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[[The Johns Hopkins Medical Journal|The Johns Hopkins Hospital Bulletin]]
 
[[The Johns Hopkins Medical Journal|The Johns Hopkins Hospital Bulletin]]
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BULLETIN OF THE JOHNS HOPKINS HOSPITAL. Vol. IX. - No. 82. BALTIMORE, JANUARY, 1898.
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==Contents==
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* On Certain Activities of tiie Epithelial Tissue of the Skin of the Guinea-pig, and Similar Occurrences in Tumors. By Leo Loeb, M. D ,
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* The Successful Treatment of Extra-peritoneal Rupture of the Bladder, complicated by Fracture of the Pelvis, by Operation and the Continuous Bath. Report of Case. By J. F. Mitchell, M. D.,
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* The Physiological and Pathological Relations between the Nose and the Sexual Apparatus of Man. By John Noland JIacKENZIE, M.D.,
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* Proceedings of Societies : Hospital Medical Society, - On the Hfematozoan Infection of Birds [Dr. W. G. MacC'allum] ; — The Presence in the Blood of Free Granules derived from Leucocytes, and their possible Relations to Immunity [Dr. W. R. Stokes and Dr. A. Wegefaetu].
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* Notes on New Books
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Books Received
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===ON CERTAIN ACTIVITIES OF THE EPITHELIAL TISSUE OF THE SKIN OF THE GUINEAFIG, AND SIMILAR OCCURRENCES IN TUMORS===
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By Leo Loeb, M. D., Baltimore.
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Iq order to cause migration of the epithelial tissue in the guinea-pig the most certain method is to make a wound in the epithelium, thus, to use Weigert's expression, removing the tension on one side. Under these circumstances the whole epithelial mass in the immediate neighborhood of the injury begins to move. The boundaries between the cells become invisible, and we have one large protoplasmatic mass with nuclei. The size of this tissue increases very much, and the nuclei also become enlarged. The latter often turn to that Bide towards which the whole mass is migrating. This can sometimes be seen very distinctly in pigmented epithelium, where the pigment caj)s turn with the nuclei. The shape of the nuclei and the surrounding protoplasm becomes elongated in the direction of the wandering tissue, the granular and keratine layers disapj)ear, and instead we see a homogeneous mass, which may be called the upper protoplasmatic layer, which contains nuclei that have taken the form of rods.
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These changes are seen not only at the edge of the wound, but also somewhat removed from it, throughout that extent to which the epithelium is moving. Now there soon begins
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•This is to a great extent a preliminary account of a part of my investigations on the regeneration of the epithelium, the more detailed description of which will appear in the Archiv fiir Entwickelungsmechanik, Bd. VI, 3.
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an increase in the number of dividing nuclei, but this does not occur before the migration has begun. The migration is certainly not the result of the increase in the nuclear divisions. In the lower layers of the epithelium the form of division is mitotic ; the form of division which occurs in the upper layers of the epithelium is amitotic. This migration may be directed sidewards in the wound or downwards, in which case a certain kind of atypical epithelial growth is thus produced. The shape of the protoplasm and of the nuclei, as described above, indicates very often the direction of the migrating tissue. We have a control for this in the wandering of epithelial tissue in blood-clots, where we are enabled to see that the epithelial tissue migrates in that direction which is indicated by the structure of the whole epithelial mass. This appearance is still more marked, in that the fibrillar structure of the epithelial tissue becomes very clear under these conditions, so much so indeed that it can easily be seen without staining. These fibres connect all nuclei, no interruption being discernible between them that could correspond to cell boundaries. It may be added that under certain conditions* it is possible to show very distinctly the connection of the epithelial protoplasm with the fibrillar network below the epithelium. Some
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Arch. f. Entwickelungsmechanik, loc. cit.
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2
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 82.
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times the sub-epithelial fibres appear to be the direct continuation of the epithelial fibres, the epithelial cell seems to ramify, aud it is in fact impossible to determine which part of this sub-epithelial fibrillar network is of epithelial origin and which part of it originates from the connective tissue below the epithelium. According to the direction in which the tissue is wandering, which direction is indicated by the position of the foremost nuclei together with their surrounding protoplasm, traction comes to be exercised on the tissue behind by the advancing line of epithelium, aud these circumstances determine the different types of structures of the epithelium. (See Figs. 1 and 3.) In structures as indicated by Fig. 3, one can see that the protoplasm gives way between the nuclei under the influence of the traction.
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^' , ,/ b ^^^
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Fig. 1.
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a, epithelial nuclei,
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J, holes in protoplasm produced by the traction.
