ophthalmic practice for students and practitioners. By G. E. de Schweinitz, A.M., M. D. Second edition, thoroughly revised. 1896. 8vo, 679 pages. W. B. Saunders, Philadelphia.
and practitioners. By G. E. de Schweinitz, A.M., M. D. Second  
 
edition, thoroughly revised. 1896. 8vo, 679 pages. W. B.  
 
Saunders, Philadelphia.  
 
  
Transactions of the Michigan State Medical Society, for the year 1896.  
+
Transactions of the Michigan State Medical Society, for the year 1896. Vol. XX. 8vo, 834 pages. Published by the Society. Grand Kapids.
Vol. XX. 8vo, 834 pages. Published by the Society. Grand  
 
Kapids.  
 
  
A Text-Book of Materia Medica, Therapeutics and Pharmacology. By  
+
A Text-Book of Materia Medica, Therapeutics and Pharmacology. By George Frank Butler, Ph. G., M.D. 1896. 8vo, 858 pages. W.
George Frank Butler, Ph. G., M.D. 1896. 8vo, 858 pages. W.  
 
  
B. Saunders, Philadelphia.  
+
B. Saunders, Philadelphia.
  
Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America.  
+
Twentieth Century Practice. An international encyclopedia of modern medical science by leading authorities of Europe and America. Edited by Thomas L.Stedman, M. D. Vol. VII. Diseasesof the respiratory organs and blood, and functional sexual disorders. 1896. 8vo, 796 pages. William Wood & Co., New York.
Edited by Thomas L.Stedman, M. D. Vol. VII. Diseasesof the  
 
respiratory organs and blood, and functional sexual disorders.  
 
1896. 8vo, 796 pages. William Wood & Co., New York.  
 
  
A Treatise on Appendicitis. By John B. Deaver, M. D. Containing  
+
A Treatise on Appendicitis. By John B. Deaver, M. D. Containing 32 full-page plates and other illustrations. 8vo. 1896. 168 pages. P. Blakiston, Son & Co., Philadelphia.
32 full-page plates and other illustrations. 8vo. 1896. 168 pages.  
 
P. Blakiston, Son & Co., Philadelphia.  
 
  
Index-Catalogue of the Library of the Surgeon-Oeneral's Office, U.S. A.  
+
Index-Catalogue of the Library of the Surgeon-Oeneral's Office, U.S. A. Authors and subjects. Second series- Vol. I. A-Azzurri. 1896. 4to, 828 pages. Government Printing Office. Wathington.
Authors and subjects. Second series- Vol. I. A-Azzurri. 1896.  
 
4to, 828 pages. Government Printing Office. Wathington.  
 
  
Transactions of the Texas State Medical Association. 28th annual  
+
Transactions of the Texas State Medical Association. 28th annual session held at Fort Worth, Texas, April 28th-30tli and May 1st, 1896. 8vo, 458 pages. Eugene von Boeckmann, printer, Austin, Texas.
session held at Fort Worth, Texas, April 28th-30tli and May 1st,  
 
1896. 8vo, 458 pages. Eugene von Boeckmann, printer, Austin,  
 
Texas.  
 
  
The British Guiana Medical Annual. Ed. by J. S. Wallbridge and  
+
The British Guiana Medical Annual. Ed. by J. S. Wallbridge and
  
C. W. Daniels. Eighth year of issue. 8vo, 1896. 95 -}- xxxix  
+
C. W. Daniels. Eighth year of issue. 8vo, 1896. 95 -}- xxxix pages. Printed by Baldwin & Co., Demerara.
pages. Printed by Baldwin & Co., Demerara.  
 
  
Twenty-seventh An7iual Report of tlie Slate Board of Health of Massachusetts, 1895. 8vo, 807 pages. Wright & Potter Printing Co.,  
+
Twenty-seventh An7iual Report of tlie Slate Board of Health of Massachusetts, 1895. 8vo, 807 pages. Wright & Potter Printing Co., Boston. 1896.
Boston. 1896.  
 
  
Essentials of Physical Diagnosis of the Thorax. By Arthur M. Corwin, A. M., M. D. 2d ed. 1896. 12mo, 199 pages. W. B. Saunders, Philadelphia.  
+
Essentials of Physical Diagnosis of the Thorax. By Arthur M. Corwin, A. M., M. D. 2d ed. 1896. 12mo, 199 pages. W. B. Saunders, Philadelphia.
  
Atlas of the Diseases of the Skin. By H. Radcliffe Crocker, M. D.,  
+
Atlas of the Diseases of the Skin. By H. Radcliffe Crocker, M. D., F. R.C. P. Fol. n. d. 2 vols. Young J. Pentland, Edinburgh and London.
F. R.C. P. Fol. n. d. 2 vols. Young J. Pentland, Edinburgh  
 
and London.  
 
  
  
  
16  
+
16
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
[No, 70.  
+
[No, 70.
  
  
  
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL  
+
PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL
  
  
  
THE JOHNS HOPKINS HOSPITAL REPORTS.  
+
THE JOHNS HOPKINS HOSPITAL REPORTS. Volume I. 423 pages, 99 plates.
Volume I. 423 pages, 99 plates.  
 
  
Report in Putliology.  
+
Report in Putliology.
  
The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;  
+
The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
  
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the  
+
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the
  
Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D,  
+
Vena Portae and its Influence upon the Circulation. By F. P. Mall, M. D, A Contribution to the Pathulog-y of the Gelatinous Type of Cerebellar Sclerosis
A Contribution to the Pathulog-y of the Gelatinous Type of Cerebellar Sclerosis  
 
  
(Atrophy). By Henry J. Berkley, M. D.  
+
(Atrophy). By Henry J. Berkley, M. D. Reticulated' Tissue and its Relation to the Connective Tissue Fibrils. Bv F. P.
Reticulated' Tissue and its Relation to the Connective Tissue Fibrils. Bv F. P.  
 
  
Mall, if. D.  
+
Mall, if. D.
  
Report in Dermatolog-y.  
+
Report in Dermatolog-y. Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By  
 
  
T. C. Gilchrist, M. D., and Emmet Rixford. M. D.  
+
T. C. Gilchrist, M. D., and Emmet Rixford. M. D. A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of
A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of  
 
  
Protozoa, and the Blastomyces found in the preceding Cases, with the so-called  
+
Protozoa, and the Blastomyces found in the preceding Cases, with the so-called
  
Parasites found in Various Lesions of the Skin, etc. ; Two Cases of Molluscum  
+
Parasites found in Various Lesions of the Skin, etc. ; Two Cases of Molluscum
  
Fibrosum; Tlie Pathology of a Case of Dermatitis Herpetiformis (Duhring). By  
+
Fibrosum; Tlie Pathology of a Case of Dermatitis Herpetiformis (Duhring). By
  
T. C. Gilchrist, M. D.  
+
T. C. Gilchrist, M. D.
  
Report in Pathologry.  
+
Report in Pathologry. An Experimental Study of the Thyroid Gland of Dogs, with especial consideration
An Experimental Study of the Thyroid Gland of Dogs, with especial consideration  
 
  
of Hypertrophy of this Gland. By W. S. Halsted, M. D.  
+
of Hypertrophy of this Gland. By W. S. Halsted, M. D.
  
  
  
Volume II. 570 pages, witli 28 plates and figures.  
+
Volume II. 570 pages, witli 28 plates and figures.
  
Report in Medicine.  
+
Report in Medicine.
  
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with  
+
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
  
Gallstones. By William Oslek. M. D.  
+
Gallstones. By William Oslek. M. D. Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, H. D. On Pyrodin. By H. A. LxFLEnR, M. D. Cases of Post-febrile Insanity. By William Osler, M. D. Acute Tubercuiosis in an Infant of Four Months. By Harry Toulmin, M. D. Rare Forms of Cardiac Thrombi. By William Osler, M. D. Notes on Endocarditis in PhtMsis. By William Osler, M. D.
Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, H. D.  
 
On Pyrodin. By H. A. LxFLEnR, M. D.  
 
Cases of Post-febrile Insanity. By William Osler, M. D.  
 
Acute Tubercuiosis in an Infant of Four Months. By Harry Toulmin, M. D.  
 
Rare Forms of Cardiac Thrombi. By William Osler, M. D.  
 
Notes on Endocarditis in PhtMsis. By William Osler, M. D.  
 
  
Report in Medicine.  
+
Report in Medicine. Tubercular Peritonitis. By William Osler, M. D. A Case of Raynaud's Disease. By H. M. Thomas, M. D. Acute Nephritis in Typhoid Fever. By William Osler, M. D.
Tubercular Peritonitis. By William Osler, M. D.  
 
A Case of Raynaud's Disease. By H. M. Thomas, M. D.  
 
Acute Nephritis in Typhoid Fever. By William Osler, M. D.  
 
  
Report in Gynecology.  
+
Report in Gynecology. Tlie Gj-neeological Operating Room. By Howard A. Kelly, M. D. The Laparotomies performed from October 16, 1S89, to March 3, 1890. By Howard
Tlie Gj-neeological Operating Room. By Howard A. Kelly, M. D.  
 
The Laparotomies performed from October 16, 1S89, to March 3, 1890. By Howard  
 
  
A. Kelly, M. D.. and Hunter Robb, M. D.  
+
A. Kelly, M. D.. and Hunter Robb, M. D. The Report of the Autopsies in Two Cases Dying in the GjTiecological Wards vrith out Operation ; Composite Temperature and Pulse Charts of Forty Cases of
The Report of the Autopsies in Two Cases Dying in the GjTiecological Wards vrith
 
out Operation ; Composite Temperature and Pulse Charts of Forty Cases of  
 
  
Abdominal Section. By Howard A. Kelly, M. D.  
+
Abdominal Section. By Howard A. Kelly, M. D. The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,
The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,  
 
  
M. D.  
+
M. D. The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;
The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;  
 
  
Ovarian Tumor; General Gynecological Operations from October 15, 1SS9, to  
+
Ovarian Tumor; General Gynecological Operations from October 15, 1SS9, to
  
March 4. 1890. By Howard A. Kelly, M. D.  
+
March 4. 1890. By Howard A. Kelly, M. D. Report of the ITrinary Examination of Ninety-one Gynecological Cases. By Howard
Report of the ITrinary Examination of Ninety-one Gynecological Cases. By Howard  
 
  
A. Kelly, M. D., and Albert A. Ghriskey, M. D.  
+
A. Kelly, M. D., and Albert A. Ghriskey, M. D. Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking
Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking  
 
  
Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D.  
+
Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D. Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, il. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D. Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D. Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment
Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, il. D.  
 
Elephantiasis of the Clitoris. By Howard A. Kelly, M. D.  
 
Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D.  
 
Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment  
 
  
of Ureteral Stricture; Record of Deaths following Gynecological Operations. By  
+
of Ureteral Stricture; Record of Deaths following Gynecological Operations. By
  
Howard A. Kelly, M. D.  
+
Howard A. Kelly, M. D.
  
Report in Siirgery, I.  
+
Report in Siirgery, I. The Treatment of Wounds with Especial Reference to the Value of the Blood Clot
The Treatment of Wounds with Especial Reference to the Value of the Blood Clot  
 
  
in the Management of Dead Spaces. By W. S. Halsted, M. D.  
+
in the Management of Dead Spaces. By W. S. Halsted, M. D. Report in Neurology, I. A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. ' By Charles E. Simon, M. D. Haematomyelia. By August Hoch, JI. D. A Case of Cerehro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By
Report in Neurology, I.  
 
A Case of Chorea Insaniens. By Henry J. Berkley, M. D.  
 
Acute Angio-Neurotic Oedema. ' By Charles E. Simon, M. D.  
 
Haematomyelia. By August Hoch, JI. D.  
 
A Case of Cerehro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By  
 
  
Henry M. Thomas, M. D.  
+
Henry M. Thomas, M. D.
  
Report in Pathology, I.  
+
Report in Pathology, I. Ama3bic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.
Ama3bic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleur, M. D.  
 
  
  
  
Volume III. 766 pages, with 69 plates and figm-es.  
+
Volume III. 766 pages, with 69 plates and figm-es.
  
Report in Pathology.  
+
Report in Pathology.
  
Papillomatous Tumors of the Ovarj'. By J. Whitridge Williams, M. D.  
+
Papillomatous Tumors of the Ovarj'. By J. Whitridge Williams, M. D.
  
Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D.  
+
Tuberculosis of the Female Generative Organs. By J. Whitridge Williams, M. D. Report in Patliology.
Report in Patliology.  
 
  
Multiple Lj-rapho -Sarcomata, with a report of Two Cases. Bv Simon Flexner, M. D,  
+
Multiple Lj-rapho -Sarcomata, with a report of Two Cases. Bv Simon Flexner, M. D,
  
The Cerebellar Cortex of the Dog. By Henry J. Berkley, M". D.  
+
The Cerebellar Cortex of the Dog. By Henry J. Berkley, M". D.
  
A Case of Chronic Nephritis in a Cow. Bv W. T. Councilman, M. D.  
+
A Case of Chronic Nephritis in a Cow. Bv W. T. Councilman, M. D.
  
Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.  
+
Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.
  
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.  
+
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.
  
Report in Gynecology.  
+
Report in Gynecology.
  
The Gynecological Operating Room; An Kxtornal Direct Method of Measurins: the  
+
The Gynecological Operating Room; An Kxtornal Direct Method of Measurins: the Conjugata Vera; Prolapsus Uteri witliout Diverticulum and with Anterior Entorocele; Lipoma of the- Labium Majus; Deviations of the Rectum and Sigmoid Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retrofiexed Uterus. By Howard A. Kelly, M. D.
Conjugata Vera; Prolapsus Uteri witliout Diverticulum and with Anterior Entorocele; Lipoma of the- Labium Majus; Deviations of the Rectum and Sigmoid  
 
Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retrofiexed Uterus. By Howard A.  
 
Kelly, M. D.  
 
  
Potassium Permanganate and Oxalic Acid as Germicides against the Pyogenic Cocci.  
+
Potassium Permanganate and Oxalic Acid as Germicides against the Pyogenic Cocci. By Mary Sherwood. M. D.
By Mary Sherwood. M. D.  
 
  
Intestinal Worms as a Complication in Abdominal Sxu-gery. By A. L. Stately, M. D.  
+
Intestinal Worms as a Complication in Abdominal Sxu-gery. By A. L. Stately, M. D.
  
  
  
Gynecological Operations not invohnng Coeliotomy, By Howard A. Kellt, M. D.  
+
Gynecological Operations not invohnng Coeliotomy, By Howard A. Kellt, M. D. Tabulated by A. L. Stavely, M. D.
Tabulated by A. L. Stavely, M. D.  
 
  
The Employment of an Artificial Retroposition of the Uterus in covering Extensive  
+
The Employment of an Artificial Retroposition of the Uterus in covering Extensive Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.
Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.  
 
  
Photography applied to Surgery. By A. S. Murray.  
+
Photography applied to Surgery. By A. S. Murray.
  
Traumatic Atresia of the Vagina with Haematokolpos and Haematometra. By Howard  
+
Traumatic Atresia of the Vagina with Haematokolpos and Haematometra. By Howard A. Kelly, M. D.
A. Kelly, M. D.  
 
  
Urinalysis in Gynecology. By W. W. Russell, M. D.  
+
Urinalysis in Gynecology. By W. W. Russell, M. D.
  
The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.  
+
The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.
  
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.  
+
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.
  
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age.  
+
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age. By Howard A. Kelly, M. D., and Mary Sherwood, M. D.
By Howard A. Kelly, M. D., and Mary Sherwood, M. D.  
 
  
Abdominal Operations performed in the Gynecological Department, from March 5,  
+
Abdominal Operations performed in the Gynecological Department, from March 5, 1890, to December 17, 1892. By Howard A. Kelly, M. D.
1890, to December 17, 1892. By Howard A. Kelly, M. D.  
 
  
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to  
+
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to May 4, 1S92.
May 4, 1S92.  
 
  
  
  
Volume IV. 504 pages, 33 charts and illustrations.  
+
Volume IV. 504 pages, 33 charts and illustrations.
  
Report on Typhoid Fever.  
+
Report on Typhoid Fever.
  
By William Osler, M. D., with additional papers by W, S. Thayer, M. D., and J.  
+
By William Osler, M. D., with additional papers by W, S. Thayer, M. D., and J. Hewetson, M. D.
Hewetson, M. D.  
 
  
Report in Neurology.  
+
Report in Neurology. Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonao' Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of ifu'^ muscuhir. The Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berklet, M. D.
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The  
 
Intrinsic Pulmonao' Nerves in Mammalia; The Intrinsic Nerve Supply of the  
 
Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of ifu'^ muscuhir. The Intrinsic Nerves of the Thyroid Gland of  
 
the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berklet,  
 
M. D.  
 
  
Report in Surgery.  
+
Report in Surgery. The Results of Operations for the Cure of Cancer of the Breast, from June, 1SS9, to January, 1894. By W. S. Halsted, M. D.
The Results of Operations for the Cure of Cancer of the Breast, from June, 1SS9, to  
 
January, 1894. By W. S. Halsted, M. D.  
 
  
Report in Gynecology.  
+
Report in Gynecology. Hydrosalpinx, with a report of twentv-seven cases; Post -Operative Septic Peritonitis; Tuberculosis of the Endometrium. By T. S. Cullen, M. B. Report in Pathology. Deciduoma Malignum. By J. Whitridge W^illiams, M. D.
Hydrosalpinx, with a report of twentv-seven cases; Post -Operative Septic Peritonitis;  
 
Tuberculosis of the Endometrium. By T. S. Cullen, M. B.  
 
Report in Pathology.  
 
Deciduoma Malignum. By J. Whitridge W^illiams, M. D.  
 
  
  
  
Volume V. 480 pages, mth 32 charts and illustrations.  
+
Volume V. 480 pages, mth 32 charts and illustrations.
  
CONTENTS:  
+
CONTENTS: The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D. A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B. Studies in Typhoid Fever.
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D.  
 
A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B.  
 
Studies in Typhoid Fever.  
 
  
By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon  
+
By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon Flexner, M. D., Walter Reed, 51. D., and H. C. Parscns, M. D.
Flexner, M. D., Walter Reed, 51. D., and H. C. Parscns, M. D.  
 
  
  
  
Volume VI. About 500 pages, many ilhistrations.  
+
Volume VI. About 500 pages, many ilhistrations.
  
Report in Neurology.  
+
Report in Neurology.
  
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical  
+
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.
Nerve Cell (Studies Nos. I to V). By Henry J. Berkley, M. D.  
 