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We have seen that all layers of the epithelium participate in the migration, the shape of the different layers becoming very similar to each other, with excejjtion of the upper protoplasmatic layer. But there is one marked difference, namely, the velocity with which the different layers are moving, in so far as the upjjer protoplasmatic layer moves fastest, the velocity gradually decreasing towards the deeper layers, the basal layer being usually the slowest. Indeed the upper protoplasmatic layer, which corresponds to those structures that seem to have lost the greatest part of their vitality, is migrating so fast that after 36 hours a part of the wound is covered by it, and the remains of this layer form a considerable part of the scab together with the rod-like nuclei found in the middle of the scab, where they seem to undergo disintegration.
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The activity of the epithelial tissue goes further than merely to migrate. It can and in most cases does actually penetrate into the blood-clot, occasionally into the connective tissue; and it was even j)ossible to get microscopical specimens in which all stages of the epithelial tissue breaking through the cartilage of the ear aud dissolving it could be seen. But it must be stated that in these cases it is not to be excluded that the cartilage and connective tissue may have been lessened in their vitality, although microscopically the cartilage appeared quite normal. At some places one sees this process nearly finished; the plate of ear cartilage being divided in two parts by the epithelial tissue. There are in the nearly re-established epithelial layer still some round hyaline or granular bodies visible as the remainder of the cartilage at
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the very place where it was to be expected. In other places one sees how the epithelial protoplasm with nuclei begins forcibly to break through the still nearly intact cartilage, especially in this case protoplasm and nuclei having a very elongated shape. Between these two extreme cases different phases in which the epithelial protoplasmatic masses have broken through and are fiowing around those round bodies just mentioned — which are nothing else than the cartilage cells in a swollen state — may be made out. This swollen condition of the disintegrated cartilage seems to be preparatory to its perfect dissolution. In the same way the migrating epithelial cells have the power to break through connective tissue. Not quite so rarely one can see how the protoplasmatic masses move sidewards and downwards in the infiltrated connective tissue, the different arms of the divided epithelial masses separating it in islands and at last dissolving it wholly. This process is very similar to an amoeba-like multinuclear mass flowing around a foreign body and digesting it. This process is also similar to the action of the egg-cells of Polyclades, which form later on the intestinal epithelium and which break in the same way through the yolk and dissolve it. In an apparently equal way the syncytium seems to act in what is usually called deciduoma maliguum, a malignant growth which is, according to Marchand, brought about by the activity of the syncytium. Here also protoplasmatic masses break through the tissue, the different arms of the divided masses separating it in islands ; and there is no reason to doubt that they act on the tissue in the same way as the epithelial masses do, namely, to dissolve it, the microscopical appearances and the results being in both cases very similar. In connection with this it may be mentioned that the growth of the epithelium in carciuomata of the skin shows some resemblances to the migrating epithelium produced by injuring the normal skin. The formation of keratine seems to bear often more resemblance to the upper protoplasmatic layer than to the keratine layer of the normal skin. Pianese shows, in his work on carcinoma, pictures of the same kind of arrangement of the epithelial tissue, especially of the arrangement of the epithelial fibres, and in carcinomata one sees not rarely columns of epithelial masses that have an elongated shape moving towards the connective tissue, at the ajjex of which connective tissue cells are sometimes included between the epithelial cells. At other places one sees more isolated cells advancing.
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As stated above, the epithelial masses that penetrate in the scab or through the cartilage have as a rule an elongated shape. In this connection it may be mentioned that H. Driech made the interesting observation that the meseuchym cells of echinus microtuberculatus also assume an elongated shape if they begin to migrate. So we may assume that the epithelial cells of carcinomata have the same activity as the regenerating epithelium and migrate through the tissues, and that especially the elongated shape of the cells indicates active migration, especially through tissues which offer a certaiu amount of resistance. Similar pictures, so far as the structure of the whole epithelium, and especially the fibrillar structure, is concerned, are met with in different skin diseases, among which may be mentioned psoriasis. In these pathological conditions such pictures have been differently exjjlaiued.
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January, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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The significance of those pictures observed ia experimental healing of wounds is open to little doubt; and it may be suggested that alsii the other changes in the arrangement of the epithelial masses which are met in carcinoma and in skin diseases, and which have been referred to above, are brought about by migration or the tendency to migration and the traction caused by this activity on the part of the epithelial elements.
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The best proof that the epithelial tissue really breaks through the. connective tissue is found in those cases where one can see the epithelial masses migratiug beneath a hair follicle that is lying in connective tissue, this gland being so entirely separated from its surroundings.
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A phenomenon more frequently observed than the foregoing is the penetration of the epithelial masses into the scab, which consists, as is well known, partly of coagulated blood. Here under one form or another one sees the epithelial masses breaking in all directions through the clot, extending in the form of arms, and dissolving fibrin and blood corpuscles. I will mention a few of the ways in which this takes place. Of all the layers, the upper ones of epithelium, which are the quickest ones to migrate, are also most active in breaking through the tissue and scab. At places where more resistance is offered to the advancing epithelium, the protoplasmatic masses of the epithelial tissue fiow around these obstacles in circles that continually become closer, and if possible dissolve them. From this there result not unusually cyst-like formations that lie, in the case that the upper protoplasmatic layer has formed them, above the newly formed epithelium. These upper protoplasmatic cysts are only of short duration. The nature of the action by which the epithelial protoplasm is able to dissolve the tissue is unknown. It is certain that phagocytosis plays no part in it, the epithelial protoplasm does not engulf the foreign body, but the close contact with it seems to be suflBcient to cause the secretion of the substance which, be it of the character of a proteolytic ferment or some other chemical agent, has this dissolving effect. The circumstance that it seems easier for this solving effect to be exerted upon injured rather than healthy tissue would favor the assumption that the hypothetical body is a ferment, for this is a well-known condition of action of trypsin. Further investigations which have already beeu started may possibly yield more certain knowledge of this question; but in any case contact with the foreign body seems to be the stimulus that brings about tlie secretion of this substa)ice, in the same way as the glands of the alimentary canal secrete their digestive substances when in contact with food. Leucocytes not improbably have the same faculty.
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It is a well known fact that the cells of malignant tumors, especially of carciuomata, break through all kinds of tissue; but the precise manner of this action has been conceived by different observers in different ways. If we study experimentally the regeneration of epithelium, we see, in the course of a few days, all the changes described above. Indeed, we not only appreciate that cartilage is destroyed, but we may even follow all stages of the process, and thus really obtain a picture not only of the results, which could be explained in different ways, but also of the kind of activity of the tissue
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by which this result is achieved. And if there can be no doubt that in regeneration the epithelium has the above described power, we may conclude that the carcinomatous cells which can penetrate through all tissues do so in very much the same way, that is, by actually dissolving the tissues by chemical means. This is the more probable inasmuch as the histological pictures in spreading malignant epithelial tumors ofteu show places strongly resembling the penetration of regenerating epithelium. The principal reason that this kind of activity of the carcinomatous tissue has so far not been more generally recognized, may jirobably be found in the circumstance that such a power would have been to be regarded as a new quality of the epithelial cells for which no analogy had existed. But seeing now that the regenerating epithelial tissue possesses this faculty, this objection no longer holds good. That malignant tumors act also by other means, as e. g. by pressure on the surrounding tissue, is, however, not excluded. It has long been known that endothelial and connective tissue cells have the power to penetrate into blood-clots as into thrombi, and also in foreign bodies, and to replace these by connective tissue. We have seen that the epithelial tissue replaces blood-clots quite in the same way, and the result of this replacement is, in many cases, the production of an epithelial tissue which occupies the position formerly held by the blood-clot, or even the cartilage and connective tissue. We may therefore speak of this process as ejnthelial organization, in contradistinction to the well-known connective tissue organization. The similarity between the behavior of the epithelial tissue towards a blood-clot with the action of the endothelial and connective tissue or vessels in the organization of thrombi, would probably still be more apparent if it were possible to replace the cutis by blood in such a manner that the deeper epithelial layers come to lie in close contact with the blood-clot.
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Although so far only those changes of regenerating tissue have been described that occur in the skin of the guinea-pig, there seems to be little doubt that also other epithelial tissue has the same kind of activity. The account which Peipers gives of the regeneration of the kidney makes it very probable that also the kidney cells have the faculty of penetrating into the blood-clot and dissolving it. The same holds probably good of the liver and salivary glands. I have already begun experiments in order to ascertain how far there is an analogy in the activity of these cells and of the epithelial cells of the skin.
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When we see the epithelial tissue thus in motion we may ask, are there any linutations as to the directions in which it may move, or is it possible to detect any kind of influence of the surroundings that determines the direction of the migration ? As to the first point, there is no limitation in the directions of migration. One might suppose that the epithelial masses are able only to move in the wound because only this movement would be of value in the healing of the injury. But this is not the case ; the epithelial masses have the faculty even to go in the directly opposite way, and indeed a part of the protoplasmatic masses may go in one direction while another part branches through another side. The whole process reminds one of an amoeba that creeps and sends protoplasmatic arms to different sides. But there is one circumstance that invariably
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 82.
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determines the direction of the flowing epithelial mass, that is, the contact with a solid body. If it once toaiches a foreign body it never leaves it again, but flows all around it. One can see how it flows around the balls formed by the hair-glands, similar to what is observed in Dewitz's experiments, in which spermatozoa are seen to wander around glass balls, never ceasing to touch them. The epithelial masses follow every furrow on the lapper side of the scab, and especially of the upper side of the wounded connective tissue; and the contact with the latter especially is the cause that in wound-healing the epithelial masses are brought usually to cover the connective tissue, in this way restoring the normal epithelial layer. There is no difference in the different layers of the epithelium in regard to this irritability, and one can sometimes observe how the upper protoplasmatic layer with its characteristic nuclei migrates in contact with the edge of the deeper layer. Fig. 3 shows such an occurrence. The above-described rod-like nuclei seem to continue the basal layers. Hence we see a factor that comes into play to determine the sti'ucture of the epithelial tissue of a mammalian is the same that is active in the life of plants and of the simplest forms of invertebrate animals and of spermatozoa.*
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jteS&cDO
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imooo
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m
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a, basal layer.