  
Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the  
+
Introductory. — Recent Literature on the Pathology of Diseases of the Brain by the Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol): Part II. — Serum Poisoning. — Experimental Lesions induced by the Action of the Dog's Serum on the Cortical Nerve Cell; Part HI. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic Ricin Poisoning; Part IV.— Hydrophobic Toxaemia. — Lesions of the Cortical Nerve Cell produced hy the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of Alcohol and Ricin Intoxication; Addenda. By Henry J. Bereixy, M. D.
Chromate of Silver Methods; Part I. — Alcohol Poisoning. — Experimental Lesions  
 
produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental  
 
Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol): Part II. — Serum  
 
Poisoning. — Experimental Lesions induced by the Action of the Dog's Serum on  
 
the Cortical Nerve Cell; Part HI. — Ricin Poisoning. — Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic  
 
Ricin Poisoning; Part IV.— Hydrophobic Toxaemia. — Lesions of the Cortical  
 
Nerve Cell produced hy the Toxine of Experimental Rabies; Part V. — Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of  
 
Alcohol and Ricin Intoxication; Addenda. By Henry J. Bereixy, M. D.  
 
  
Report in Pathology.  
+
Report in Pathology.
  
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Tuomas S.  
+
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Tuomas S.
  
Cullen, M. B.  
+
Cullen, M. B. Pregnancy in a Rudimentary Uterine Horn. Rupture. Death. Probable Migration of
Pregnancy in a Rudimentary Uterine Horn. Rupture. Death. Probable Migration of  
 
  
Ov-um and Spermatozoa. By Thomas S. Cullen. M. B.. and G. L. Wilkiss, M. D.  
+
Ov-um and Spermatozoa. By Thomas S. Cullen. M. B.. and G. L. Wilkiss, M. D. Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, M. B. A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By
Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, M. B.  
 
A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By  
 
  
William D. Booker, M. D.  
+
William D. Booker, M. D. The Pathology of Toxalbumin Intoxications. By Simon Flesn-er, M. D. The price of a set bound in cloth [Vols. Z-TJ] of the Hospital Jteftorts is
The Pathology of Toxalbumin Intoxications. By Simon Flesn-er, M. D.  
 
The price of a set bound in cloth [Vols. Z-TJ] of the Hospital Jteftorts is  
 
  
$30.00. Vols. I, II and III are not sold separately. The jtrice of  
+
$30.00. Vols. I, II and III are not sold separately. The jtrice of
  
Vols. IV, V and VI is $5.00 each.  
+
Vols. IV, V and VI is $5.00 each.
  
  
  
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TATHOID FEVER.  
+
MONOGRAPHS ON DERMATOLOGY, MALARIAL FEVERS AND TATHOID FEVER. The following papers are reprinted from Vols. I, IV and V of the Reports, for those who desire to purchase in this form: STUDIES IN DERMATOLOGY. By T. C. Gilchrist. M. D., and Emmet Rixford,
The following papers are reprinted from Vols. I, IV and V of the Reports, for those  
 
who desire to purchase in this form:  
 
STUDIES IN DERMATOLOGY. By T. C. Gilchrist. M. D., and Emmet Rixford,  
 
  
M. D. 1 voliune of 164 pages and 41 full-page plates. Price, bound in paper,  
+
M. D. 1 voliune of 164 pages and 41 full-page plates. Price, bound in paper,
  
?3.00.  
+
?3.00. THE MALARIAL FEVERS OF BALTIMORE. Bv W. S. Thayer. M. D., and J.
THE MALARIAL FEVERS OF BALTIMORE. Bv W. S. Thayer. M. D., and J.  
 
  
Hewetson. M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.  
+
Hewetson. M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.
  
By Lewellys F. Barker, M. B. 1 volume of 2S0 pages. Price, in paper, $2.75.  
+
By Lewellys F. Barker, M. B. 1 volume of 2S0 pages. Price, in paper, $2.75. STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. E.-rtracted
STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. E.-rtracted  
 
  
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 4S1  
+
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 4S1
  
pages. Price, bound in paper, ?3.00.  
+
pages. Price, bound in paper, ?3.00.
  
Subscriptions for the above publications may be sent to  
+
Subscriptions for the above publications may be sent to
  
The Johns HorKiNS Press, Baltimore, Md.  
+
The Johns HorKiNS Press, Baltimore, Md.
  
  
  
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies  
+
The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies may he procured from Messrs. GUSHING d: CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.0(» a year, may he addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE ; singU copies will be sent by mail for fifteen cents each.
may he procured from Messrs. GUSHING d: CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.0(» a year, may he  
 
addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE ; singU copies will be sent by mail for fifteen cents each.  
 
  
  
  
BULLETIN  
+
BULLETIN
  
  
  
OF  
+
OF
  
  
  
THE JOHNS HOPKINS HOSPITAL.  
+
THE JOHNS HOPKINS HOSPITAL.
  
  
  
Vol. Vlll.-No. 71.]  
+
Vol. Vlll.-No. 71.]
  
  
  
BALTIMORE. FEBRUARY, 1897.  
+
BALTIMORE. FEBRUARY, 1897.
  
  
Line 2,392: Line 1,030:
  
  
GOiTTZEITTS.  
+
GOiTTZEITTS.
  
  
  
A Case of Dermatitis due to the x Rays. By T. C. Gilchrist,  
+
A Case of Dermatitis due to the x Rays. By T. C. Gilchrist, M. R. C. S., L. S. A.,
M. R. C. S., L. S. A.,  
 
  
Lesions induced by the Action of Certain Poisons on the Nerve  
+
Lesions induced by the Action of Certain Poisons on the Nerve Cell. Study VI.— Diphtheria. By Henhy J. Berkley, M. D.,
Cell. Study VI.— Diphtheria. By Henhy J. Berkley, M. D.,  
 
  
Puerperal Sepsis due to Infection with the Bacillus Aerogenes  
+
Puerperal Sepsis due to Infection with the Bacillus Aerogenes Capsulatus. By George W. Dobbin, M. D., - . - .
Capsulatus. By George W. Dobbin, M. D., - . - .  
 
  
  
  
Proceedings of Societies :  
+
Proceedings of Societies :
  
Hospital Medical Society, 29  
+
Hospital Medical Society, 29
  
The Surgical Significance of Gall Stones [Dr. F. Lakge].  
+
The Surgical Significance of Gall Stones [Dr. F. Lakge]. Correspondence :
Correspondence :  
 
  
A Case of Pneumo-cardial Rupture. By Geo. S. Brown, M.D., 33  
+
A Case of Pneumo-cardial Rupture. By Geo. S. Brown, M.D., 33
  
  
  
A CASE OF DERMATITIS DUE TO THE x RAYS.  
+
A CASE OF DERMATITIS DUE TO THE x RAYS.
  
By T. 0. Gilchrist, M. E. C. S., L. S. A., Associate in Dermatology, Johns Hopkins University and Hospital.  
+
By T. 0. Gilchrist, M. E. C. S., L. S. A., Associate in Dermatology, Johns Hopkins University and Hospital.
  
  
  
Since the discovery of the x rays by Rontgen, thousands of  
+
Since the discovery of the x rays by Rontgen, thousands of observations and experiments have been made with them both in Europe and in this country, and hundreds of investigators have exposed various portions of the body, particularly the hands, frequently, iind for long periods of time, yet, after searching the literature, records of only twenty-three cases (including the present one) have been given where injurious results have followed their use, and in these, lesions of the skin only have been described. Of these twenty-three cases, twelve occurred in this country, one in Canada, four in England and six in Germany.
observations and experiments have been made with them both  
 
in Europe and in this country, and hundreds of investigators have exposed various portions of the body, particularly  
 
the hands, frequently, iind for long periods of time, yet, after  
 
searching the literature, records of only twenty-three cases  
 
(including the present one) have been given where injurious  
 
results have followed their use, and in these, lesions of the  
 
skin only have been described. Of these twenty-three cases,  
 
twelve occurred in this country, one in Canada, four in  
 
England and six in Germany.  
 
  
The first report which 1 have been able to find was a  
+
The first report which 1 have been able to find was a communication in the Deutsche Medicinische Wochenschrift , No. 28, 1896 (July 9th), from 0. Leppiu, an engineer, who had used his left hand a great deal in experimenting with the X rays. He remarked that the rays had the power of producing cutaneous lesions like sunburn. The hand presented a peculiar redness, was swollen, and a vesicular eruption appeared later on the middle and ring fingers. Where the skin was hidden by a ring it was white and quite normal. Even five weeks after discontinuing the use of the rays the altered skin gave the hand an older look than the normal one.
communication in the Deutsche Medicinische Wochenschrift ,  
 
No. 28, 1896 (July 9th), from 0. Leppiu, an engineer, who  
 
had used his left hand a great deal in experimenting with the  
 
X rays. He remarked that the rays had the power of producing cutaneous lesions like sunburn. The hand presented  
 
a peculiar redness, was swollen, and a vesicular eruption appeared later on the middle and ring fingers. Where the skin  
 
was hidden by a ring it was white and quite normal. Even  
 
five weeks after discontinuing the use of the rays the altered  
 
skin gave the hand an older look than the normal one.  
 
  
Professor Daniel, of Vauderbilt University, reported a case  
+
Professor Daniel, of Vauderbilt University, reported a case of alopecia as the result of exposure to the x rays three months previous to Leppin's communication.
of alopecia as the result of exposure to the x rays three  
 
months previous to Leppin's communication.  
 
  
After examining the other reports (the references are given  
+
After examining the other reports (the references are given at the end of the article) it was found that the eruptions of the skin presented many points of similarity, and differed chiefly in
at the end of the article) it was found that the eruptions of the  
 
skin presented many points of similarity, and differed chiefly in  
 
  
  
  
severity, according to either the length of time and frequency  
+
severity, according to either the length of time and frequency of exposure to the rays or to idiosyncrasy of the patient.
of exposure to the rays or to idiosyncrasy of the patient.  
 
  
In Dr. Sehrwald's case, which was described fully, the  
+
In Dr. Sehrwald's case, which was described fully, the lesion occurred after one exposure of forty-five minutes to the X rays, and Dr. Crocker's patient had also experienced only one exposure of one hour when an eruption appeared. In Dr. Kolle's case, the patient, a boy, was exposed once, for forty minutes, when a pronounced alopecia followed, and a similar result is recorded by Professor Daniel in a man after one sitting; but the most interesting case of all was Professor Thomson's, of Harvard, who, being skeptical as to the deleterious results of the rays, made the only experiment which has so far been recorded, by exposing his finger to the x rays for half an hour and at one and a quarter inches from the tube, with a definite purpose of producing lesions if possible. The cutaneous trouble followed in nine days after the exposure. In two cases the patients had two sittings ; in Dr. Dunn's case the first exposure was one hour, and the second, seven days later, lasted one hour and a half ; and in Dr. White's case the patient had two exposures of thirty and forty-five minutes each on successive days.
lesion occurred after one exposure of forty-five minutes to the  
 
X rays, and Dr. Crocker's patient had also experienced only  
 
one exposure of one hour when an eruption appeared. In Dr.  
 
Kolle's case, the patient, a boy, was exposed once, for forty  
 
minutes, when a pronounced alopecia followed, and a similar  
 
result is recorded by Professor Daniel in a man after one  
 
sitting; but the most interesting case of all was Professor  
 
Thomson's, of Harvard, who, being skeptical as to the deleterious results of the rays, made the only experiment which  
 
has so far been recorded, by exposing his finger to the x rays  
 
for half an hour and at one and a quarter inches from the  
 
tube, with a definite purpose of producing lesions if possible.  
 
The cutaneous trouble followed in nine days after the exposure. In two cases the patients had two sittings ; in Dr.  
 
Dunn's case the first exposure was one hour, and the second,  
 
seven days later, lasted one hour and a half ; and in Dr.  
 
White's case the patient had two exposures of thirty and  
 
forty-five minutes each on successive days.  
 
  
In Drs. Stern's and Richardson's cases the lesions appeared  
+
In Drs. Stern's and Richardson's cases the lesions appeared after three sittings, and Dr. Skinner experienced cutaneous lesions after three or four exposures of short duration. In eleven cases the results had only followed after prolonged and constant use, the duration varying.
after three sittings, and Dr. Skinner experienced cutaneous  
 
lesions after three or four exposures of short duration. In  
 
eleven cases the results had only followed after prolonged and  
 
constant use, the duration varying.  
 
  
I append a table of the cases which I have been able to find  
+
I append a table of the cases which I have been able to find in the literature.
in the literature.  
 
  
  
  
18  
+
18
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
[No. 71.  
+
[No. 71.
  
  
  
Distribution.  
+
Distribution.
  
  
  
Character of the Lesions.  
+
Character of the Lesions.
  
  
  
Subjective  
+
Subjective Symptoms.
Symptoms.  
 
  
  
  
O. Leppin (person  
+
O. Leppin (person al experience). .
al experience). .  
 
  
  
  
Used very frequently for  
+
Used very frequently for many days.
many days.  
 
  
  
  
Left hand and  
+
Left hand and
  
  
  
Peculiar redness, swollen, vesicles  
+
Peculiar redness, swollen, vesicles on middle and ring fingers.
on middle and ring fingers.  
 
  
  
  
Dr. Marcuee.  
+
Dr. Marcuee.
  
  
  
Young man, 17, exposed  
+
Young man, 17, exposed 5-10 minutes once or twice a day for four weeks.
5-10 minutes once or  
 
twice a day for four  
 
weeks.  
 
  
  
  
Dr. Feilchenfeld  
+
Dr. Feilchenfeld Dr. Conrad.
Dr. Conrad.  
 
  
  
  
Left half of Brownish redness on face, fol  
+
Left half of Brownish redness on face, fol face.backand lowed by desquamation ; later, chest. patch of alopecia above right
face.backand lowed by desquamation ; later,  
 
chest. patch of alopecia above right  
 
  
ear ; on back, large raw patch,  
+
ear ; on back, large raw patch, exposing the corium with hemorrhagic points and exudation and a number of bullae ; on chest slighter changes, exhibited a somewhat similar case (no details given) to the
exposing the corium with hemorrhagic points and exudation  
 
and a number of bullae ; on  
 
chest slighter changes,  
 
exhibited a somewhat similar case (no details given) to the  
 
  
  
  
No mention. After five weeks hand still  
+
No mention. After five weeks hand still
  
looks "older" than the  
+
looks "older" than the other.
other.  
 
  
No pain in face ;lThree months later, hair  
+
No pain in face ;lThree months later, hair
  
  
  
back much  
+
back much tenderness, but no pain was felt until just previous to the eruption.
tenderness, but  
 
no pain was felt  
 
until just previous to the eruption.  
 
  
  
  
returning on the bald  
+
returning on the bald spot. Chest and back healed, but numerous fine cicatricial lines on the back and brown pigmentation.
spot. Chest and back  
 
healed, but numerous fine  
 
cicatricial lines on the  
 
back and brown pigmentation.  
 
  
  
  
Dr. Paul Fuchs  
+
Dr. Paul Fuchs (personal expe rience).
(personal expe  
 
rience).  
 
  
  
  
Dr. Sehrwald.  
+
Dr. Sehrwald.
  
  
  
S. J. R. (personal  
+
S. J. R. (personal experience).
experience).  
 
  
  
  
Dr. H. C. Dunn.  
+
Dr. H. C. Dunn.
  
  
  
Dr. G. C. Skinner  
+
Dr. G. C. Skinner (personal expe rience).
(personal expe  
 
rience).  
 
  
  
  
J. Macintyre (personal experience).  
+
J. Macintyre (personal experience).
  
  
  
Dr. Freund.  
+
Dr. Freund.
  
  
  
Aphotographerbad used  
+
Aphotographerbad used the X rays very fre quently and for some time.
the X rays very fre  
 
quently and for some  
 
time.  
 
  
  
  
After prolonged use of  
+
After prolonged use of the X rays.
the X rays.  
 
  
  
  
In a boy 13 years old.  
+
In a boy 13 years old. Only one exposure of 45 minutes duration Two weeks later erup tion appeared.
Only one exposure of  
 
45 minutes duration  
 
Two weeks later erup  
 
tion appeared.  
 
  
  
  
Used the rays several  
+
Used the rays several hours daily and eruption appeared three weeks after.
hours daily and eruption appeared three  
 
weeks after.  
 
  
  
  
Man aged 35 years. Ex  
+
Man aged 35 years. Ex posed first for one hour and afterwards for an hour and a half, the second with inter val of seven days. Two days later eruption appeared.
posed first for one  
 
hour and afterwards  
 
for an hour and a half,  
 
the second with inter  
 
val of seven days. Two  
 
days later eruption appeared.  
 
  
  
  
Exposed the wrist 10-15  
+
Exposed the wrist 10-15 minutes for 3 or4day8 in succession. Ten days later eruption followed.
minutes for 3 or4day8  
 
in succession. Ten  
 
days later eruption followed.  
 
  
Worked for months with  
+
Worked for months with the X rays before cutaneous lesions were produced.
the X rays before cutaneous lesions were  
 
produced.  
 
  
10 days, child who had  
+
10 days, child who had hypertrichosis.
hypertrichosis.  
 
  
  
  
1st and 2d fin  
+
1st and 2d fin gers, left hand.
gers, left  
 
hand.  
 
  
  
  
Left hand and  
+
Left hand and fingers.
fingers.  
 
  
  
  
Abdomen.  
+
Abdomen.
  
  
  
Right hand and  
+
Right hand and fingers. Later left band.
fingers. Later  
 
left band.  
 
  
  
  
Abdomen.  
+
Abdomen.
  
  
  
Wrist.  
+
Wrist.
  
  
  
Neck, back, upper arm and  
+
Neck, back, upper arm and scalp.
scalp.  
 
  
  
  
Swelling and stiffness of the  
+
Swelling and stiffness of the joints; Istand 2d fingers swollen and of a livid brown color on the dorsal surface from the tips to the carpometacarpal joints Sense of touch greatly diminished. Mustache falling out and color was changed.
joints; Istand 2d fingers swollen  
 
and of a livid brown color on  
 
the dorsal surface from the tips  
 
to the carpometacarpal joints  
 
Sense of touch greatly diminished. Mustache falling out  
 
and color was changed.  
 
  
Much swollen; skin was wrinkled  
+
Much swollen; skin was wrinkled cracked and stained quite brown ; condition of skin like a frozen hand ; later, on further exposure, a vesicular eruption appeared.
cracked and stained quite  
 
brown ; condition of skin like a  
 
frozen hand ; later, on further  
 
exposure, a vesicular eruption  
 
appeared.  
 