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b, rod-like nuclei of the upper protoplasmic layer.
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The possibility of a chemotropic irritability of the epithelial cells in addition to the stereotroi3ism described, is not to be wholly excluded, especially as the epithelial masses tend to penetrate in the blood-clot. But thus far it has not been possible to prove the presence of this form of irritability.
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fWe have now spoken of several different activities of the epithelial masses, but there is still another and very curious kind which can be called epithelial infiltration, by which is meant the penetration and replacement of an epithelial tissue by a neighboring one. This process of epithelial infiltration can be produced by transplanting the pigmented skin of a
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The endothelial cells of a vessel which organize a thrombus
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seem to have the same kind of irritability. In the drawings that Cornil gives e. g. (Journal de Tanatomie, 1897) one sees how the endothelial cells migrate around the thrombus, api)lying themselves to every furrow and penetrating later on its substance. Ranvier (C. r. vol. 112) describes, in inflammation of the peritoneum that leads to adhesions, the endothelial cells, which are to become connective tissue cells, as creeping along in contact with the fibrin films. That seems to be another instance of stereotropism.
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1 For a fuller account of the following part it may be referred to Arch. f. Entwickelungsmechanik, Bd. VI, 1.: Ueber Transplantation von weisser Haut etc. am Ohr des Meerschweinchens. These experiments on transplantation have been carried out at the suggestion of Prof. Ribbert in the Pathol. Institut in Zurich.
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guinea-pig to a place where the original skin is unpigmented, or conversely by transplanting unpigmented skin to a pigmented area. Without discussing how far these experiments on transplantation answer questions relating to the problems of transplantation in general, it may be mentioned that after the transplantation the black skin not only keeps its own pigment, but one can see, after a variable period in different cases, even with the naked eye, that the boundaries of the transplanted skin which before were very distinct become indistinct, a darker line appearing at the margins, and gradually the pigmented area spreads in the white skin. The same happens under certain conditions when white skin is transplanted to dark, the black pigment spreading in the white skin. This behavior was also observed by Carnot and Jllle. Deflandre, who gave an account of it in the Comptes rendus (see also Carnot's report in the Bulletin scientifique). But the fact alone could be explained in different ways. It is in the first place possible that the transplantation causes an augmentation iu the production of pigment by the pigmented epithelium. The surplus of pigment would be carried away either by leucocytes or by some other means, and brought into the neighboring white epithelium, gradually causing it to become pigmented. After some time the effect of the transplantation ceases, and therefore the surjilus production of the pigment, and there would be no further progress in the pigmentation of the white skin. That this explanation is not correct is shown by the following experiment. The transplanted black skin is made to regenerate, from which one observes that the transplanted black skin regenerates wholly, like the original black skin, going through four distinct stages which need not be mentioned here. Next one makes that part of the skin regenerate which has originally been white but had afterwards become black through the influence of the neighboring transplanted black skin. Fig. 4 gives a sketch of both cases. In the latter case one sees that this secondarily black skin regenerates in precisely the same manner as the originally black skin did, namely in four stages. Now if the pigment had only been passively transferred to the white skin, this characteristic kind of regeneration could -not have taken place. The white skin would have regenerated as white skin does.
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Fig. 4.
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«, transplanted black skin.
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A, area where transplanted skin has grown.
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c, skin that was afterwards removed.
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This experiment proves that the white skin in the neighborhood of transplanted black skin becomes true pigmented skin.
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January, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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This can take place only by the emigration of the black epithelial tissue into the white. Any iniluence of the underlying connective tissue could with certainty be excluded. Microscopically we see in this intermediate zone, where the white epithelium becomes black, chromatophores in the deepest layer of the epithelium. Soon afterwards the cap pigment around the nuclei appears, until at last the whole epithelium has the character of the typical pigmented epithelium. One might be tempted from the microscopical appearance to take it for granted that the pigmentation of the originally white epithelium is caused by the emigration of chromatophores which act as a kind of unicellular glands, gradually supplying the pigment to the whole epithelial tissue. But this explanation is not applicable, for there are facts that show that the chromatophores do not act as glands. There remain two other possibilities. Either the chromatophores are able in the same way as the basal cells of the epithelium to give rise by cell division to the upper layer of the epithelium and the basal cells as well, or not only are the chromatophores migrating and infiltrating, but also the other cells of the pigmented epithelium, which, however, under the changed conditions of this process lose for a short time their pigment. As strange as it may seem that the widely branched chromatophores should be equivalent to the basal epithelial cells, there are a number of facts in favor of the view that the chromatophores in the epithelium are only modified epithelial cells. Two facts, however, are in favor of the latter assumption : First, in the third stage of the regeneration of the' pigmented epithelium, the epithelium has nearly the same ajipearance as described here, that is, chromato
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phores in the basal layer are the only pigmented cells present in the epithelium; and in the fourth stage the upper layers gradually gain their pigment. Hence in this situation what seems to belong still to the white epithelium, belongs in fact to the regenerating black epithelium if the second assumption is the right one. Secondly, one can sometimes see that the highest epithelial layers have pigment around the nuclei, so that these nuclei certainly must have come from the black eiiithelium.
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So far it has been impossible to decide with certainty which of these two explanations is the right one, but in any case it may be taken as proved that the living white epithelium is substituted by the transplanted black epithelium by means of a process of infiltration. But it must be added that under these circumstances there are no signs of a phagocytosis by which the black cells destroy the white ones. And it results from this that we must take into account the possibility that there are also at other times in the epithelium not only growing movements upwards from below from the basal layer in the direction of the corneal layer, but that there can also be sidewards movements as in the case described. The distinction of color made it possible to recognize this kind of activity of the epithelial tissue. Without this distinction the recognition would have been very difficult, because the last described activity of the epithelial tissue is one that proceeds much slower than the migration described first.
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I wish to express my especial thanks to Dr. Flexner, to whose kindness I am indebted for a carcinoma of the skin, and to Dr. Cullen for sections of a deciduonui malignum.
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THE SUCCESSFUL TREATMENT OF EXTRA-PERITONEAL RUPTURE OF THE BLADDER, COMPLICATED BY FRACTURE OF THE PELVIS, BY OPERATION AND THE CONTINUOUS BATH. REPORT OF CASE.
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By J. F. Mitchell, M. D., Resident Medical Officer, The Johns Hopkins Hospital.
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Through the kindness of Dr. Bloodgood I am permitted to report the following case from the surgical service of the Johns Hopkins Hospital :
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A. A., Lithuanian woman, age 53. Admitted May 30th, 1896, with the following history. On May 19th, about 11 p. m., 10 hours before admission, she was thrown from a wagon, the wheels passing over the hips and lower abdomen at the level of anterior iliac spines. On admission at 9 a. m., 10 hours after the accident, the pulse is 100-130; temjjerature, 100.8°. Mental condition seems to be one of stupor. There is frequent moaning, and when the left hip is moved she cries out with pain. Over the lower abdomen and thighs the skin has been scratched and is covered with gravel and dirt, the entire superficial epidermis seeming to have been brushed away, but at no point is the fat exposed. The abdomen is not distended nor tender except over the skin bruises, and there is no muscle spasm nor any evidence of intraabdominal injury.
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At 10..30 a. m. catheterization yielded 140 cc. of smoky urine
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with a sediment of blood corpuscles, and at 3.30 p. m., four hours later, 160 cc. of similar urine. On distending the bladder with 500 cc. of boric acid solution not more than 350-300 cc. could be withdrawn, and examination by means of a speculum showed the bladder to be quite empty, demonstrating conclusively a rupture. It was impossible to ascertain whether urine was passed befoi'e admission, but between admission and operation there was no attempt to void urine and there was no dribbling.
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Operation by Dr. Bloodgood, 17 hours after the accident, under ether. On opening into the space of Ketzius through the middle line, it was found filled with a large quantity of blood-stained urine which was not ammoniacal, and there was as yet no sign of inflammation. The peritoneum was pushed up to within 4 cm. of the umbilicus, and in the lumbar regions almost to the margins of the 13th ribs. This fluid was carefully sponged out and the peritoneal cavity opened in the middle line to examine the bladder for any intraperitoneal opening. As none could be found and there was no fluid in
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 82.
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the peritoneal cavity, the peritoneum was closed with a double row of silk sutures. The opening in the bladder was demonstrated by passing a silver catheter through the urethra. It appeared to be about 2 cm. to the left of the median line at the level of the pubes, that is, just behind the seat of fracture, which was in the ramus of the left pubes. The line of fracture was oblique, and two ragged points projected towards the bladder. The bladder wound was closed with silk sutures which did not include the mucous membrane. Lateral incisions were then made in both inguinal regions and the three wounds were packed with bismuth gauze, the upper half of the median incision being closed with two mattress sutures in the recti muscles and a continuous subcutaneous silver suture. There was no loss of blood, and the pulse was excellent at the end of the operation. Temperature, 100.2°; pulse, 106. Cultures and cover-slips from the extravasated fluid were negative and there were only a few leucocytes.
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May 21st. Patient passed a fairly comfortable night. From 8 p. m. until noon she was catheterized 7 times, 12-35 cc. of urine being obtained each time, total amount being 162 cc. of bloody iiriue. The gauze on the abdomen is saturated with iirine, showing that the sutures of the bladder have not held or that there is another rupture. Temperature, 102.2°; pulse, 106-110 ; respiration, 30-35 ; condition of stupor more marked than on admission. 3.30 p. m., patient placed in bath of water at 100° F. 8 p. m., patient has been in bath 4 hours. The pulse is 100 and better ; respiration, 24 and decidedly improved; temperature, 100.8°. The condition of stupor has been replaced by a much brighter mental state and the patient looks a great deal better.