  
At first hypersemia, then avesicu  
+
At first hypersemia, then avesicu lar eruption. Four weeks later central portion healed, but peripheral portion covered whole abdomen. Brown color. Exfoliation soon followed.
lar eruption. Four weeks later  
 
central portion healed, but  
 
peripheral portion covered  
 
whole abdomen. Brown color.  
 
Exfoliation soon followed.  
 
  
Numerous dark little blisters appeared on right fingers ; then  
+
Numerous dark little blisters appeared on right fingers ; then marked redness and inflammation of the skin, which later became hard, very dry and yellow like parchment. Exfoliation followed. On further exposure tips of fingers became much swollen and nails affected. A colorless, bad smelling discharge came from beneath the nails, which were gradually thrown off. Left hand was substituted and similar symp toms followed.
marked redness and inflammation of the skin, which later  
 
became hard, very dry and  
 
yellow like parchment. Exfoliation followed. On further  
 
exposure tips of fingers became  
 
much swollen and nails affected. A colorless, bad smelling  
 
discharge came from beneath  
 
the nails, which were gradually  
 
thrown off. Left hand was  
 
substituted and similar symp  
 
toms followed.  
 
  
Three hours after first exposure  
+
Three hours after first exposure some nausea. After second exposure, nausea, and on second day abdomen slightly red, like sunburn; redness increased in intensity until fourth day, vesicles appeared, which developed into bullae. Eighteen days later the patch was T/zx8}i inches between umbilicus and chest, and was smooth, glazed and weeping for some days, notwithstanding treatment.
some nausea. After second  
 
exposure, nausea, and on second  
 
day abdomen slightly red, like  
 
sunburn; redness increased in  
 
intensity until fourth day, vesicles appeared, which developed  
 
into bullae. Eighteen days  
 
later the patch was T/zx8}i  
 
inches between umbilicus and  
 
chest, and was smooth, glazed  
 
and weeping for some days,  
 
notwithstanding treatment.  
 
  
Reddening of the skin appeared  
+
Reddening of the skin appeared first; this increased until it was almost purple ; considerable swelling followed. Desquamation followed.
first; this increased until it was  
 
almost purple ; considerable  
 
swelling followed. Desquamation followed.  
 
  
Appearance of a sunburn. Skin  
+
Appearance of a sunburn. Skin red and swollen, followed by exfoliation of the " epidermis" and loss of hair.
red and swollen, followed by  
 
exfoliation of the " epidermis"  
 
and loss of hair.  
 
  
X rays used as a depilatory for 10  
+
X rays used as a depilatory for 10 days, when the hair began to fall nut.
days, when the hair began to  
 
fall nut.  
 
  
  
  
Berlin Medical Society.  
+
Berlin Medical Society.
  
Fingers extremely No mention,  
+
Fingers extremely No mention, sensitive and pain was of a burning and scalding character.
sensitive and  
 
pain was of a  
 
burning and  
 
scalding character.  
 
  
  
  
None given.  
+
None given.
  
  
  
Itching when the  
+
Itching when the vesicles appeared.
vesicles appeared.  
 
  
  
  
After inflamma  
+
After inflamma tion hand smarted very much Skin became insensible to the touch. After second exposure serious discom fort and pain followed.
tion hand smarted very much  
 
Skin became insensible to the  
 
touch. After  
 
second exposure  
 
serious discom  
 
fort and pain  
 
followed.  
 
  
  
  
No subjective  
+
No subjective symptoms ; neither itching nor pain ; the rawsurface painless and almost insensitive.
symptoms ;  
 
neither itching  
 
nor pain ; the  
 
rawsurface painless and almost  
 
insensitive.  
 
  
  
  
Great pain and ex  
+
Great pain and ex cessive tenderness.
cessive tenderness.  
 
  
  
  
Cured in 9 or 10 weeks.  
+
Cured in 9 or 10 weeks.
  
  
  
Results similar to those of  
+
Results similar to those of sunburn but much more acute.
sunburn but much more  
 
acute.  
 
  
  
  
None given.  
+
None given.
  
  
  
Eruption healed after 28  
+
Eruption healed after 28 days, but skin was like boiled fish skin. After cauterization of surface a slough separated and a tough yellow opaque membrane formed.
days, but skin was like  
 
boiled fish skin. After  
 
cauterization of surface a  
 
slough separated and a  
 
tough yellow opaque  
 
membrane formed.  
 
  
  
  
Process of repair was very  
+
Process of repair was very slow.
slow.  
 
  
  
  
Authorthinksconditiondue  
+
Authorthinksconditiondue to heat and electricity ; the latter the chief cause of injury to the tissues.
to heat and electricity ;  
 
the latter the chief cause  
 
of injury to the tissues.  
 
  
  
  
February, 1897.]  
+
February, 1897.]
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
19  
+
19
  
  
  
Dr. E. E. King.  
+
Dr. E. E. King.
  
  
  
Dr. M. J. Stern.  
+
Dr. M. J. Stern.
  
  
  
Dr. F. Kolle.  
+
Dr. F. Kolle.
  
  
  
Dr. J. C. White.  
+
Dr. J. C. White.
  
  
  
Prof. E. Thomson  
+
Prof. E. Thomson
  
  
  
Dr. H.R.Crocker  
+
Dr. H.R.Crocker
  
  
  
Prof. John Daniel  
+
Prof. John Daniel
  
  
  
Dr. M. H. Rich  
+
Dr. M. H. Rich ardson.
ardson.  
 
  
  
  
Dr. W. E. Parker.  
+
Dr. W. E. Parker.
  
  
  
University of  
+
University of Minnesota.
Minnesota.  
 
  
Dr. Banister, U  
+
Dr. Banister, U S. Army.
S. Army.  
 
  
  
  
Dr. T.C.Gilchrist.  
+
Dr. T.C.Gilchrist.
  
  
  
Patient used the x rays  
+
Patient used the x rays for two and a half months from two to six hours daily before cutaneous lesion ap peared.
for two and a half  
 
months from two to  
 
six hours daily before  
 
cutaneous lesion ap  
 
peared.  
 
  
  
  
Patient was exposed at  
+
Patient was exposed at three sittings of 40-50 minutes duration. Eruption appeared two days afterward.
three sittings of 40-50  
 
minutes duration.  
 
Eruption appeared two  
 
days afterward.  
 
  
A boy 12yearsold. Whole  
+
A boy 12yearsold. Whole body exposed 40 minutes. Sixteen days later alopecia appeared.
body exposed 40 minutes. Sixteen days  
 
later alopecia  
 
appeared.  
 
  
Young lady exposed to  
+
Young lady exposed to the rays 30 minutes on one day and 45minutes on the next day. Eruption appeared the following day.
the rays 30 minutes on  
 
one day and 45minutes  
 
on the next day. Eruption appeared the following day.  
 
  
Exposed half an hour at  
+
Exposed half an hour at a distance of one and one-half inches from the tube. Eruption appeared nine days after.
a distance of one and  
 
one-half inches from  
 
the tube. Eruption  
 
appeared nine days  
 
after.  
 
  
Boy aged 16. One exposure of one hour.  
+
Boy aged 16. One exposure of one hour. Eruption appeared next day.
Eruption appeared  
 
next day.  
 
  
  
  
Distribution.  
+
Distribution.
  
  
  
Hand, left.  
+
Hand, left.
  
  
  
Man ; exposure 1 hour  
+
Man ; exposure 1 hour Alopecia 21 days later.
Alopecia 21 days  
 
later.  
 
  
Woman. Exposed three  
+
Woman. Exposed three times to the rays, 20, 30 and 3.5 minutes. Eruption appeared two days later.
times to the rays, 20,  
 
30 and 3.5 minutes.  
 
Eruption appeared two  
 
days later.  
 
  
Man. Exposed five  
+
Man. Exposed five times, from 20 minutes to 80 minutes.
times, from 20 minutes  
 
to 80 minutes.  
 
  
Man whose ear was exmined for several  
+
Man whose ear was exmined for several hours.
hours.  
 
  
Man. Numerous expo  
+
Man. Numerous expo
  
sures.  
+
sures.
  
  
  
ray operator. Eruption began after frequent and continued  
+
ray operator. Eruption began after frequent and continued exposures.
exposures.  
 
  
  
  
Extended from  
+
Extended from thesideof the face down to the umbilicus.
thesideof the  
 
face down to  
 
the umbilicus.  
 
  
Right side of  
+
Right side of head.
head.  
 
  
  
  
Sternal region  
+
Sternal region
  
  
  
Little finger of  
+
Little finger of left hand.
left hand.  
 
  
  
  
Epigastrium.  
+
Epigastrium.
  
  
  
One side of  
+
One side of scalp.
scalp.  
 
  
Abdominal re  
+
Abdominal re gion, particu larly over liver area.
gion, particu  
 
larly over  
 
liver area.  
 
  
  
  
Jaw and neck.  
+
Jaw and neck.
  
  
  
Ear and surrounding  
+
Ear and surrounding scalp.
scalp.  
 
  
Abdomen,  
+
Abdomen, chest and beard.
chest and  
 
beard.  
 
  
  
  
Right hand,  
+
Right hand, wrist, and lower portion of forearm dorsal sursurface.
wrist, and  
 
lower portion  
 
of forearm  
 
dorsal sursurface.  
 
  
  
  
Character of Lesions.  
+
Character of Lesions.
  
  
  
Hand felt stiff, then became  
+
Hand felt stiff, then became swollen and large " blisters formed ; after five weeks rest he exposed the hand again 7-8 hours daily. In two weeks left hand became swollen, tender, discolored ; vesicles followed, and the fingernails began to fall off. The hairs disappeared. Left side of the face was also affected. The skin was swollen and erythematous, and the hair over the temple disappeared. Eyebrows were almost gone and left side of the mustache had almost disappeared.
swollen and large " blisters  
 
formed ; after five weeks rest  
 
he exposed the hand again 7-8  
 
hours daily. In two weeks left  
 
hand became swollen, tender,  
 
discolored ; vesicles followed,  
 
and the fingernails began to  
 
fall off. The hairs disappeared.  
 
Left side of the face was also  
 
affected. The skin was swollen  
 
and erythematous, and the hair  
 
over the temple disappeared.  
 
Eyebrows were almost gone and  
 
left side of the mustache had  
 
almost disappeared.  
 
  
Erythematous blush first appeared, which a few days later ap  
+
Erythematous blush first appeared, which a few days later ap peared like a severe burn, followed by a large slough.
peared like a severe burn, followed by a large slough.  
 
  
Large area of alopecia over the  
+
Large area of alopecia over the region exposed to the rays Hair fell out all at once the night previous. Skin slightly cedematous.
region exposed to the rays  
 
Hair fell out all at once the  
 
night previous. Skin slightly  
 
cedematous.  
 
  
Skin was first reddened, then  
+
Skin was first reddened, then blistered. Three months later the patch showed angry-looking granulations which had refused to heal.
blistered. Three months later  
 
the patch showed angry-looking  
 
granulations which had refused  
 
to heal.  
 
  
Finger became hypersensitive,  
+
Finger became hypersensitive, then dark red, swollen, stiff, and soon after vesiculation occurred. Pus formed and the epidermis became detached, but pustules remained over 3 weeks
then dark red, swollen, stiff,  
 
and soon after vesiculation occurred. Pus formed and the epidermis became detached, but  
 
pustules remained over 3 weeks  
 
  
A Crookes tube placed five inches  
+
A Crookes tube placed five inches distant — flanelette shirt inter vened. Next day, skin deep red in color. Nine days later vesicles appeared. Palm-sized patch, well-defined, purplish red. Vesicles increased in number ; 9 days later the epidermis had separated. Healing very slow. Alopecia very slight.
distant — flanelette shirt inter  
 
vened. Next day, skin deep  
 
red in color. Nine days later  
 
vesicles appeared. Palm-sized  
 
patch, well-defined, purplish  
 
red. Vesicles increased in number ; 9 days later the epidermis  
 
had separated. Healing very  
 
slow. Alopecia very slight.  
 
  
Tube was 1^'4 inches distant from  
+
Tube was 1^'4 inches distant from head. Bald spot was 2 inches in diameter ; skin healthy.
head. Bald spot was 2 inches  
 
in diameter ; skin healthy.  
 
  
Bulb was 18 inches distant. First  
+
Bulb was 18 inches distant. First appearance was that of sunburn, gradually became brown, and ulcer, 8 inches in diameter, formed ; slough thrown off ; very slow in healing.
appearance was that of sunburn, gradually became brown,  
 
and ulcer, 8 inches in diameter,  
 
formed ; slough thrown off ;  
 
very slow in healing.  
 
  
After two exposures face and  
+
After two exposures face and neck became swollen and red. The later sittings were also followed by eruption.
neck became swollen and red.  
 
The later sittings were also followed by eruption.  
 
  
The parts presented later a frozen  
+
The parts presented later a frozen appearance. All the hair from this side of scalp was lost.
appearance. All the hair from  
 
this side of scalp was lost.  
 
  
At first a patch, red, inflamed,  
+
At first a patch, red, inflamed, hypersesthetic, about half the size of a man's hand. The lesion increased in size until a denuded surface .SxlS inches was formed. Exudation profuse and uncontrollable. Beard turned white in places and growth stopped.
hypersesthetic, about half the  
 
size of a man's hand. The  
 
lesion increased in size until a  
 
denuded surface .SxlS inches  
 
was formed. Exudation profuse and uncontrollable. Beard  
 
turned white in places and  
 
growth stopped.  
 
  
Hypersemia and swelling of back  
+
Hypersemia and swelling of back of hand ; afterwards inflammation of fingers and hand. Skin became dark brown in color and gradually exfoliated.
of hand ; afterwards inflammation of fingers and hand. Skin  
 
became dark brown in color  
 
and gradually exfoliated.  
 
  
  
  
Subjective  
+
Subjective Symptoms.
Symptoms.  
 
  
  
  
Great pain follow  
+
Great pain follow ed the appear ance of the blis ters.
ed the appear  
 
ance of the blis  
 
ters.  
 
  
Second eruption  
+
Second eruption followed by aching.
followed by  
 
aching.  
 
  
Face became tender and painful.  
+
Face became tender and painful.
  
  
  
No symptoms.  
+
No symptoms.
  
  
  
Granulation sur  
+
Granulation sur face very sen si five and the seat of severe neural gic pain.
face very sen si  
 
five and the seat  
 
of severe neural  
 
gic pain.  
 
  
Pain.  
+
Pain.
  
  
  
Stiffnessfeltatfirsl  
+
Stiffnessfeltatfirsl and soreness when the vesicles appeared.
and soreness  
 
when the vesicles appeared.  
 
  
  
  
None.  
+
None.
  
  
  
Pain accompanied  
+
Pain accompanied the first appearance of the lesion.
the first appearance of the  
 
lesion.  
 
  
  
  
No pain or sensation at the time.  
+
No pain or sensation at the time.
  
Raw surface, very  
+
Raw surface, very painful and hyperjesthetic. Pain agonizing even six weeks after.
painful and hyperjesthetic.  
 
Pain agonizing  
 
even six weeks  
 
after.  
 
  
  
  
No pain at first, but  
+
No pain at first, but afterwards severe aching and shooting pains, which lasted about 2 weeks.*
afterwards severe aching and  
 
shooting pains,  
 
which lasted  
 
about 2 weeks.*  
 
  
  
  
The case has been carefully  
+
The case has been carefully and continuously watched.
and continuously  
 
watched.  
 
  
  
  
Examination of the chest  
+
Examination of the chest after a gun-shot wound.
after a gun-shot wound.  
 
  
  
  
Later, lanugo hairs began  
+
Later, lanugo hairs began to appear.
to appear.  
 
  
  
  
At the timeof writingthere  
+
At the timeof writingthere were still two open spots.
were still two open spots.  
 
  
  
  
Four months later, even  
+
Four months later, even after curetting, granulating surface 4 inches in diameter still remained.
after curetting, granulating surface 4 inches in  
 
diameter still remained.  
 
  
  
  
16 days afterwards skin discolored and exfoliated.  
+
16 days afterwards skin discolored and exfoliated.
  
  
  
Patient confined to bed for  
+
Patient confined to bed for one month, and will probably be in bed another month.
one month, and will  
 
probably be in bed another month.  
 
  
  
  
•February 5, 1897, patient writes, " My hand is much about the same. I cannot use those (first) three lingers much better : and my nails are coming off, that  
+
•February 5, 1897, patient writes, " My hand is much about the same. I cannot use those (first) three lingers much better : and my nails are coming off, that Is, the old nail is like a shingle on top of the new one."
Is, the old nail is like a shingle on top of the new one."  
 
  
  
Line 3,227: Line 1,550:
  
  
As far as the cutaneous lesions were concerned, the skin of  
+
As far as the cutaneous lesions were concerned, the skin of the trunk appeared to suffer the most severely, although when the hand was attacked the pain was the most prominent feature.
the trunk appeared to suffer the most severely, although when  
 
the hand was attacked the pain was the most prominent  
 
feature.  
 
  
As to the character of the lesions produced, the majority of  
+
As to the character of the lesions produced, the majority of observers describe a peculiar redness or erythema at first, then swelling of the derma, followed by a deep discoloration of the skin until it became quite a dark brown color. Exfoliation of the pigmented skin followed later. In a number of cases vesiculation occurred after the hyperajmia, and quite a serious eruption resulted in two cases after only two exposures. The most severe effects followed after exposing the same region again to the rays when the lesion had only partially or wholly healed.
observers describe a peculiar redness or erythema at first, then  
 
swelling of the derma, followed by a deep discoloration of  
 
the skin until it became quite a dark brown color. Exfoliation of the pigmented skin followed later. In a number of  
 
cases vesiculation occurred after the hyperajmia, and quite a  
 
serious eruption resulted in two cases after only two exposures.  
 
The most severe effects followed after exposing the same  
 
region again to the rays when the lesion had only partially or  
 
wholly healed.  
 
  
The cases of Dr. Dunn, Dr. Banister and S. J. K. showed  
+
The cases of Dr. Dunn, Dr. Banister and S. J. K. showed perhaps the most severe results. Other lesions produced were alopecia, loss of the finger-nails, and obstinate ulceration. In connection with the subjective symptoms, severe pain and aching were present in the majority of the crises, especially with the eruptions on the hands. The lesions on the abdomen and back were, rather curiously enough, unaccompanied by pain.
perhaps the most severe results. Other lesions produced were  
 
alopecia, loss of the finger-nails, and obstinate ulceration.  
 