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May 26th. The patient was taken out of the bath for 4J hours, during which time no urine leaked from the wound. There was some pain and a little hemorrhage. The removal of the packing was followed by a rise of temperature to 102°, but no discomfort.
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June 8th. The patient has been almost continuously in the bath since May 21st, being removed only for an hour at a time to clean the tub, and then she cries to be returned. The pulse has been good, but there has been continuous fever from 100.5° to 101°, and yesterday after examination and removal of two small pieces of bone from the fracture the temperature reached 103.5°. The packing has been out since May 26th (7th day). The lumbar wounds closed two days later and the superficial wound has entirely healed. The abdomen is soft and there is no evidence of infiltration beyond the suprapubic sinus. Appetite and general condition good.
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June 27th. There has been more or less fever during the past three weeks, and in the last four or five days several shaking chills, the temperature in one instance reaching 107°. Examination of blood is negative and there is no leucocytosis. The urine shows a faint trace of albumin and many polymorphonuclear leucocytes. The abdomen is soft and not distended, and nothing can be found indicating any accumulation of pus. Spleen and kidneys not palpable. On irrigation the opening between the suprapubic wound and bladder is not large enough to prevent distension of the bladder and 250 cc. can be retained. On examination of the suprapubic wound a small cavity was found just to the left of the sinus and com
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municating with it by an opening 2-3 mm. in diameter. This was completely dilated with the index finger and packed with bismuth gauze. Extravasation of urine into this cavity may explain the chills and temperature; no other explanation has been found.
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July 20th. Following the dilation of the above cavity the temperature fell rapidly and there were no more chills and no rise of temperature. The patient was removed from the bath on June 28th, 40 days after the accident. Since then the sinus and bladder have been irrigated daily with boric acid solution, and to-day gauze removed from the sinus is slightly moist with urine. The sinus is closing rapidly. Except for some swelling and pain in the left leg and hip, the patient has been fairly comfortable and for two days has been up in a wheel-chair. It is now two months since the accident.
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Sept. 2d. The general condition is much improved. Her appetite is good and she rests comfortably. The suprapubic sinus is still open, its external orifice barely admitting the tip of the little finger, and a probe passed to the bottom strikes roughened bone. No mobility can be obtained at the seat of fracture. She voids urine without difiBculty and the urine is greatly improved.
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Sept. 29th. The sinus is about 2 cm. deep and does not communicate with the bladder or seat of fracture. The patient has been walking without any difficulty for some time, although there seems to be some motion at the seat of fracture. The urine contains only a few leucocytes and is acid.
 +
 +
Oct. 8th. Discharged. Sinus closed and urine clear.
 +
 +
Dec. '96. Patient returns with a small reducible hernia 2 cm. long in the scar in the right groin.
 +
 +
Feb. 13th, '97. Operation for hernia.
 +
 +
Mar. 3rd, '97. Discharged cured. Patient has recovered | perfectly her normal state of health. She walks without | difficulty and there is no evidence of mobility at the seat of fracture.
 +
 +
Considering the great number of surgical cases of all kinds treated in hospitals, neither fracture of the pelvis nor rupture of the bladder is a frequent occurrence ; for statistics show that in Berlin in 10,867 surgical cases there were only 3 ruptured bladders, and in Loiulon in 16,711, only 2. In the Johns Hopkins Hospital among 7268 surgical patients there have been 5 ruptured bladders. It is generally stated that fractures of the pelvic bones compose about 1 per cent, of all fractures. Either is a serious lesion ; but with the two combined the prognosis is always grave. According to its relation to the peritoneum, the rupture may be one of three varieties: intraperitoneal, subperitoneal, and extraperitoneal. I To the last, in combination with fracture of the pelvis, we • will confine our attention as bearing directly on the case just shown. We have collected 90 similar cases scattered through the literature of the past century, and on an analysis of these reports base the remarks which follow. In many instances the reports are very meagre and cause the statistician much trouble in collecting and analyzing cases.
 +
 +
The injury is met with much more frequently in men than in women, and most commonly between the ages of 20 and 60, that is, in the most active period of man's life when his habits
 +
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 +
January, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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and occupation expose him to violence. Harrison, of Dublin, thinks the greater size of the pelvis and the protective pad offered by the uterus account for the greater rarity of rupture of the bladder in the female. In boys the bladder is not as likely to be allowed to become distended — an important factor in the causation of rupture— while after 60 a man has usually retired from active and dangerous service.
 +
 +
As might be imagined, the direct cause is traumatism of some violent character, for example the passage of a wheel over the body, as in the present instance. Fully one-third of all the cases are due to this cause alone. Many are caused by a fall from a height or a crushing weight received on the lower abdomen. An interesting case is recorded in which the man was thrown from his horse, landing rather forcibly on the ground in a sitting posture. The symphysis was separated and the bladder wall torn asunder. Another man while intoxicated stepped from a second story window which he mistook for the door. He alighted on one foot and sustained a fracture of the pelvis complicated by a ruptured bladder.
 +
 +
As a predisposing cause alcoholic indulgence ranks high, not only on account of greater exposure to violence in intoxicated persons, but owing also to the fact of the increased liability to distension of the bladder and the consequent loss of tone, elasticity and resistance of its walls.
 +
 +
As to the immediate causes of the tear in the bladder walls, opinions differ. Undoubtedly many are due to a continuation of the same crushing force that fractured the pelvis; but in a great number the cause is by no means so evident. A considerable proportion can be attributed to direct penetration of the bladder by a displaced or fractured bone. In 21 cases it is stated to have occurred, though from the position of the tear and the nature of the fracture in many other cases it must be much more common. Still others are due to concussion favored by a wall distended and weakened by chronic alcoholism. The bladder when empty lies behind and wholly protected by the pubic bones, and it would be difficult to conceive of a rupture of an empty bladder caused by actual pressure without penetration by bone, as in cases where there is simply separation of the symphysis without any anteroposterior displacement. Allis explains such a rent as being due to actual tearing apart of the bladder wall by the anterior ligaments which connect the front of the bladder with the pubic bones, one on either side of the symphysis. When the bladder is distended the walls themselves are weakened by a separation of the muscular fibres, and the anatomical position is much more favorable to rupture ; for the bladder then rises above the symphysis pubis and in part loses the protection afforded by it. The opening is most often in the anterior wall communicating directly with the space of Retzius. It was situated here in 63 per cent, of the reported cases. Next in frequency comes the neck as a seat of rupture, while in a few instances the rent is in the side or base.
 +
 +
Fracture is oftentimes multiple, and by far the commonest location is in the pubic bones— 49 cases thus recorded. Separation of the symphysis pubis is of frequeut occurrence, while tearing apart of the sacro-iliac synchondrosis is not very uncommon. Fractures of other bones are not so numerous, the sacrum and ischium being about equally often and the
 +
 +
 +
 +
ilium rarely involved — the latter only 6 times in our collection.
 +
 +
The symptomatology is quite definite. After the accident the patient is usually unable to walk or even to rise from the ground, and is often rendered unconscious, though accounts are given of patients walking some distance. Peaslee reports a case of a man who, with 7 fractures and a ruptured bladder, could actually walk a few steps. The subjects often describe a sensation as of something tearing within them at the time of the accident. They are brought to the hospital in a semistupid condition, complaining of intense pain in the hypogastric region or at the seat of fracture. Many go at once into a state of collapse or coma from which they never rally, dying in a few hours. A pretty constant and characteristic symptom is great desire to micturate, with either total inability to jjass any urine, or the passage of a small amount of blood-stained urine or pure blood. Sometimes, however, urination is not interfered with and the patient voids perfectly clear urine; these are rare exceptions. Again, the patient may at first pass no urine, but after a time be able to do so. There may be one or repeated shaking chills.
 +
 +
The condition of the patient depends somewhat upon the time elapsed since the accident. Very commonly it is one of collapse with marked pallor, rapid and weak pulse, hurried and shallow respiration and high temperature. The body is bent forward and the legs drawn up. There may be vomiting and diffuse abdominal pain, with distension and tenderness and signs of general peritonitis ; but this picture by no means always denotes involvement of the peritoneum in the rupture. Tumefaction, due to extravasation of urine and blood, may be seen in various localities according to the situation of the rupture of the bladder or the fracture of the pelvis, and there may be localized abdominal dullness. Extravasation of urine may be absent entirely, or may be extreme and yet overlooked, because on account of the violence necessary to the production of the lesion it has not followed the classical paths. It has been known to ascend as high as the shoulders, or to follow the psoas muscle, stripping up the peritoneum as far as the kidneys. In one case at the time of the accident a rounded and fluctuating tumor appeared on the thigh not far above the knee. This on being opened some two weeks later was filled with urine, pus and blood. If seen late, there is likely to be infection, especially if the patient has been catheterized.
 +
 +
From the signs given the diagnosis can generally be made, but there are certain aids which make the extraperitoneal rupture plainer and distinguish it from the intraperitoneal form. Catheterization yields important information. As a rule one obtains by the catheter only a small amount of urine and this is mixed with blood. Sometimes catheterization is imjiossible. In rare instances clear urine has been obtained, and quite frequently nothing at all, which latter condition Willard explained in his case as being due to suppression of urine rather than escape from the bladder.