In connection with the subjective symptoms, severe pain and  
 
aching were present in the majority of the crises, especially  
 
with the eruptions on the hands. The lesions on the abdomen  
 
and back were, rather curiously enough, unaccompanied by  
 
pain.  
 
  
Many theories have been advanced to explain the injurious  
+
Many theories have been advanced to explain the injurious lesions produced by the x rays. tSome have supposed them to be entirely due to frequent and loug exposures ; but that is not tenable, because in five cases (Dr. Sehrwald's, Dr. Kolle's, Dr. Crocker's, Professor Daniel's and Professor Thomson's) marked results followed a single exposure, and in two cases two sittings only preceded the eruptive phenomena, and finally three other cases experienced deleterioiis results after only three exposures. Others again have compared all the phenomena to severe sunburn, but it can be demonstrated that more severe results have followed the use of the rays than have ever been known from exposure to the sun. Tesla believes that the hurtful action of the x rays is not due to the rays but to the ozone generated in contact with the skin. Ozone, he says, when abundantly produced, attacks the cutaneous surface, its action being no doubt heightened by the heat and moisture of the skin. In his discussion of the rays themselves he speaks of the disintegration of the electrodes, especially if they are of alumiuum, but this is so slow that no appreciable diminution of the weight results, even after long use; it follows, he says, that the matter conveyed by the Eontgen stream is so minute as to escape detection. Some bulbs which he has used for a number of months showed that the bombarded spot of the glass was entirely permeated with particles of the aluminum electrode, but it would probably require years of constant use to accumulate any appreciable amount of matter outside. He further remarks " that no experimenter need be deterred from carrying on an investigation of the rays for fear of poisonous or generally deleterious action, for it seems reasonable to conclude that it would take centuries to accumulate enough of such matter to interfere seriously with the process of life of a person." His last remark is certainly incorrect. His ozone theory is also incorrect, as I shall show later.
lesions produced by the x rays. tSome have supposed them to  
 
be entirely due to frequent and loug exposures ; but that is not  
 
tenable, because in five cases (Dr. Sehrwald's, Dr. Kolle's, Dr.  
 
Crocker's, Professor Daniel's and Professor Thomson's) marked  
 
results followed a single exposure, and in two cases two sittings  
 
only preceded the eruptive phenomena, and finally three other  
 
cases experienced deleterioiis results after only three exposures.  
 
Others again have compared all the phenomena to severe sunburn, but it can be demonstrated that more severe results  
 
have followed the use of the rays than have ever been known  
 
from exposure to the sun. Tesla believes that the hurtful  
 
action of the x rays is not due to the rays but to the ozone  
 
generated in contact with the skin. Ozone, he says, when  
 
abundantly produced, attacks the cutaneous surface, its action  
 
being no doubt heightened by the heat and moisture of the  
 
skin. In his discussion of the rays themselves he speaks of  
 
the disintegration of the electrodes, especially if they are of  
 
alumiuum, but this is so slow that no appreciable diminution  
 
of the weight results, even after long use; it follows, he says,  
 
that the matter conveyed by the Eontgen stream is so minute  
 
as to escape detection. Some bulbs which he has used for a  
 
number of months showed that the bombarded spot of the  
 
glass was entirely permeated with particles of the aluminum  
 
electrode, but it would probably require years of constant use  
 
to accumulate any appreciable amount of matter outside. He  
 
further remarks " that no experimenter need be deterred  
 
from carrying on an investigation of the rays for fear of poisonous or generally deleterious action, for it seems reasonable  
 
to conclude that it would take centuries to accumulate enough  
 
of such matter to interfere seriously with the process of life  
 
of a person." His last remark is certainly incorrect. His  
 
ozone theory is also incorrect, as I shall show later.  
 
  
Professor Thomson, with the definite idea of producing  
+
Professor Thomson, with the definite idea of producing cutaneous lesions, exposed his finger to a bulb of low potential and used a small 34-plate static machine. " The rays came from
cutaneous lesions, exposed his finger to a bulb of low potential  
 
and used a small 34-plate static machine. " The rays came from  
 
  
  
  
a bombarded spot, and were limited to the area which the  
+
a bombarded spot, and were limited to the area which the Kontgen rays could reach. The tube was of blue glass, with a clear German glass window from 1* to It inches in diameter opposite the bombarded spot." One striking feature was the fact that the fingers opposite the blue glass were not affected, as this was so dense as to absorb the rays. Only where the little finger was opposite the clear glass was it affected with a sharp line of demarcation. He says the blue glass would have been transparent to the ultra-violet rays. He also thinks that brush discharges have nothing to do with the cutaneous phenomena. His theory is that the deleterious effects are due to the X rays themselves or something that goes with them.
Kontgen rays could reach. The tube was of blue glass, with  
 
a clear German glass window from 1* to It inches in diameter  
 
opposite the bombarded spot." One striking feature was the  
 
fact that the fingers opposite the blue glass were not affected, as  
 
this was so dense as to absorb the rays. Only where the little  
 
finger was opposite the clear glass was it affected with a sharp  
 
line of demarcation. He says the blue glass would have been  
 
transparent to the ultra-violet rays. He also thinks that  
 
brush discharges have nothing to do with the cutaneous phenomena. His theory is that the deleterious effects are due to  
 
the X rays themselves or something that goes with them.  
 
  
The case which I will now report presents a suflBcient number of interesting points to make it worthy of record.  
+
The case which I will now report presents a suflBcient number of interesting points to make it worthy of record.
  
The patient is a healthy-looking man, Z'l years of age, who  
+
The patient is a healthy-looking man, Z'l years of age, who came to me November 18, 1896, with the following history: During the first week in September he exposed his right hand, wrist and lower portion of the forearm to the x rays while exhibiting an apparatus, each exposure lasting two or three minutes. No bad results followed, but on October 1st he came to Baltimore and resumed the use of the x rays for the same jjurposes. After he had exposed his hand for three weeks for four hours daily he noticed that the skin of the back of the hand, wrist and forearm began to turn very red and became " puffed up," although he suffered no pain. The swelling first occurred on the back of the hand from the knuckles to the wrist, then "inflammation set in " and he was compelled to stop his demonstrations. From about October 31st the hand, wrist and lower fourth of the forearm gradually became more inflamed and swollen, and the lesions spread to the fingers. The affected area ached and throbbed so much that he frequently could not sleep at night; there were also shooting pains which gradually increased in intensity and extended up the forearm along the ulnar side. These symptoms continued for a week when the patient consulted Professor Chambers, of Baltimore, who advised him to bathe the hand frequently in hot water and ordered bromides internally with benefit. The symptoms were much relieved and the swelling had gone down considerably in two weeks time. Three weeks after he had first sought medical advice he consulted me about the diseased condition of the skin.
came to me November 18, 1896, with the following history:  
 
During the first week in September he exposed his right  
 
hand, wrist and lower portion of the forearm to the x rays  
 
while exhibiting an apparatus, each exposure lasting two or  
 
three minutes. No bad results followed, but on October 1st  
 
he came to Baltimore and resumed the use of the x rays for  
 
the same jjurposes. After he had exposed his hand for three  
 
weeks for four hours daily he noticed that the skin of the  
 
back of the hand, wrist and forearm began to turn very red  
 
and became " puffed up," although he suffered no pain. The  
 
swelling first occurred on the back of the hand from the  
 
knuckles to the wrist, then "inflammation set in " and he was  
 
compelled to stop his demonstrations. From about October  
 
31st the hand, wrist and lower fourth of the forearm gradually became more inflamed and swollen, and the lesions spread  
 
to the fingers. The affected area ached and throbbed so much  
 
that he frequently could not sleep at night; there were also  
 
shooting pains which gradually increased in intensity and  
 
extended up the forearm along the ulnar side. These symptoms continued for a week when the patient consulted Professor Chambers, of Baltimore, who advised him to bathe the  
 
hand frequently in hot water and ordered bromides internally  
 
with benefit. The symptoms were much relieved and the  
 
swelling had gone down considerably in two weeks time.  
 
Three weeks after he had first sought medical advice he consulted me about the diseased condition of the skin.  
 
  
Ooii'lition at the time of the first exumination. The right  
+
Ooii'lition at the time of the first exumination. The right hand on its dorsal surface presented a deeply pigmented condition. The skin over the dorsal surface of the fingers, hand and wrist was of a very dark brown color, and part of it was already exfoliating. The skin was dry, infiltrated and wrinkled. The patient says the skin was more of a greenish hue at the end of the first week after it became affected. In places near the lateral margins of the hand a slightly vesicular appearance was presented. They were not true vesicles, but were due to the loosening of the surface of the epidermis, and contained only air. The pigmented skin could very easily be peeled off from the hand without any pain, leaving a dull, dry, reddish surface beneath.
hand on its dorsal surface presented a deeply pigmented  
 
condition. The skin over the dorsal surface of the fingers,  
 
hand and wrist was of a very dark brown color, and part  
 
of it was already exfoliating. The skin was dry, infiltrated  
 
and wrinkled. The patient says the skin was more of a  
 
greenish hue at the end of the first week after it became  
 
affected. In places near the lateral margins of the hand a  
 
slightly vesicular appearance was presented. They were not  
 
true vesicles, but were due to the loosening of the surface of  
 
the epidermis, and contained only air. The pigmented skin  
 
could very easily be peeled off from the hand without any  
 
pain, leaving a dull, dry, reddish surface beneath.  
 
  
On comparing the two hands they were found to be practically of the same temperature. The fingers of both were of  
+
On comparing the two hands they were found to be practically of the same temperature. The fingers of both were of about the same calibre. A photograph, which is represented here (Fig. 1), was taken of the hand the first time I sawj him,
about the same calibre. A photograph, which is represented  
 
here (Fig. 1), was taken of the hand the first time I sawj him,  
 
  
  
  
Febrdaet, 1897.]  
+
Febrdaet, 1897.]
  
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.  
+
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
  
21  
+
21
  
  
  
and it shows very well the exfoliatiou of the epidermis. It  
+
and it shows very well the exfoliatiou of the epidermis. It also represents the position of the hand which was most restful and least painful to the patient. The palmar surface was dry and paler than that of the normal hand, but the palmar surface of the fingers appeared swollen.
also represents the position of the hand which was most restful  
 
and least painful to the patient. The palmar surface was dry  
 
and paler than that of the normal hand, but the palmar surface of the fingers appeared swollen.  
 
  
I saw the patient ten days later, and the exfoliating epidermis had all been removed; the skin now presented a glossy  
+
I saw the patient ten days later, and the exfoliating epidermis had all been removed; the skin now presented a glossy appearance, and over the lingers it appeared to be tighter than on the corresponding fingers of the healthy hand. The palmar surface was still a little drier.
appearance, and over the lingers it appeared to be tighter than  
 
on the corresponding fingers of the healthy hand. The palmar  
 
surface was still a little drier.  
 
  
On careful examination the patient comjjlained of rather  
+
On careful examination the patient comjjlained of rather severe pain when the first phalanx of his right index finger was grasped, and it was then noticed that this bone was distinctly thickened, especially as compared with the corresponding phalanx of the other hand. The first and second phalanges of all the fingers were found to be thickened, but the increase in size was most marked in the first phalanges of the index and second fingers. Further careful examination of the other bones of the hand revealed a very painful spot over the wrist joint. The metacarpals were also tender on pressure, and the head of the second metacarpal was enlarged. The hairs were found to be less numerous on the affected hand, but they may have been removed in tearing off the exfoliating epidermis.
severe pain when the first phalanx of his right index finger  
 
was grasped, and it was then noticed that this bone was distinctly thickened, especially as compared with the corresponding phalanx of the other hand. The first and second phalanges  
 
of all the fingers were found to be thickened, but the increase  
 
in size was most marked in the first phalanges of the index  
 
and second fingers. Further careful examination of the other  
 
bones of the hand revealed a very painful spot over the wrist  
 
joint. The metacarpals were also tender on pressure, and the  
 
head of the second metacarpal was enlarged. The hairs were  
 
found to be less numerous on the affected hand, but they may  
 
have been removed in tearing off the exfoliating epidermis.  
 
  
Mbvemeids of the hands. All movements were found to be  
+
Mbvemeids of the hands. All movements were found to be quite difficult of accomplishment and very painful. When the patient first consulted me, voluntary movements of both fingers and hand were abolished, except of the little finger, which could be slightly flexed. Wrist movements were also very limited in extent and caused much pain. The thumb and fingers could scarcely be apposed. The patient could not pick up a lead pencil or penholder, and could grasj) with but slight force; if he could get his finger or thumb beneath an oVject he could pick it up. He complained of the joints being very stiff.
quite difficult of accomplishment and very painful. When  
 
the patient first consulted me, voluntary movements of both  
 
fingers and hand were abolished, except of the little finger,  
 
which could be slightly flexed. Wrist movements were also  
 
very limited in extent and caused much pain. The thumb  
 
and fingers could scarcely be apposed. The patient could not  
 
pick up a lead pencil or penholder, and could grasj) with but  
 
slight force; if he could get his finger or thumb beneath an  
 
oVject he could pick it up. He complained of the joints being  
 
very stiff.  
 
  
Sensation was very much impaired before exfoliation occurred,  
+
Sensation was very much impaired before exfoliation occurred, and even after that it was much diminished as compared with the normal hand. The sense of touch on the palmar surface was also markedly decreased.
and even after that it was much diminished as compared with  
 
the normal hand. The sense of touch on the palmar surface  
 
was also markedly decreased.  
 
  
When the distinct thickening of the phalanges was detected  
+
When the distinct thickening of the phalanges was detected I requested him to obtain careful x ray photographs of both hands under similar conditions at the same distance from the bulb. The accom23anying photographs show the bones of the two hands clearly, and I am particularly indebted to Professor W. C. A. Hammel, of Baltimore, for such excellent pictures.
I requested him to obtain careful x ray photographs of both  
 
hands under similar conditions at the same distance from the  
 
bulb. The accom23anying photographs show the bones of the  
 
two hands clearly, and I am particularly indebted to Professor  
 
W. C. A. Hammel, of Baltimore, for such excellent pictures.  
 
  
The hands were placed exactly twelve and a half inches  
+
The hands were placed exactly twelve and a half inches from the x ray tube, the distance being carefully measured from a plane passing through the long diameter of the tube to the fixed support on which the hand rested. The time of exposure was exactly three minutes for each hand.
from the x ray tube, the distance being carefully measured  
 
from a plane passing through the long diameter of the tube  
 
to the fixed support on which the hand rested. The time of  
 
exposure was exactly three minutes for each hand.  
 
  
It will at once be noticed from the photographs how much  
+
It will at once be noticed from the photographs how much thicker all the first phalanges of the right hand (Fig. 3) are than those of the left normal hand (Fig. 2). The increase in size is particularly marked in the first phalanges of the index and second finger; that of the little finger is less marked The second row of phalanges is also thicker than normal, but less thick than those of the first row. The heads of the second and third metacarpal bones are enlarged, and their shafts are also slightly thickened. It cannot be said, from the
thicker all the first phalanges of the right hand (Fig. 3) are  
 
than those of the left normal hand (Fig. 2). The increase in  
 
size is particularly marked in the first phalanges of the index  
 
and second finger; that of the little finger is less marked  
 
The second row of phalanges is also thicker than normal, but  
 
less thick than those of the first row. The heads of the  
 
second and third metacarpal bones are enlarged, and their  
 
shafts are also slightly thickened. It cannot be said, from the  
 
  
  
  
photographs alone, that any of the carpal bones of the affected  
+
photographs alone, that any of the carpal bones of the affected hand were at all increased in size.
hand were at all increased in size.  
 
  
A number of other points were discovered from these photographs. The spaces between the bones at the joints, particularly at the metacarpo-phalangeal and the interphalangeal  
+
A number of other points were discovered from these photographs. The spaces between the bones at the joints, particularly at the metacarpo-phalangeal and the interphalangeal joints, were much less marked and narrower than in those of the normal hand. The outline of the affected bone« was also more irregular and rougher than that of the left hand. On looking at the hand as a whole, it is also, I think, noticed that all the bones are denser in appearance in the affected hand.*
joints, were much less marked and narrower than in those of  
 
the normal hand. The outline of the affected bone« was also  
 
more irregular and rougher than that of the left hand. On  
 
looking at the hand as a whole, it is also, I think, noticed  
 
that all the bones are denser in appearance in the affected  
 
hand.*  
 
  
Two portions of skin were excised for histological purposes  
+
Two portions of skin were excised for histological purposes on the first day. One portion was taken from dorsal surface of the phalangeal region of the third finger, and the other from the lateral margin of the hand over tlie base of the metacarpal of the little finger. Neither stained nor unstained sections demonstrated the presence of any foreign particles, and only showed chronic inflammatory changes. The horny layer was thickened and half of it was partially detached. A large number of brown pigment granules were found in the exfoliating portion. The mucous layer was not thickened, but it was more pigmented than normal. In the corium the vessels were dilated, and the pigment cells of thepapillas were almost as numerous as are usually found in a section of negro skin. It was suggested that particles of platinum might have passed from the tube through the glass bulb deep into the tissues.
on the first day. One portion was taken from dorsal surface  
 
of the phalangeal region of the third finger, and the other  
 
from the lateral margin of the hand over tlie base of the  
 
metacarpal of the little finger. Neither stained nor unstained  
 
sections demonstrated the presence of any foreign particles,  
 
and only showed chronic inflammatory changes. The horny  
 
layer was thickened and half of it was partially detached. A  
 
large number of brown pigment granules were found in the  
 
exfoliating portion. The mucous layer was not thickened,  
 
but it was more pigmented than normal. In the corium the  
 
vessels were dilated, and the pigment cells of thepapillas were  
 
almost as numerous as are usually found in a section of negro  
 
skin. It was suggested that particles of platinum might have  
 
passed from the tube through the glass bulb deep into the  
 
tissues.  
 
  
Portions of the exfoliating skin were accordingly submitted  
+
Portions of the exfoliating skin were accordingly submitted to Professor Abel for chemical analysis, and he has very kindly furnished me with the following brief report: "I could find no platinum in the pieces of epidermis that you left with me for analysis. These pieces weighed, just as you sent them, 6-iO milligrams, or about ten grains."
to Professor Abel for chemical analysis, and he has very kindly  
 
furnished me with the following brief report: "I could find  
 
no platinum in the pieces of epidermis that you left with me  
 
for analysis. These pieces weighed, just as you sent them,  
 
6-iO milligrams, or about ten grains."  
 
  
Summary. In reviewing this case, there is here an example  
+
Summary. In reviewing this case, there is here an example of a disease of the skin which was brought about by frequent and prolonged exposure to the x rays. The lesions, as I have already described, were first those of byperajmia, then cedema, without the accompaniment of pain. Subjective symptoms were felt later, and continued to increase in severity (he was still using his hand for exhibition purposes) until, on account of the severe pain, he was compelled to stop his work. These subjective symptoms consisted of aching, tiirobbing and shooting pains. The color of the skin gradually changed to a deep brown, and the epidermis began to exfoliate. The bones of the hand were very tender on pressure, particularly the first phalanges of the index and second finger and the carpal bones. The movements of the hand became so limited that it was practically useless for some weeks. Sensation was also much impaired, but after exfoliation occurred it recovered again, but only gradually. Recovery of all the lesions has been very gradual indeed.
of a disease of the skin which was brought about by frequent  
 
and prolonged exposure to the x rays. The lesions, as I have  
 
already described, were first those of byperajmia, then cedema,  
 
without the accompaniment of pain. Subjective symptoms  
 
were felt later, and continued to increase in severity (he was  
 
still using his hand for exhibition purposes) until, on account  
 
of the severe pain, he was compelled to stop his work. These  
 
subjective symptoms consisted of aching, tiirobbing and shooting pains. The color of the skin gradually changed to a deep  
 
brown, and the epidermis began to exfoliate. The bones of  
 
the hand were very tender on pressure, particularly the first  
 
phalanges of the index and second finger and the carpal  
 
bones. The movements of the hand became so limited that it  
 
was practically useless for some weeks. Sensation was also  
 
much impaired, but after exfoliation occurred it recovered  
 
again, but only gradually. Recovery of all the lesions has  
 
been very gradual indeed.  
 
  
The photographs have revealed what has never been observed  
+
The photographs have revealed what has never been observed before, viz. a distinct osteoplastic periostitis, and probably an osteitis, particularly of the first and second rows of phalanges of the index and second fingers, also of the heads of meta
before, viz. a distinct osteoplastic periostitis, and probably an  
 
osteitis, particularly of the first and second rows of phalanges  
 
of the index and second fingers, also of the heads of meta
 
  
  
*As .an interesting point the photographs show the outlines even
 
of the finger-nails and the interosaei muscles.
 
  
 +
As .an interesting point the photographs show the outlines even
 +
of the finger-nails and the interosaei muscles.
  
  
22
 
  
 +
22
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
[No. 71.
 
  
 +
[No. 71.
  
  
carpal bones of the same fingers, and judging from the symptoms, even of some of the carpal bones.
 
  
This then accounts for the severe symptoms, the aching,  
+
carpal bones of the same fingers, and judging from the symptoms, even of some of the carpal bones.
throbbing and shooting pain which prevented sleep. The
 
density of these bones has also been increased, showing that
 
even bone tissue has been affected.  
 
  
A complete demonstration is thus afforded of the powerful,  
+
This then accounts for the severe symptoms, the aching, throbbing and shooting pain which prevented sleep. The density of these bones has also been increased, showing that even bone tissue has been affected.
piercing character of the x rays, and the severe, painful symptoms which have been described by other observers are probably due to the iuflamniatiou of the periosteum, and possibly
 
the bone, besides the softer tissues.  
 
  
This iniiammation has also extended into the joints, which  
+
A complete demonstration is thus afforded of the powerful, piercing character of the x rays, and the severe, painful symptoms which have been described by other observers are probably due to the iuflamniatiou of the periosteum, and possibly the bone, besides the softer tissues.
would explain the loss of movements, and pain, when they
 
could be used later.  
 
  
As the result of these observations, it proves that the x rays
+
This iniiammation has also extended into the joints, which would explain the loss of movements, and pain, when they could be used later.
are even more powerful than have been generally thought,
 
that the deleterious effects can iu some cases be quite serious,  
 
and that the cutaneous manifestations are not the most severe
 
of the lesions, but those of the deeper tissues, and particularly
 
of periosteum and bones, being more severe.  
 
  
The discovery of this deeper and more profound effect at
+
As the result of these observations, it proves that the x rays are even more powerful than have been generally thought, that the deleterious effects can iu some cases be quite serious, and that the cutaneous manifestations are not the most severe of the lesions, but those of the deeper tissues, and particularly of periosteum and bones, being more severe.
once overthrows many of the explanations which have been
 
advanced to account for the cutaneous lesions. Tesla's theory
 
of the ozone generated in contact with the skin will not
 
explain these deeper effects. Prof. Thomson has demonstrated
 
that they are not due to the ultra-violet rays. They cannot be
 
compared to sunburn, since no case, as far as is at present known,
 
has been published wheresunburu has produced periostitis and
 
even osteitis. Nor can such serious results be produced by
 
brush discharges, and Thomson has also proved that these
 
cannot be the causes. His further explanation that the effects
 
(he was not aware of the deeper injuries to the soft tissues and  
 
bone) are due to the x rays themselves or something which accompanies them, is rather indefinite. It was suggested to me, as
 
I have already mentioned, that it might be due to the platinum
 
particles piercing the bulb and then attacking the tissues, but
 
this almost appears impossible, since serious cutaneous effects
 
have even followed only one exposure of half an hour {vide
 
Thomson's case).  
 
  
I consulted with Professor Ames, Associate Pi'ofessor of  
+
The discovery of this deeper and more profound effect at once overthrows many of the explanations which have been advanced to account for the cutaneous lesions. Tesla's theory of the ozone generated in contact with the skin will not explain these deeper effects. Prof. Thomson has demonstrated that they are not due to the ultra-violet rays. They cannot be compared to sunburn, since no case, as far as is at present known, has been published wheresunburu has produced periostitis and even osteitis. Nor can such serious results be produced by brush discharges, and Thomson has also proved that these cannot be the causes. His further explanation that the effects (he was not aware of the deeper injuries to the soft tissues and bone) are due to the x rays themselves or something which accompanies them, is rather indefinite. It was suggested to me, as I have already mentioned, that it might be due to the platinum particles piercing the bulb and then attacking the tissues, but this almost appears impossible, since serious cutaneous effects have even followed only one exposure of half an hour {vide Thomson's case).
Physics in the Johns Hopkins University, who, after reviewing
 
all the facts of the case, kindly wrote as follows concerning
 
the present theory of the x rays :
 
  
" The radiation in an ' a; ray tube ' may be divided provisionally into three classes: ether-waves, which may have wavelengths from 150 to 800,a/j^, approximately; kathode rays, which
+
I consulted with Professor Ames, Associate Pi'ofessor of Physics in the Johns Hopkins University, who, after reviewing all the facts of the case, kindly wrote as follows concerning the present theory of the x rays :
undoubtedly are streams of matter, electrically charged ;
 
X rays, about whose nature there is no conclusive evidence at
 
the present time. If the walls of the tube are thin enough
 
and of suitable material, all these radiations will emerge and
 
pass into the surrounding air. It is a matter of doubt if the
 
kathode rays observed outside the vacuum-tube are the same
 
as those inside ; but the inner ones undoubtedly cause the
 
outer ones. There is no evidence that x rays carry with them
 
particles of matter, or that they directly cause a stream of
 
particles; in fact, all known facts seem to point to the belief
 
that they are ether-waves of extreme shortness."
 
  
It will thus be seen that the opinion expressed here does
+
" The radiation in an ' a; ray tube ' may be divided provisionally into three classes: ether-waves, which may have wavelengths from 150 to 800,a/j^, approximately; kathode rays, which undoubtedly are streams of matter, electrically charged ; X rays, about whose nature there is no conclusive evidence at the present time. If the walls of the tube are thin enough and of suitable material, all these radiations will emerge and pass into the surrounding air. It is a matter of doubt if the kathode rays observed outside the vacuum-tube are the same as those inside ; but the inner ones undoubtedly cause the outer ones. There is no evidence that x rays carry with them particles of matter, or that they directly cause a stream of particles; in fact, all known facts seem to point to the belief that they are ether-waves of extreme shortness."
  
 +
It will thus be seen that the opinion expressed here does
  
  
not make it possible for the x rays themselves to produce such
 
deleterious effects as have already been described, but Dr. Ames
 
mentions the fact that the kathode rays are undoubtedly
 
streams of matter electrically charged. Here then we have
 
some possible grounds for the theory that the lesions may be
 
due to the entrance of particles (platinum in our case) into
 
the injured tissues, and that the kathode rays which accompany the X rays may be the cause of the trouble, and not the
 
X rays themselves.
 
  
On clinical grounds there is considerable support for this,  
+
not make it possible for the x rays themselves to produce such deleterious effects as have already been described, but Dr. Ames mentions the fact that the kathode rays are undoubtedly streams of matter electrically charged. Here then we have some possible grounds for the theory that the lesions may be due to the entrance of particles (platinum in our case) into the injured tissues, and that the kathode rays which accompany the X rays may be the cause of the trouble, and not the X rays themselves.
at first sight, improbable theory. If the lesion extends at all
 
deeply, it leads to the formation of ulcers, which are extremely
 
intractable, and they may be due to irritating particles still
 
present in the tissues.  
 
  
I do not think that the possibility of injury ought to deter
+
On clinical grounds there is considerable support for this, at first sight, improbable theory. If the lesion extends at all deeply, it leads to the formation of ulcers, which are extremely intractable, and they may be due to irritating particles still present in the tissues.
one from using these wonderful rays in surgical work, because
 
only a few have been affected out of thousands who have been
 
exposed to them. By keeping, as Thomson says, some distance
 
away from the rays, injurious effects will hardly follow their
 
use, and when the exposure is for a short time, unless, as may  
 
happen in all other diseases, idiosyncrasy plays a prominent
 
part.  
 
  
When I viewed my own hand two or three times near a new
+
I do not think that the possibility of injury ought to deter one from using these wonderful rays in surgical work, because only a few have been affected out of thousands who have been exposed to them. By keeping, as Thomson says, some distance away from the rays, injurious effects will hardly follow their use, and when the exposure is for a short time, unless, as may happen in all other diseases, idiosyncrasy plays a prominent part.
Edison bulb, through a tungstate of calcium screen, after four
 
or five minutes I distinctly felt a tingling sensation throughout the dorsum of the hand; this symptom lasted for ten or
 
fifteen minutes and passed away without any further results.
 
It occurred to me that x ray operators and experimenters should
 
expose to the rays the palmar surface of the hand, which is  
 
protected by a much thicker horny layer, rather than the back
 
of the hand, which is much less protected.  
 
  
In conclusion I would strongly advise all x ray operators  
+
When I viewed my own hand two or three times near a new Edison bulb, through a tungstate of calcium screen, after four or five minutes I distinctly felt a tingling sensation throughout the dorsum of the hand; this symptom lasted for ten or fifteen minutes and passed away without any further results. It occurred to me that x ray operators and experimenters should expose to the rays the palmar surface of the hand, which is protected by a much thicker horny layer, rather than the back of the hand, which is much less protected.
and experimenters who develop any special idiosyncrasy, to
 
abstain from their use if they find that the slightest deleterious results follow an exposure to them.  
 
  
Bibliography.  
+
In conclusion I would strongly advise all x ray operators and experimenters who develop any special idiosyncrasy, to abstain from their use if they find that the slightest deleterious results follow an exposure to them.
  
John Daniel : Medical Record, April 25, 1896, vol. 49,
+
Bibliography.
No. 17.  
 
  
0. Leppin: Deutsche medicin. Wochensch., No. 28 (July
+
John Daniel : Medical Record, April 25, 1896, vol. 49, No. 17.
9), 189G, p. 454-.  
 
  
Marcuse: Deutsche medicin. Wochensch., No. 30 (July  
+
0. Leppin: Deutsche medicin. Wochensch., No. 28 (July 9), 189G, p. 454-.
23), 189G, and No. 42 (October 15), 1896 ; also abstract in
 
Brit. Med. Journal, Aug. 15, 1896.  
 
  
Feilchenfeld : Deutsche medicin. Wochensch., No. 30 (July  
+
Marcuse: Deutsche medicin. Wochensch., No. 30 (July 23), 189G, and No. 42 (October 15), 1896 ; also abstract in Brit. Med. Journal, Aug. 15, 1896.
23), 1896.  
 
  
Conrad: Codex Medicus, August, 1896.  
+
Feilchenfeld : Deutsche medicin. Wochensch., No. 30 (July 23), 1896.
  
Paul Fuchs: Deutsche medicin. Wochensch., No. 35 (Aug.
+
Conrad: Codex Medicus, August, 1896.
27), 1896, p. 569.  
 
  
Sehrwald: Deutsche medicin. Wochensch., No. 41 (Oct. 8),  
+
Paul Fuchs: Deutsche medicin. Wochensch., No. 35 (Aug. 27), 1896, p. 569.
1896; abstract in Brit. Med. Journal, Nov. 7, 1896.  
 
  
S. J. R.: Nature, No. 1409, vol. 54, Oct. 29, 1896.  
+
Sehrwald: Deutsche medicin. Wochensch., No. 41 (Oct. 8), 1896; abstract in Brit. Med. Journal, Nov. 7, 1896.
  
H. C. Dunn: Brit. Med. Journal, Nov. 7, 1896.  
+
S. J. R.: Nature, No. 1409, vol. 54, Oct. 29, 1896.
  
G. C. Skinner: The Journal of the American Medical Association, No. 20, vol. XXVII, Nov. 14, 1896.  
+
H. C. Dunn: Brit. Med. Journal, Nov. 7, 1896.
  
Macintyre: Nature, No. 1412, vol. 55, Nov. 19, 1896.  
+
G. C. Skinner: The Journal of the American Medical Association, No. 20, vol. XXVII, Nov. 14, 1896.
  
K. E. King: Canadian Practitioner, Nov. 1896.  
+
Macintyre: Nature, No. 1412, vol. 55, Nov. 19, 1896.
  
 +
K. E. King: Canadian Practitioner, Nov. 1896.
  
  
  
Case of J ray dermatitis. Photograph showing exfoliation of the epidermis.
 
  
 +
Case of J ray dermatitis. Photograph showing exfoliation of the epidermis.
  
  
"^
 
  
 +
"^
  
  
 
  
 +
  
  
  
  
FIG. 2.
 
X ray photograph of left hand (normal).
 
  
 +
FIG. 2. X ray photograph of left hand (normal).
  
  
FIG. 3.
 
  
X ray photograph of the right hand showinj
+
FIG. 3.
thickening of some of the bones.  
 
  
 +
X ray photograph of the right hand showinj thickening of some of the bones.
  
  
February, -1897.]
 
  
 +
February, -1897.]
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
23
 
  
 +
23
  
  
M. J. Stern : The American Medico-Surgical Bulletin, Nov.
 
31, 1896.
 
  
F. Kolle: Brooklyn Medical Journal, December, 1896, vol.
+
M. J. Stern : The American Medico-Surgical Bulletin, Nov. 31, 1896.
X, No. 12.  
 
  
J. C. White: Boston Medical and Surgical Journal, Dec. 3,  
+
F. Kolle: Brooklyn Medical Journal, December, 1896, vol. X, No. 12.
1896, vol. CXXXV, No. 23.  
 
  
E. Thomson : Boston Medical and Surgical Journal, Dec.  
+
J. C. White: Boston Medical and Surgical Journal, Dec. 3, 1896, vol. CXXXV, No. 23.
10, 1896, vol. CXXXV, No. 24.  
 
  
Nikola Teslu: Abstract in Public Opinion, vol. XXI,  
+
E. Thomson : Boston Medical and Surgical Journal, Dec. 10, 1896, vol. CXXXV, No. 24.
No. 24.  
 
  
 +
Nikola Teslu: Abstract in Public Opinion, vol. XXI, No. 24.
  
  
M. H. Kichardson: The Medical News, Dec. 26, 1896, vol.
 
LXIX, No. 1250.
 
  
The Medical Record : References to case at University of
+
M. H. Kichardson: The Medical News, Dec. 26, 1896, vol. LXIX, No. 1250.
Minnesota, vol. 50, No. 25, Dec. 19, 1896.  
 
  
W. E. Parker : New Orleans Medical Journal, Sept. 1896,  
+
The Medical Record : References to case at University of Minnesota, vol. 50, No. 25, Dec. 19, 1896.
vol. XLIX, No. 3.  
 
  
H. R. Crocker: Brit. Med. Journal, Jan. 2, 1897, No. 1879.  
+
W. E. Parker : New Orleans Medical Journal, Sept. 1896, vol. XLIX, No. 3.
  
W. B. Banister: Medical Record, vol. LII, No. 4, Jan. 23,  
+
H. R. Crocker: Brit. Med. Journal, Jan. 2, 1897, No. 1879.
1897.  
 
  
Ereund : Miinch. Med. Woch., No. 3, Jahrg. 44, Jan. 19, 1897.  
+
W. B. Banister: Medical Record, vol. LII, No. 4, Jan. 23, 1897.
  
 +
Ereund : Miinch. Med. Woch., No. 3, Jahrg. 44, Jan. 19, 1897.
  
  
LESIONS INDUCED BY THE ACTION OF CERTAIN POISONS ON THE NERVE CELL
 
  
Study VI.— DIPHTHERIA.
+
LESIONS INDUCED BY THE ACTION OF CERTAIN POISONS ON THE NERVE CELL
By Henry J. Berkley, M. D.
 
  
 +
Study VI.— DIPHTHERIA. By Henry J. Berkley, M. D.
  
  
During the course of this investigation, an article by Ceni*
 
on the same subject came into my hands, and the results determined, by both investigations are so entirely similar that it
 
seems hardly necessary to repeat in full the details of the
 
study.
 
  
Ceni's work was done on rabbits and horses, with an acute
+
During the course of this investigation, an article by Ceni* on the same subject came into my hands, and the results determined, by both investigations are so entirely similar that it seems hardly necessary to repeat in full the details of the study.
and a chronic series. The first, after the inoculations with diphtheria cultures, lived from three to four days, and showed, in  
 
exquisite form, the beginning of the moniliform swellings of
 
the dendrites of the cortical and hippocampal cells common
 
to the action of all the toxins of the infectious series. The
 
chronic series lived from 36 to 41 days after the inoculation
 
with the toxin, during which period they lost full half their
 
weight. Ceni also utilized the cerebra of horses which had
 
been used in the Milan Bacteriological Laboratory to produce
 
diphtheria serum. In these, after three or four months of the
 
treatment, he found the cortical cells far degenerated, and to
 
a degree not seen with the rabbits, the stouter dendrites and
 
corpora of the cells being extensively involved in the destructive process.  
 
  
Interesting to note, he also finds distinct lesions of the  
+
Ceni's work was done on rabbits and horses, with an acute and a chronic series. The first, after the inoculations with diphtheria cultures, lived from three to four days, and showed, in exquisite form, the beginning of the moniliform swellings of the dendrites of the cortical and hippocampal cells common to the action of all the toxins of the infectious series. The chronic series lived from 36 to 41 days after the inoculation with the toxin, during which period they lost full half their weight. Ceni also utilized the cerebra of horses which had been used in the Milan Bacteriological Laboratory to produce diphtheria serum. In these, after three or four months of the treatment, he found the cortical cells far degenerated, and to a degree not seen with the rabbits, the stouter dendrites and corpora of the cells being extensively involved in the destructive process.
vascular neuroglia, principally tumefaction of the bodies and  
 
branches, the one attached to the blood-vessels' walls showing
 
the alterations most distinctly, all being identical with those
 
described and recorded in the III. study of this series (Art.
 
Ricin Poisoning).  
 
  
Our present series consisted of five diphtheria guinea-pigs,  
+
Interesting to note, he also finds distinct lesions of the vascular neuroglia, principally tumefaction of the bodies and branches, the one attached to the blood-vessels' walls showing the alterations most distinctly, all being identical with those described and recorded in the III. study of this series (Art. Ricin Poisoning).
whose brains had been sent me by Dr. Flexner for the purposes
 
of the study. The first two brains, after hardening and examination of the sections, were rejected on account of the  
 
possible presence of post-mortem changes. The other three
 
cerebra were carefully hardened in Miiller's fluid and treated
 
afterwards by the silver phospho-molybdate formula.  
 
  
Guinea-pig No. 3 received an injection of the toxin at 2.30
+
Our present series consisted of five diphtheria guinea-pigs, whose brains had been sent me by Dr. Flexner for the purposes of the study. The first two brains, after hardening and examination of the sections, were rejected on account of the possible presence of post-mortem changes. The other three cerebra were carefully hardened in Miiller's fluid and treated afterwards by the silver phospho-molybdate formula.
P. M. and died about 3 A. M. the following morning. No. 4
 
was inoculated at 2 P. M., was re-inoculated two days later at
 
10.30 A. M., and died two days afterwards at noon. No. 5
 
  
 +
Guinea-pig No. 3 received an injection of the toxin at 2.30 P. M. and died about 3 A. M. the following morning. No. 4 was inoculated at 2 P. M., was re-inoculated two days later at 10.30 A. M., and died two days afterwards at noon. No. 5
  
  
•Carlo Ceni : Riforma Medica, vol. I, 1896.
 
  
 +
•Carlo Ceni : Riforma Medica, vol. I, 1896.
  
  
went through the same course of treatment as No. 4 and
 
died approximately at the same hour.
 
  
The local manifestations at the site of the inoculation were
+
went through the same course of treatment as No. 4 and died approximately at the same hour.
experimental membranes, oedema, and slight central necrosis.  
 
The lymph glands throughout the body were enlarged, there
 
were small hemorrhages in the mucous membranes, and  
 
ecchymoses and necroses of the abdominal organs, with considerable fluid in both the thoracic and abdominal cavities.  
 
  
With Case 3 the dendrites only show beginning changes.
+
The local manifestations at the site of the inoculation were experimental membranes, oedema, and slight central necrosis. The lymph glands throughout the body were enlarged, there were small hemorrhages in the mucous membranes, and ecchymoses and necroses of the abdominal organs, with considerable fluid in both the thoracic and abdominal cavities.
There are numerous small moniliform swellings scattered over
 
their branches, not focally but uniformly throughout the
 
cortex, and over the sites of these tumefactions the gemmules
 
are either lost or are very sparingly present, while on those
 
that have normal dendrites they are undiminished in numbers. On the stretch of dendrite between the swellings, which
 
either appears normal or slightly below the natural calibre,
 
the lateral buds are beginning to disappear, as shown by the
 
paucity of their numbers and lessened tendency to assume a
 
deej) black tint. The bodies of the cells do not appear to be
 
in any way changed in staining properties, or to have lost in  
 
any degree the angularity of their contours.  
 
  
The vascular neuroglia cells are uniformly stained throughout the outer layers of the cortex, and have their tentacles,  
+
With Case 3 the dendrites only show beginning changes. There are numerous small moniliform swellings scattered over their branches, not focally but uniformly throughout the cortex, and over the sites of these tumefactions the gemmules are either lost or are very sparingly present, while on those that have normal dendrites they are undiminished in numbers. On the stretch of dendrite between the swellings, which either appears normal or slightly below the natural calibre, the lateral buds are beginning to disappear, as shown by the paucity of their numbers and lessened tendency to assume a deej) black tint. The bodies of the cells do not appear to be in any way changed in staining properties, or to have lost in any degree the angularity of their contours.
jiarticularly the vascular foot, somewhat swollen, the degree
 
being considerably less than in some specimens we have noted
 
after the injection of other toxins. The axis-cylinders are distinct, and show no alterations. The tei-minal apparatus of  
 
the cortical fibres were so infrequently stained that it is
 
hardly possible to determine with certainty whether they were
 
pathologically altered or no, but those found appeared to be
 
normal.  
 
  
The larger vessels showed neither thickenings nor ruptures
+
The vascular neuroglia cells are uniformly stained throughout the outer layers of the cortex, and have their tentacles, jiarticularly the vascular foot, somewhat swollen, the degree being considerably less than in some specimens we have noted after the injection of other toxins. The axis-cylinders are distinct, and show no alterations. The tei-minal apparatus of the cortical fibres were so infrequently stained that it is hardly possible to determine with certainty whether they were pathologically altered or no, but those found appeared to be normal.
of their coats.  
 
  
With cases Nos. 4 and 5 the pathological alteration is
+
The larger vessels showed neither thickenings nor ruptures of their coats.
similar to that in No. 3, only increased in intensity, from the
 
longer duration of the poisoning, and, perhaps, also from the
 
repetition of the inoculations. The moniliform nodules are
 
well marked over long stretches of cells in the pyramidal
 
region of the sections, and are uniformly larger than in the
 
more acute case. Also the denudation of the gemmules is
 
  
 +
With cases Nos. 4 and 5 the pathological alteration is similar to that in No. 3, only increased in intensity, from the longer duration of the poisoning, and, perhaps, also from the repetition of the inoculations. The moniliform nodules are well marked over long stretches of cells in the pyramidal region of the sections, and are uniformly larger than in the more acute case. Also the denudation of the gemmules is
  
  
24
 
  
 +
24
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
[No. n.
 
  
 +
[No. n.
  
  
marked by the greater absence of these pin-like projections
 
from the dendrites.
 
  
Some of the psychical cells are beginning to show alterations
+
marked by the greater absence of these pin-like projections from the dendrites.
of their outlines, appearing now rounded in contrast to the  
 
third case.  
 
  
The vascular neuroglia also shows signs of more advanced
+
Some of the psychical cells are beginning to show alterations of their outlines, appearing now rounded in contrast to the third case.
swelling, the tentacles being thicker and the pseudopodia
 
more prominent.  
 
  
The axons and collaterals are well stained, but show no
+
The vascular neuroglia also shows signs of more advanced swelling, the tentacles being thicker and the pseudopodia more prominent.
unusual varicosity or other departure from the normal. A
 
few of the cells having upturned axons are well stained, but
 
the morbid changes are of less intensity than with the pyramidal variety.  
 
  
 +
The axons and collaterals are well stained, but show no unusual varicosity or other departure from the normal. A few of the cells having upturned axons are well stained, but the morbid changes are of less intensity than with the pyramidal variety.
  
  
The cerebellar cells, as in the previous studies, showed less
 
damage than those of the cerebrum. The Purkinje variety
 
was the only one recognisably involved. The peculiar axons
 
of the basket cells were natural, and the various nerve fibres
 
throughout the outer lamina of the cortex retained their histological appearance.
 
  
From the studies conducted on the cerebra of hydrophobic
+
The cerebellar cells, as in the previous studies, showed less damage than those of the cerebrum. The Purkinje variety was the only one recognisably involved. The peculiar axons of the basket cells were natural, and the various nerve fibres throughout the outer lamina of the cortex retained their histological appearance.
and diphtheritic guinea-pigs it would appear that all severe
 
infections were followed by brain-cell degeneration of an order
 
not dissimilar to that found in the cells of the abdominal
 
viscera under similar conditions, a degenerative process unaccompanied by inflammatory reaction and a tendency to atrophy
 
and necrosis.  
 
  
 +
From the studies conducted on the cerebra of hydrophobic and diphtheritic guinea-pigs it would appear that all severe infections were followed by brain-cell degeneration of an order not dissimilar to that found in the cells of the abdominal viscera under similar conditions, a degenerative process unaccompanied by inflammatory reaction and a tendency to atrophy and necrosis.
  
  
PUERPERAL SEPSIS DUE TO INFECTION WITH THE BACILLUS AEROGENES CAPSULATUS.
 
  
By George W. Dobbin, M. D., Resident Obstetrician, The Johns Hopkins Hospital.  
+
PUERPERAL SEPSIS DUE TO INFECTION WITH THE BACILLUS AEROGENES CAPSULATUS.
  
 +
By George W. Dobbin, M. D., Resident Obstetrician, The Johns Hopkins Hospital.
  
  
The following case, which occurred in the Out-patient Obstetrical Department of the Johns Hopkins Hospital, is interesting from the fact that we have been able to lind reports of
 
only a few similar cases in the literature.
 
  
We were called to see the patient, Paulina A., about eleven
+
The following case, which occurred in the Out-patient Obstetrical Department of the Johns Hopkins Hospital, is interesting from the fact that we have been able to lind reports of only a few similar cases in the literature.
o'clock on the evening of March second, the messenger saying that she had been in labor about two days and the midwife was unable to deliver the child.  
 
  
As the patient and midwife were Polish it was exceedingly
+
We were called to see the patient, Paulina A., about eleven o'clock on the evening of March second, the messenger saying that she had been in labor about two days and the midwife was unable to deliver the child.
difficult to obtain an accurate subjective history of the case,  
 
but after considerable difficulty it was found that she had had
 
an abdominal operation done a year ago in Germany, the nature
 
of which we were unable to ascertain. She was at the end of
 
her third pregnancy, and had been in labor two days.  
 
  
Examination showed her to be a person of medium size, of  
+
As the patient and midwife were Polish it was exceedingly difficult to obtain an accurate subjective history of the case, but after considerable difficulty it was found that she had had an abdominal operation done a year ago in Germany, the nature of which we were unable to ascertain. She was at the end of her third pregnancy, and had been in labor two days.
an exceedingly pinched and pale appearance about the face,  
 
with weak and rapid pulse, running from 130 to 140 beats
 
per minute.  
 
  
The abdomen was enlarged to about the size of a full-term
+
Examination showed her to be a person of medium size, of an exceedingly pinched and pale appearance about the face, with weak and rapid pulse, running from 130 to 140 beats per minute.
pregnancy. Just above the symphysis was the pigmented
 
cicatrix of the abdominal operation referred to. The fundus
 
of the uterus presents the bullet-shaped appearance suggestive
 
of pelvic contraction ; it reaches to a point midway between
 
the umbilicus and xyphoid cartilage, and was in a condition of
 
tetanic contraction. Palpation showed a large child in the lef toccipito-iliac-anterior position, with the head impacted in the
 
pelvis. The fojtal heart could not be heard, and the patient
 
was not having regular labor pains.  
 
  
Measurements of the pelvis showed that she had a generally
+
The abdomen was enlarged to about the size of a full-term pregnancy. Just above the symphysis was the pigmented cicatrix of the abdominal operation referred to. The fundus of the uterus presents the bullet-shaped appearance suggestive of pelvic contraction ; it reaches to a point midway between the umbilicus and xyphoid cartilage, and was in a condition of tetanic contraction. Palpation showed a large child in the lef toccipito-iliac-anterior position, with the head impacted in the pelvis. The fojtal heart could not be heard, and the patient was not having regular labor pains.
contracted pelvis, with a conjuc/dta vera of approxinuitely 8
 
cm.; the other measurements were as follows : distance between
 
iliac spines 32.5 cm., between iliac crests 25 cm., between
 
trochanters 38 cm., Baudeloque diameter 17 cm., and a diagonal conjugate of 10.5 cm.  
 
  
By vaginal examination we found that the vaginal outlet
+
Measurements of the pelvis showed that she had a generally contracted pelvis, with a conjuc/dta vera of approxinuitely 8 cm.; the other measurements were as follows : distance between iliac spines 32.5 cm., between iliac crests 25 cm., between trochanters 38 cm., Baudeloque diameter 17 cm., and a diagonal conjugate of 10.5 cm.
was much relaxed. There was a very large caput succedaueum
 
I)resenting in the vagina. The head was very firmly impacted in the pelvis and could not be pushed up. The
 
sagittal suture was in the transverse diameter of the pelvis,
 
  
 +
By vaginal examination we found that the vaginal outlet was much relaxed. There was a very large caput succedaueum I)resenting in the vagina. The head was very firmly impacted in the pelvis and could not be pushed up. The sagittal suture was in the transverse diameter of the pelvis,
  
  
with the small fontanelle to the left. The impaction of the
 
head was so great that the cranial bones overlapped one
 
another to the extent of one centimeter.
 
  
On approaching the bed a very sweetish, offensive odor
+
with the small fontanelle to the left. The impaction of the head was so great that the cranial bones overlapped one another to the extent of one centimeter.
became noticeable, and a distinct bubbling, crackling sound
 
could be heard. This was thought at first to be due to the  
 
escape of gas from the rectum, but on turning down the bedclothes it was seen to come from the vulva, which was bathed
 
in a dirty reddish-brown fluid containing many gas-bubbles.
 
The bubbling, crackling sound was continuous, and was much
 
more apparent when the patient's genitals were exposed.  
 
  
Diagnosis. Generally contracted pelvis, with conjugata vira
+
On approaching the bed a very sweetish, offensive odor became noticeable, and a distinct bubbling, crackling sound could be heard. This was thought at first to be due to the escape of gas from the rectum, but on turning down the bedclothes it was seen to come from the vulva, which was bathed in a dirty reddish-brown fluid containing many gas-bubbles. The bubbling, crackling sound was continuous, and was much more apparent when the patient's genitals were exposed.
of about 8 cm. ; large child in left occipito-iliac anterior
 
position, with head impacted in the pelvis; arrest of labor.  
 
  
Owing to the mother's condition, and as the child was already
+
Diagnosis. Generally contracted pelvis, with conjugata vira of about 8 cm. ; large child in left occipito-iliac anterior position, with head impacted in the pelvis; arrest of labor.
dead, immediate delivery was indicated. She was given chloroform, placed across the bed in the lithotomy position, and a
 
Tarnier axis-traction forceps was applied by Dr. Williams.
 
The head was brought down to the outlet with great difficulty,
 
and as it became more and more crushed out of shape with
 
each traction it allowed the forceps blades to slip several
 
times. The lateral blades of the Tarnier basiotribe were then
 
applied, screwed tightly together, and the crushed head
 
delivered.  
 
  
Tractions now made on the delivered head showed that the
+
Owing to the mother's condition, and as the child was already dead, immediate delivery was indicated. She was given chloroform, placed across the bed in the lithotomy position, and a Tarnier axis-traction forceps was applied by Dr. Williams. The head was brought down to the outlet with great difficulty, and as it became more and more crushed out of shape with each traction it allowed the forceps blades to slip several times. The lateral blades of the Tarnier basiotribe were then applied, screwed tightly together, and the crushed head delivered.
sh'oulders were so firmly impacted in the pelvis that they
 
could not be delivered without tearing the head from the body.  
 
The blunt hook was then put into the posterior axilla and
 
that shoulder brought down; this manipulation caused the
 
separation of the epiphysis from the shaft of the humerus,  
 
and in order to effect delivery of the trunk it was necessary to  
 
put the blunt hook between the ribs beneath the substernal
 
notch and literally drag the child from the mother.  
 
  
Just as the child was delivered there was an escape of gas
+
Tractions now made on the delivered head showed that the sh'oulders were so firmly impacted in the pelvis that they could not be delivered without tearing the head from the body. The blunt hook was then put into the posterior axilla and that shoulder brought down; this manipulation caused the separation of the epiphysis from the shaft of the humerus, and in order to effect delivery of the trunk it was necessary to put the blunt hook between the ribs beneath the substernal notch and literally drag the child from the mother.
from the uterine cavity accompanied by an explosive sound.  
 
The gas possessed a most sickening fa>tid odor, which was so
 
intense that Dr. Williams was obliged to leave the patient and  
 
seek the outside air.  
 
  
The third stage of labor also gave considerable difficulty, for
+
Just as the child was delivered there was an escape of gas from the uterine cavity accompanied by an explosive sound. The gas possessed a most sickening fa>tid odor, which was so intense that Dr. Williams was obliged to leave the patient and seek the outside air.
  
 +
The third stage of labor also gave considerable difficulty, for
  
  
February, 1897.]
 
  
 +
February, 1897.]
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
25
 
  
 +
25
  
  
the uterus having been for so long in a tetanic condition,
 
refused to retract, and it was finally necessary to deliver the
 
placenta manually.
 
  
Retraction still being very slow, a hot intrauterine douche
+
the uterus having been for so long in a tetanic condition, refused to retract, and it was finally necessary to deliver the placenta manually.
of boiled water was given, which had, however, little effect;
 
but there being no excessive hemorrhage, the patient was put
 
back to bed. Her condition, while very bad, was not much
 
worse than at the beginning of the operation. She was given
 
strychnia, brandy, etc., and left for the night.  
 
  
March 3rd, 9 A. M. The patient was seen by the nurse, who
+
Retraction still being very slow, a hot intrauterine douche of boiled water was given, which had, however, little effect; but there being no excessive hemorrhage, the patient was put back to bed. Her condition, while very bad, was not much worse than at the beginning of the operation. She was given strychnia, brandy, etc., and left for the night.
reported her condition in no way improved. She had repeated
 
attacks of vomiting during the night. Temperature 98.4°,  
 
pulse 144, irregular, weak and intermittent.  
 
  
5 P. M. The patient was decidedly worse than in the morning. Temperature 101., pulse 144, weak, irregular and  
+
March 3rd, 9 A. M. The patient was seen by the nurse, who reported her condition in no way improved. She had repeated attacks of vomiting during the night. Temperature 98., pulse 144, irregular, weak and intermittent.
intermittent, her face presented an anxious expression, and the
 
respirations were rapid and irregular.  
 
  
During the morning "gas bacilli" had been found in the
+
5 P. M. The patient was decidedly worse than in the morning. Temperature 101.2°, pulse 144, weak, irregular and intermittent, her face presented an anxious expression, and the respirations were rapid and irregular.
tissues of the fcetus and placenta, so a fatal prognosis was
 
given to her husband. At this time in no part of the body
 
could we detect the presence of emphysema. Slips and cultures
 
were made from the lochia, which showed staphylococci,
 
streptococci and large numbers of gas bacilli.  
 
  
As well as we have been able to find this is the first instance
+
During the morning "gas bacilli" had been found in the tissues of the fcetus and placenta, so a fatal prognosis was given to her husband. At this time in no part of the body could we detect the presence of emphysema. Slips and cultures were made from the lochia, which showed staphylococci, streptococci and large numbers of gas bacilli.
in which a diagnosis of this form of puerperal infection has
 
been made before death.  
 
  
10 P. M. The patient is decidedly worse, no gas detected
+
As well as we have been able to find this is the first instance in which a diagnosis of this form of puerperal infection has been made before death.
in the tissues. The patient died three hours later, and soon
 
afterwards the body began to swell.  
 
  
March 4th, 10 A. M. Seven hours after death. The body
+
10 P. M. The patient is decidedly worse, no gas detected in the tissues. The patient died three hours later, and soon afterwards the body began to swell.
was enormously swollen, being almost twice its original size,
 
the face was swollen entirely beyond recognition, from the
 
mouth and nose there exuded a frothy, bloody serum, and
 
from time to time large bubbles of gas could be seen to escape.  
 
The abdomen was enormously distended and gave a deep drumlike note on percussion. Over the entire body we could obtain
 
the characteristic crackling of gas in the subcutaneous tissues.  
 
  
The husband unfortunately allowed no autopsy.  
+
March 4th, 10 A. M. Seven hours after death. The body was enormously swollen, being almost twice its original size, the face was swollen entirely beyond recognition, from the mouth and nose there exuded a frothy, bloody serum, and from time to time large bubbles of gas could be seen to escape. The abdomen was enormously distended and gave a deep drumlike note on percussion. Over the entire body we could obtain the characteristic crackling of gas in the subcutaneous tissues.
  
Pathological report. The foetus and placenta were brought
+
The husband unfortunately allowed no autopsy.
back to the laboratory and the following is a copy of the
 
pathological report :
 
  
The child weighs 2900 grammes, without the brain ; its
+
Pathological report. The foetus and placenta were brought back to the laboratory and the following is a copy of the pathological report :
length is 55 cm. The head is entirely crushed, the right arm
 
almost completely torn from the body, and there is a large
 
jagged wound in the chest, all of which were caused by the  
 
craniotomy instruments and blunt hook.
 
  
The fcetus is very offensive, being much decomposed and
+
The child weighs 2900 grammes, without the brain ; its length is 55 cm. The head is entirely crushed, the right arm almost completely torn from the body, and there is a large jagged wound in the chest, all of which were caused by the craniotomy instruments and blunt hook.
macerated. The entire body is emphysematous, and everywhere, on making pressure, we obtain the characteristic "feel "
 
of gas in the subcutaneous tissue. By making pressure on the
 
chest, lai-ge bubbles of gas are seen to escape from the wound  
 
in the neck. The body was then put under water, and on
 
puncturing the abdomen there was marked escape of gas,
 
which when ignited shot up in a flame six inches high.  
 
  
Cover-slips made from the blood and subcutaneous tissues
+
The fcetus is very offensive, being much decomposed and macerated. The entire body is emphysematous, and everywhere, on making pressure, we obtain the characteristic "feel " of gas in the subcutaneous tissue. By making pressure on the chest, lai-ge bubbles of gas are seen to escape from the wound in the neck. The body was then put under water, and on puncturing the abdomen there was marked escape of gas, which when ignited shot up in a flame six inches high.
show large numbers of bacilli morphologically similar to the  
 
"gas bacillus" of Welch and Nuttall. Cultures on sugar
 
media gave the characteristic growth.  
 
  
 +
Cover-slips made from the blood and subcutaneous tissues show large numbers of bacilli morphologically similar to the "gas bacillus" of Welch and Nuttall. Cultures on sugar media gave the characteristic growth.
  
  
The placenta is of a distinctly bilobed shape, dimensions
 
being 18x14x1.5 cm. and 10x9x1.5 cm. for the greater and
 
lesser lobes respectively. Its weight is 420 grammes. The
 
entire placenta is of a dull brownish color, and a distinct vascular trunk runs from the insertion of the cord, in the larger
 
lobe, to the lesser lobe. On the maternal surface, the cotyledons are poorly marked, and here and there are seen a few
 
minute areas of calcification. There is a large white infarct,
 
3 cm. in diameter, at one margin of the lesser lobe. The
 
entire surface is crepitant, and in places small bubbles of gas
 
escape on pressure. The fojtal surface shows numerous blebs
 
and bulljB beneath the amnion, which contain gas. The larger
 
placental vessels are distended with gas, which can be pressed
 
into the smaller ramiKcations.
 
  
The umbilical cord is 36 cm. long, it is thin and fiabby,  
+
The placenta is of a distinctly bilobed shape, dimensions being 18x14x1.5 cm. and 10x9x1.5 cm. for the greater and lesser lobes respectively. Its weight is 420 grammes. The entire placenta is of a dull brownish color, and a distinct vascular trunk runs from the insertion of the cord, in the larger lobe, to the lesser lobe. On the maternal surface, the cotyledons are poorly marked, and here and there are seen a few minute areas of calcification. There is a large white infarct, 3 cm. in diameter, at one margin of the lesser lobe. The entire surface is crepitant, and in places small bubbles of gas escape on pressure. The fojtal surface shows numerous blebs and bulljB beneath the amnion, which contain gas. The larger placental vessels are distended with gas, which can be pressed into the smaller ramiKcations.
and its vessels have considerable gas within them. Coverslips made from the placental blood show large numbers of
 
typical bacilli.  
 
  
Microscopic examination of hardened portions of the placenta.
+
The umbilical cord is 36 cm. long, it is thin and fiabby, and its vessels have considerable gas within them. Coverslips made from the placental blood show large numbers of typical bacilli.
The decidua presents for the most part a normal appearance.  
 
In the serotina the cells are often necrotic and have become
 
converted into canalized fibrin, which in places is seen to be
 
continuous with the canalized fibrin of typical infarct areas
 
of the chorion. Infiltration with small round cells is noted
 
to a slight degree. The decidua is poor in gland and vessel
 
spaces, and when present they seem to have lost their epithelium
 
and endothelium.  
 
  
In that part of the chorion situated near the decidua  
+
Microscopic examination of hardened portions of the placenta. The decidua presents for the most part a normal appearance. In the serotina the cells are often necrotic and have become converted into canalized fibrin, which in places is seen to be continuous with the canalized fibrin of typical infarct areas of the chorion. Infiltration with small round cells is noted to a slight degree. The decidua is poor in gland and vessel spaces, and when present they seem to have lost their epithelium and endothelium.
serotina the villi present a typical appearance, they are  
 
closely packed together, rich in vessels, and their cellular
 
elements take the stain well. Many small infarct areas are
 
seen, particularly at the margins of the placenta, which present the usual structure. As we go deeper into the chorionic
 
substance ((. e. toward the amniotic surface), we see that the
 
villi do not lie in so close relationship with one another, but
 
are widely separated.  
 
  
The larger vessels of the chorion are seen to be plugged
+
In that part of the chorion situated near the decidua serotina the villi present a typical appearance, they are closely packed together, rich in vessels, and their cellular elements take the stain well. Many small infarct areas are seen, particularly at the margins of the placenta, which present the usual structure. As we go deeper into the chorionic substance ((. e. toward the amniotic surface), we see that the villi do not lie in so close relationship with one another, but are widely separated.
with bacilli, identical with those seen in cover-slip preparations mentioned in the macroscopic description. In some of  
 
these vessels the bacilli form a solid plug, completely filling
 
the lumen, while in others a " gas cyst " has been formed, and
 
the bacilli lie in a zone around its margin. As we go from
 
the vessels into the chorionic substance we find a few bacilli;
 
these do not lie in the villous capillaries, but in the stronui of
 
the villi, thus it is seen that while the larger vessels are filled
 
with organisms the capillaries are free from them. The "gas
 
cysts" mentioned above are found to lie in the placental
 
vessels and not in the intervillous spaces.  
 
  
The tissue surrounding one of these foci of bacilli presents
+
The larger vessels of the chorion are seen to be plugged with bacilli, identical with those seen in cover-slip preparations mentioned in the macroscopic description. In some of these vessels the bacilli form a solid plug, completely filling the lumen, while in others a " gas cyst " has been formed, and the bacilli lie in a zone around its margin. As we go from the vessels into the chorionic substance we find a few bacilli; these do not lie in the villous capillaries, but in the stronui of the villi, thus it is seen that while the larger vessels are filled with organisms the capillaries are free from them. The "gas cysts" mentioned above are found to lie in the placental vessels and not in the intervillous spaces.
the following characteristics: Centrally we find the mass of
 
bacilli, which may lie either closely packed together in a  
 
clump, completely filling the vessel lumen, or surrounding
 
the margin of a "gas cyst" in a zone. Going outward we  
 
first find a zone of necrotic material, the remains of the vessel
 
wall ; this is entirely necrotic and shows no trace of nuclei.
 
We next get a zone of necrotic villi, which take a pink stain
 
with eosin, and show no cell structure. That portion of the
 
villus which formerly represented its syncytial covering takes
 
  
 +
The tissue surrounding one of these foci of bacilli presents the following characteristics: Centrally we find the mass of bacilli, which may lie either closely packed together in a clump, completely filling the vessel lumen, or surrounding the margin of a "gas cyst" in a zone. Going outward we first find a zone of necrotic material, the remains of the vessel wall ; this is entirely necrotic and shows no trace of nuclei. We next get a zone of necrotic villi, which take a pink stain with eosin, and show no cell structure. That portion of the villus which formerly represented its syncytial covering takes
  
  
26
 
  
 +
26
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
[No. 71.
 
  
 +
[No. 71.
  
  
the stain somewhat deeper than the stroma. Continuing
 
outward, we next find a zone of partly necrotic villi, in which
 
each villus has retained a portion of its cell structure.
 
  
Which portion of the villus (syncytium or stroma) first succumbs to the toxic action of the organism cannot be said, for
+
the stain somewhat deeper than the stroma. Continuing outward, we next find a zone of partly necrotic villi, in which each villus has retained a portion of its cell structure.
in this zone of partly necrotic villi we sometimes see intact
 
syncytium surrounding necrotic stroma, and in other villi the
 
stroma is normal while the syncytium is represented by a  
 
narrow necrotic band. It is probable that the syncytium is
 
the more resistant of the two, as more of the first variety of
 
villi are seen.  
 
  
There is apparently no reaction on the part of the tissue,  
+
Which portion of the villus (syncytium or stroma) first succumbs to the toxic action of the organism cannot be said, for in this zone of partly necrotic villi we sometimes see intact syncytium surrounding necrotic stroma, and in other villi the stroma is normal while the syncytium is represented by a narrow necrotic band. It is probable that the syncytium is the more resistant of the two, as more of the first variety of villi are seen.
for we find no infiltration with polynuclear leucocytes. In
 
some of the sections we were able to demonstrate a few streptococci.  
 
  
The epithelium and Whartonian jelly of the cord are entirely
+
There is apparently no reaction on the part of the tissue, for we find no infiltration with polynuclear leucocytes. In some of the sections we were able to demonstrate a few streptococci.
necrotic, the vessel walls partly so, and show a few nuclei.
 
The arteries are apjiareutly free from bacilli; in the veins,
 
however, they are very numerous, but show no tendency to
 
occur in clumps.  
 
  
Bacteriological report (by Dr. Lanier). Cultures from the  
+
The epithelium and Whartonian jelly of the cord are entirely necrotic, the vessel walls partly so, and show a few nuclei. The arteries are apjiareutly free from bacilli; in the veins, however, they are very numerous, but show no tendency to occur in clumps.
placental blood show the bacillu.'^ aerogews capsulatus mixed
 
with staphylococci and streptococci. A pigeon was inoculated
 
in the pectoral muscle with 1 cc. of bloody lluid from the
 
placenta and died in about eight hours. At the autopsy there
 
was extensive gaseous crepitation to be made out over the entire
 
chest. On removing the skin, the subcutaneous tissue contained a number of gas bubbles. The muscles were extremely
 
oedematus, of a reddish brown color, and disintegrated to the
 
extent of being almost jjulpified. Cultures made from this
 
muscle grew out in the characteristic manner.  
 
  
A rabbit inoculated in the ear vein with a 24-hour bouillon
+
Bacteriological report (by Dr. Lanier). Cultures from the placental blood show the bacillu.'^ aerogews capsulatus mixed with staphylococci and streptococci. A pigeon was inoculated in the pectoral muscle with 1 cc. of bloody lluid from the placenta and died in about eight hours. At the autopsy there was extensive gaseous crepitation to be made out over the entire chest. On removing the skin, the subcutaneous tissue contained a number of gas bubbles. The muscles were extremely oedematus, of a reddish brown color, and disintegrated to the extent of being almost jjulpified. Cultures made from this muscle grew out in the characteristic manner.
culture from the original placental blood was killed by a
 
blow on the back of the neck and left for 24 hours. At the  
 
autopsy emphysematous crackling could be made out over the  
 
entire abdomen and chest, the subcutaneous tissues and all of
 
the organs contained large quantities of gas, slips from which
 
showed large numbers of encapsulated bacilli. Cultures  
 
from these organs gave the characteristic growth. The organism was also pathogenic for guinea-pigs.  
 
  
PatJiolog ical diagnosis. Bacillus aerogenes capsulatus
+
A rabbit inoculated in the ear vein with a 24-hour bouillon culture from the original placental blood was killed by a blow on the back of the neck and left for 24 hours. At the autopsy emphysematous crackling could be made out over the entire abdomen and chest, the subcutaneous tissues and all of the organs contained large quantities of gas, slips from which showed large numbers of encapsulated bacilli. Cultures from these organs gave the characteristic growth. The organism was also pathogenic for guinea-pigs.
(Welch). Infection of placenta and foetus.  
 
  
In looking over the literature of the subject we have only
+
PatJiolog ical diagnosis. Bacillus aerogenes capsulatus (Welch). Infection of placenta and foetus.
been able to find a few cases which can be said to be similar
 
to ours. The first of these cases was reported by Leduc' as
 
early as 1597, he was called to see a woman who had been in
 
labor for three days. After a very difficult extraction by means
 
of the blunt hook, he says: "Immediately after the delivery
 
of the body of the child and placenta, a violet-colored flame
 
with a sulphurous odor escaped from the vulva, this flame
 
shot out some distance from the external genitals of the
 
patient, and its heat coukl be distinctly felt by the hands of
 
the persons who held her." She died several days later.
 
It is highly probable that this gas was generated by the
 
bacillus aerogenes capsulatus, but we can hardly blame the
 
author of that period for giving to his report of the case the
 
somewhat fantastic title of " Le diable an corps."
 
  
Doleris' reported a case of a woman dead aftei- labor, of a  
+
In looking over the literature of the subject we have only been able to find a few cases which can be said to be similar to ours. The first of these cases was reported by Leduc' as early as 1597, he was called to see a woman who had been in labor for three days. After a very difficult extraction by means of the blunt hook, he says: "Immediately after the delivery of the body of the child and placenta, a violet-colored flame with a sulphurous odor escaped from the vulva, this flame shot out some distance from the external genitals of the patient, and its heat coukl be distinctly felt by the hands of the persons who held her." She died several days later. It is highly probable that this gas was generated by the bacillus aerogenes capsulatus, but we can hardly blame the author of that period for giving to his report of the case the somewhat fantastic title of " Le diable an corps."
  
 +
Doleris' reported a case of a woman dead aftei- labor, of a
  
  
bacillar infection, this was before the work of AVelch and
 
Nuttall, but the clinical history is so characteristic of the form
 
of infection we are discussing, a short quotation from his
 
report will not be out of place.
 
  
" In 1883 I submitted to the Anatomical Society a case of
+
bacillar infection, this was before the work of AVelch and Nuttall, but the clinical history is so characteristic of the form of infection we are discussing, a short quotation from his report will not be out of place.
delivery at term, complicated by a myoma, after which the
 
patient died. The labor was exceedingly difficult and marked
 
by successive intervention (forceps, cephalotripsy, etc.), and
 
I was not able to deliver the foetus. The patient succumbed
 
to a septicfemia having its origin in an intense putrefaction of  
 
the uterine tissue, physometra, and putrid emphysema of the  
 
cellular tissue of the hypogastric region. I have studied the
 
case carefully from a bacteriological point of view, and can
 
affirm that it was a typical septicfemia caused by a bacillar
 
organism and not by the streptococcus or staphylococcus."
 
  
In 1893 we find reports of two cases, one by Graham Stewart
+
" In 1883 I submitted to the Anatomical Society a case of delivery at term, complicated by a myoma, after which the patient died. The labor was exceedingly difficult and marked by successive intervention (forceps, cephalotripsy, etc.), and I was not able to deliver the foetus. The patient succumbed to a septicfemia having its origin in an intense putrefaction of the uterine tissue, physometra, and putrid emphysema of the cellular tissue of the hypogastric region. I have studied the case carefully from a bacteriological point of view, and can affirm that it was a typical septicfemia caused by a bacillar organism and not by the streptococcus or staphylococcus."
and Baldwin' and the other by P. Ernst.' As these cases
 
were both worked up very carefully from a pathological and
 
bacteriological standpoint, we give rather full abstracts.  
 
  
Dr. Stewart' was called at 1 P. M. to see a woman who had
+
In 1893 we find reports of two cases, one by Graham Stewart and Baldwin' and the other by P. Ernst.' As these cases were both worked up very carefully from a pathological and bacteriological standpoint, we give rather full abstracts.
been previously healthy and accustomed to hard work. He
 
found her suffering with intense pain in the region of the
 
uterus and ovaries. Miscarriage was suspected and denied.
 
As the pain was somewhat relieved by morphia he diagnosed
 
the case as acute metritis following abortion, and left the
 
patient. He did not see her again until several hours later,
 
during which time she became so much worse that another
 
physician had to be called. At Dr. Stewart's third visit at
 
9.30 P. M., about eight hours after the onset, he found her
 
emphysematous from " the top of her head to the soles of her
 
feet." Shortly after this she died, and swelling of the body
 
began, and increased so rapidly as to greatly alarm the undertaker when he was called in.  
 
  
At the autopsy Dr. Baldwin reports "on making the usual
+
Dr. Stewart' was called at 1 P. M. to see a woman who had been previously healthy and accustomed to hard work. He found her suffering with intense pain in the region of the uterus and ovaries. Miscarriage was suspected and denied. As the pain was somewhat relieved by morphia he diagnosed the case as acute metritis following abortion, and left the patient. He did not see her again until several hours later, during which time she became so much worse that another physician had to be called. At Dr. Stewart's third visit at 9.30 P. M., about eight hours after the onset, he found her emphysematous from " the top of her head to the soles of her feet." Shortly after this she died, and swelling of the body began, and increased so rapidly as to greatly alarm the undertaker when he was called in.
longitudinal incision, gas bubbles were found in the subcutaneous tissue, which ignited with a characteristic explosion,
 
and a small amount of gas in the peritoneal cavity. The
 
abdominal veins are markedly distended with gas, and numerous bubbles found in all the internal organs. The uterus
 
gave evidence of an abortion at about the third month."  
 
There is no record of microscopic examination of any of the  
 
organs.  
 
  
Bacteriological examination of a specimen of blood showed
+
At the autopsy Dr. Baldwin reports "on making the usual longitudinal incision, gas bubbles were found in the subcutaneous tissue, which ignited with a characteristic explosion, and a small amount of gas in the peritoneal cavity. The abdominal veins are markedly distended with gas, and numerous bubbles found in all the internal organs. The uterus gave evidence of an abortion at about the third month." There is no record of microscopic examination of any of the organs.
the presence of the bacillus aerogenes capsulatus in large
 
numbers.  
 
  
It is very interesting to note that in this case production of  
+
Bacteriological examination of a specimen of blood showed the presence of the bacillus aerogenes capsulatus in large numbers.
gas took place to a very marked extent before death.  
 
  
Ernst,' in doing an autopsy on a woman dead after operation for removal of a macerated foetus, was struck by the
+
It is very interesting to note that in this case production of gas took place to a very marked extent before death.
appearance of foam on the cut surface of the liver, which on
 
being allowed to stand increased so rapidly as to form a layer
 
several centimeters thick.  
 
  
Bacteriological examination proved this case to be one of  
+
Ernst,' in doing an autopsy on a woman dead after operation for removal of a macerated foetus, was struck by the appearance of foam on the cut surface of the liver, which on being allowed to stand increased so rapidly as to form a layer several centimeters thick.
infection with the bacillus aerogenes capsulatus. An abstract
 
of his case is as follows.  
 
  
Patient 26 years old, with anteflexion of the uterus in her
+
Bacteriological examination proved this case to be one of infection with the bacillus aerogenes capsulatus. An abstract of his case is as follows.
first pregnancy. Entered the hospital suffering with pain in
 
ilic right side of four weeks' duration. She had also lately
 
  
 +
Patient 26 years old, with anteflexion of the uterus in her first pregnancy. Entered the hospital suffering with pain in ilic right side of four weeks' duration. She had also lately
  
  
February, 1897.]
 
  
 +
February, 1897.]
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
27
 
  
 +
27
  
  
noticed a tumor in the lower abdomen. Tiiere being no definite signs of pregnancy, and the microscopic examination of
 
scrapings from the uterus showing decidua, the cervix was
 
dilated to admit manual exploration of the uterine cavity.
 
Digital examination, however, revealing nothing, a vaginal
 
tampon of iodoform gauze was introduced.
 
  
After this the patient became so much worse that the tampon had to be removed. A macerated foetus was found and
+
noticed a tumor in the lower abdomen. Tiiere being no definite signs of pregnancy, and the microscopic examination of scrapings from the uterus showing decidua, the cervix was dilated to admit manual exploration of the uterine cavity. Digital examination, however, revealing nothing, a vaginal tampon of iodoform gauze was introduced.
extracted, and the uterus repeatedly douched with antiseptic
 
solutions ; the patient, however, became steadily worse and died.  
 
  
The autopsy showed fibrinous adhesions between abdominal
+
After this the patient became so much worse that the tampon had to be removed. A macerated foetus was found and extracted, and the uterus repeatedly douched with antiseptic solutions ; the patient, however, became steadily worse and died.
wall and intestines ; cloudy sanguiueolent fluid in the pelvis.  
 
The musculature of the left ventricle is thickly beset with
 
little miliary abscesses (?), in the centre of each of which is a
 
small punctiform lumen. Fresh fibrinous exudate on the
 
under border of the lungs. Spleen tumor with fibrinous coating and many necrotic areas appearing beneath its capsule.
 
Cloudy swelling of both kidneys. In the liver, which is of a
 
yellowish icteroid color, there are countless yellowish and  
 
whitish-gray foci, the size of a millet seed, in the centre of
 
each of which there is a small lumen.  
 
  
The uterus reaches to the umbilicus, it is 15 cm. long and
+
The autopsy showed fibrinous adhesions between abdominal wall and intestines ; cloudy sanguiueolent fluid in the pelvis. The musculature of the left ventricle is thickly beset with little miliary abscesses (?), in the centre of each of which is a small punctiform lumen. Fresh fibrinous exudate on the under border of the lungs. Spleen tumor with fibrinous coating and many necrotic areas appearing beneath its capsule. Cloudy swelling of both kidneys. In the liver, which is of a yellowish icteroid color, there are countless yellowish and whitish-gray foci, the size of a millet seed, in the centre of each of which there is a small lumen.
its walls have an average thickness of 2 cm. The placental
 
site occupies the anterior wall, and here the uterus is thicker
 
(3i-3 cm). The entire uterine wall crackles on account of its  
 
containing numerous gas bubbles. The cervical portion of  
 
the uterus is 5 cm. long and is gangrenous. The uterine
 
cavity presents a ragged meshed surface of a dirty gray color.
 
A dirty, sanguineoleut fluid flows from the venous plexus of  
 
the right broad ligament.  
 
  
The uterus and ovaries are covered with a fibrinous exudate;
+
The uterus reaches to the umbilicus, it is 15 cm. long and its walls have an average thickness of 2 cm. The placental site occupies the anterior wall, and here the uterus is thicker (3i-3 cm). The entire uterine wall crackles on account of its containing numerous gas bubbles. The cervical portion of the uterus is 5 cm. long and is gangrenous. The uterine cavity presents a ragged meshed surface of a dirty gray color. A dirty, sanguineoleut fluid flows from the venous plexus of the right broad ligament.
in the right ovary is a corpus luteum of pregnancy, undergoing cystic degeneration. There is a clot in the right iliac
 
vein which is riddled with gas bubbles.  
 
  
Ernst was unfortunately prevented from making cultures
+
The uterus and ovaries are covered with a fibrinous exudate; in the right ovary is a corpus luteum of pregnancy, undergoing cystic degeneration. There is a clot in the right iliac vein which is riddled with gas bubbles.
at this time,-and later the organism had died out.  
 
  
In Ernst's article he goes very thoroughly into the histological changes produced in the internal organs. These
+
Ernst was unfortunately prevented from making cultures at this time,-and later the organism had died out.
changes are similar to those described by Welch and Nuttall,
 
so they will not be mentioned in this report.  
 
  
The changes mentioned in connection with the uterus are  
+
In Ernst's article he goes very thoroughly into the histological changes produced in the internal organs. These changes are similar to those described by Welch and Nuttall, so they will not be mentioned in this report.
especially interesting to us owing to the fact that we were
 
unable to get an autopsy in our case. Ernst mentions three
 
different organisms : a large bacillus similar to those found in
 
the internal organs, viz. the bacillus aerogenes capsulatus; a
 
short thick bacillus which he considers a saprophyte; and  
 
cocci having a tendency to chain arrangement, however, as
 
he says, not the typical chains as seen in streptococci. The
 
short thick bacilli he finds only in the necrotic uterine
 
mucosa, and they show no tendency to invade the deeper
 
structure, while the cocci are found deep down in the uterine
 
muscularis. The larger bacilli, which are found all through
 
the internal organs, are very numerous in the uterine wall;
 
they have formed "gas cysts," which give to the uterus the
 
ragged, mesh-like appearance mentioned above.  
 
  
In comparing these " gas cysts " with those found in the  
+
The changes mentioned in connection with the uterus are especially interesting to us owing to the fact that we were unable to get an autopsy in our case. Ernst mentions three different organisms : a large bacillus similar to those found in the internal organs, viz. the bacillus aerogenes capsulatus; a short thick bacillus which he considers a saprophyte; and cocci having a tendency to chain arrangement, however, as he says, not the typical chains as seen in streptococci. The short thick bacilli he finds only in the necrotic uterine mucosa, and they show no tendency to invade the deeper structure, while the cocci are found deep down in the uterine muscularis. The larger bacilli, which are found all through the internal organs, are very numerous in the uterine wall; they have formed "gas cysts," which give to the uterus the ragged, mesh-like appearance mentioned above.
liver, Ernst says the principal difference is, that while in the  
 
liver the bacilli line the cyst in an unbroken zone, in the  
 
  
 +
In comparing these " gas cysts " with those found in the liver, Ernst says the principal difference is, that while in the liver the bacilli line the cyst in an unbroken zone, in the
  
  
uterus the organisms are only found lining portions of the
 
cyst wall, and the cyst has a much more irregular contour.
 
This difference he attributes to the difference in structure of
 
the two organs, that of the liver being more or less homogeneous, while the uterine wall is made up of numerous fibres
 
running in different directions.
 
  
Thus, when a mass of bacilli begin to form gas in the liver,  
+
uterus the organisms are only found lining portions of the cyst wall, and the cyst has a much more irregular contour. This difference he attributes to the difference in structure of the two organs, that of the liver being more or less homogeneous, while the uterine wall is made up of numerous fibres running in different directions.
the resistance met with is equal in all directions and the bubble takes the form of a sphere. On the other hand, in the  
 
uterine wall, the resistance not being equal, the bubble when
 
formed will have an irregular contour, and in places along its
 
wall the bacilli will form a very thin zone or be entirely
 
absent.  
 
  
Ernst is in doubt as to whether the infection took place
+
Thus, when a mass of bacilli begin to form gas in the liver, the resistance met with is equal in all directions and the bubble takes the form of a sphere. On the other hand, in the uterine wall, the resistance not being equal, the bubble when formed will have an irregular contour, and in places along its wall the bacilli will form a very thin zone or be entirely absent.
along the veins or lymphatics, for in his specimens both contained large numbers of bacilli.  
 
  
In 1895, Kronig,'' at the Sixth Congress of the Deutsche
+
Ernst is in doubt as to whether the infection took place along the veins or lymphatics, for in his specimens both contained large numbers of bacilli.
Gesellschaft fiir Gyniikologie, reports two cases of puerperal
 
endometritis probably due to the bacillus aerogenes capsulatus.  
 
  
During the last year Schnell' reports a case which, although
+
In 1895, Kronig, at the Sixth Congress of the Deutsche Gesellschaft fiir Gyniikologie, reports two cases of puerperal endometritis probably due to the bacillus aerogenes capsulatus.
he does not consider it an infection, has a clinical history so
 
similar to our case that a short abstract will not be out of
 
place.  
 
  
Primipara, oet. 31. 24 hours after rupture of the membranes
+
During the last year Schnell' reports a case which, although he does not consider it an infection, has a clinical history so similar to our case that a short abstract will not be out of place.
was seen by a midwife from the Polyclinic, who found prolapse of an arm. Version was tried, but failed, on account of
 
contraction of the uterus; the child died during this attempt.
 
She was brought to the hospital with marked tympania uteri
 
and suffering intense pain ; 46 hours after the onset of labor
 
she was delivered by a difficult version. Immediately after
 
labor she did well, but later had quite a profuse hemorrhage,
 
for which the uterus was tamponed with iodoform gauze.
 
She then became steadily worse, and died three and a half
 
hours after delivery.  
 
  
At the autopsy 18 hours after death, in winter, nothing
+
Primipara, oet. 31. 24 hours after rupture of the membranes was seen by a midwife from the Polyclinic, who found prolapse of an arm. Version was tried, but failed, on account of contraction of the uterus; the child died during this attempt. She was brought to the hospital with marked tympania uteri and suffering intense pain ; 46 hours after the onset of labor she was delivered by a difficult version. Immediately after labor she did well, but later had quite a profuse hemorrhage, for which the uterus was tamponed with iodoform gauze. She then became steadily worse, and died three and a half hours after delivery.
abnormal was found but gas in the large veins of heart, pericardial vessels, lungs, aorta, liver and spleen.  
 
  
There is no record of any bacteriological examination, and  
+
At the autopsy 18 hours after death, in winter, nothing abnormal was found but gas in the large veins of heart, pericardial vessels, lungs, aorta, liver and spleen.
Schnell considers the death due to air having gained entrance
 
into the uterine sinuses during the successive manipulations.  
 
  
On looking over and comparing these cases with our own,
+
There is no record of any bacteriological examination, and Schnell considers the death due to air having gained entrance into the uterine sinuses during the successive manipulations.
the following points are of interest: In every case the infection was very rapid and fatal. In all of the cases except that
 
of Graham Stewart and Baldwin, there was for some time a
 
dead fostus in the uterus, and the organism found an excellent
 
medium for development in its dead tissues and in the
 
placenta, and probably did not gain entrance to the general
 
circulation until after death of the patient. In the case of
 
Graham Stewart and Baldwin, on the other hand, there was
 
nothing in the uterine cavity ; it only " gave evidence of a
 
recent abortion." Here it is probable that the infection was
 
more in the nature of a true septiciBmia, and the bacilli gained  
 
direct entrance to the vessels and lymphatics at the abraded
 
placental site. As this was the only case in which gas was
 
detected in the subcutaneous tissues before death, the above
 
theory is not out of the line of probability.  
 
  
In Schnell's case we feel sure that had a bacteriological
+
On looking over and comparing these cases with our own, the following points are of interest: In every case the infection was very rapid and fatal. In all of the cases except that of Graham Stewart and Baldwin, there was for some time a dead fostus in the uterus, and the organism found an excellent medium for development in its dead tissues and in the placenta, and probably did not gain entrance to the general circulation until after death of the patient. In the case of Graham Stewart and Baldwin, on the other hand, there was nothing in the uterine cavity ; it only " gave evidence of a recent abortion." Here it is probable that the infection was more in the nature of a true septiciBmia, and the bacilli gained direct entrance to the vessels and lymphatics at the abraded placental site. As this was the only case in which gas was detected in the subcutaneous tissues before death, the above theory is not out of the line of probability.
examination been made, the organism would have been found.  
 
  
 +
In Schnell's case we feel sure that had a bacteriological examination been made, the organism would have been found.
  
  
28
 
  
 +
28
  
  
JOHNS HOPKINS HOSPITAL BULLETIN.
 
  
 +
JOHNS HOPKINS HOSPITAL BULLETIN.
  
  
[No. 71.
 
  
 +
[No. 71.
  
  
There are in our case two questions wliich deserve consideration, in the first place, the origin of the infection, and
 
in the second, the action of the organism after it had entered
 
the body.
 
  
The first question, in the absence of an accurate subjective
+
There are in our case two questions wliich deserve consideration, in the first place, the origin of the infection, and in the second, the action of the organism after it had entered the body.
history, cannot be answered with certainty. Suffice it to say
 
that as the patient had been in labor two days before we were
 
called In, and during that time a midwife had been in constant attendance, it is more than probable that the organisms
 
were introduced by her during her examinations.  
 
  
In regard to the action of the organism after it entered the
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The first question, in the absence of an accurate subjective history, cannot be answered with certainty. Suffice it to say that as the patient had been in labor two days before we were called In, and during that time a midwife had been in constant attendance, it is more than probable that the organisms were introduced by her during her examinations.
body, i. e. whether the case was one of saprajmla or septicemia,  
 
we can say as follows: Welch and Nuttall' have proved by
 
inoculation into rabbits, that when the organism Is introduced  
 
into the general circulation, death of the animal does not
 
follow, but if shortly after the Inoculation the rabbit be
 
killed, the bacillus develops very rapidly, with abundant
 
formation of gas in the various organs.  
 
  
In their experiments on rabbits, in only one case did the  
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In regard to the action of the organism after it entered the body, i. e. whether the case was one of saprajmla or septicemia, we can say as follows: Welch and Nuttall' have proved by inoculation into rabbits, that when the organism Is introduced into the general circulation, death of the animal does not follow, but if shortly after the Inoculation the rabbit be killed, the bacillus develops very rapidly, with abundant formation of gas in the various organs.
inoculation prove fatal. This occurred in a pregnant rabbit
 
in which two of the embryos were dead and macerated at the  
 
time of the experiment. Here the bacilli gained foothold and
 
developed.  
 
  
From the above we can then argue that the organisms were
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In their experiments on rabbits, in only one case did the inoculation prove fatal. This occurred in a pregnant rabbit in which two of the embryos were dead and macerated at the time of the experiment. Here the bacilli gained foothold and developed.
introduced by the midwife early in labor. She failed to recognize the obstruction offered by the deformed pelvis, and
 
allowed the case to go on. The child, after becoming firmly
 
impacted in the pelvis, died, and the bacilli, which had before
 
undergone little development, now having the most favorable
 
culture medium for their growth, i. e. dead tissue deficient in
 
oxygen, increased to an enormous extent and partly filled the
 
uterine cavity with gas.  
 
  
Thus, by the time we were called in to see the patient she
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From the above we can then argue that the organisms were introduced by the midwife early in labor. She failed to recognize the obstruction offered by the deformed pelvis, and allowed the case to go on. The child, after becoming firmly impacted in the pelvis, died, and the bacilli, which had before undergone little development, now having the most favorable culture medium for their growth, i. e. dead tissue deficient in oxygen, increased to an enormous extent and partly filled the uterine cavity with gas.
was not only weakened by the prolonged labor, hut also profoundly poisoned by the toxines produced in the uterine  
 
cavity.  
 
  
Why did not her general condition Improve after removal of
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