 +
 +
Sometimes the catheter will pass through the rent in the bladder and then a large amount of bloody urine may be withdrawn. The ordinary procedure, and a very useful one, is to inject into the bladder a known amount of some mild solution
 +
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8
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 82.
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(in the present case half-saturated boric acid solution was used), and then measure the fluid withdrawn, any considerable decrease indicating leakage through a rupture. Sometimes the patient will feel the liquid escaping immediately from the bladder. This method has been opposed on the ground of being dangerous in case of intraperitoneal rupture ; but as immediate laparotomy is here indicated, it is not an important objection, and with proper precautions the gravity of the case need not be increased. In locating the position of the tear during operation, this injection is also very useful. Walsham suggested that air be introduced by means of a hand-ball apparatus as a substitute for fluid. Kivington has advised a preliminary perineal incision and digital examination of the bladder as a means of diagnosis. Eectal, vaginal, and cystoscopic examinations occasionally give useful data in ruptures about the neck, and rectal and vaginal examinations are especially useful in the location of fractures.
 +
 +
The prognosis has always been grave, though with the progress of surgery the death rate has greatly lessened. Hippocrates thought rupture of the bladder necessarily fatal, while Galen admitted the possibility of recovery in extraperitoneal injuries. In 1878 liartels collected 169 cases of rupture of all varieties, with a mortality of 89.3 per cent., and at that time there was only one recorded recovery in intraperitoneal rupture. Cramer in 1896 gave the mortality for all forms as 54 per cent. Q^his drop in the death rate has been to a large extent due to the improved treatment of intraperitoneal cases. In our 90 reports there were 15 recoveries, making the mortality 83.3 per cent. Taking only those which have occurred in the last 15 years, we find 34 with 7 recoveries, i. e. a mortality of 70.8 per cent., so that under improved treatment the decrease in deaths has not been great, and it is still considered a very grave injury and one whose treatment has been rather unsatisfactory. When we consider how likely it is to have only recoveries reported it is not probable that this estimate is an exaggerated one. In the majority (55 per cent, of our collected cases) death occurred in the first four days, while in the first week 73 per cent. died. Those surviving the first few hours rally from the shock and later show signs of peritonitis or extravasation of urine ; the lingering cases die finally of sei> tica^mia.
 +
 +
At autopsy the space of Retzius and other seats of infiltration are found filled with a bloody urino-purulent fluid, and the tissues about are necrotic and sloughing. The sloughing may reach an extreme grade. General peritonitis may result, or the peritonitis may be more or less localized, according to the extent of the infection. Spontaneous cure is jiossible even in cases of extensive infiltration.
 +
 +
It is well known that perfectly sterile urine flowing over tissues has little effect except when absorbed in great amounts, and that it does not materially interfere with the repair of open wounds; but the flow, if continued for a long time, or dammed up without exit, does provoke irritation and lower vital resistance, so that we have a most favorable medium for infection. Strauss and TuflSer have done some interesting work to shed light on this point. They injected aseptic urine into the peritoneal cavity, the space of lletzius and the muscle of dogs, and found that the urine was absorbed and there
 +
 +
 +
 +
was no reaction. On repeating these injections, using urine mixed with blood, ammonium sulphide or ammonium chloride, the same result was obtained. On cutting one ureter, however, and allowing the urine to flow into the peritoneal cavity, the dogs died in 8-20 days of uraemic poisoning and peritonitis. They conclude that sterile urine in itself has no action, but that prolonged exposure so irritates and lowers the resistance of the parts as to allow organisms to pass through the intestinal wall and set up a peritonitis. Unfortunately they do not state what orgiinisms were concerned.
 +
 +
Urine is in itself, however, an excellent culture medium, and on account of the common practice of catheterization is rarely if ever sterile for any time after the accident with which we are concerned, and thus it acts as a carrier of infection.
 +
 +
The treatment therefore is plainly indicated, viz. immediate relief of the extravasated urine and prevention of reaccumulation by proper drainage and suture.
 +
 +
As far as the fracture is concerned little is to be done except to fix the parts, though it is sometimes necessary to remove spicules of bone or wire the fragments together. To get rid of the extravasated urine has been a simple matter, but the question of efficient drainage seems to have been a difficult one.
 +
 +
The earliest cases were treated by hot applications, leeches and bloodletting, and two i-ecoveries are reported in 53 cases where no other treatment save these and catheterization was employed.
 +
 +
In all 37 cases were treated by various operative procedures, with a resulting mortality of 64.9 per cent. In many of the recoveries the convalescence has been slow and tedious, with a history of long-continued suppuration and the existence of one or more fistulous tracts for months or years.
 +
 +
Statistics show nothing as to the advantage of early operation, for there were more recoveries where the operation was in the second week. But we know that it is best to operate as soon as possible, and it is a question as to whether these late cases would not have recovered spontaneously by rupture of the abscesses and formation of fistula?. The first attempt at operation amounted merely to incisions for extravasation plus a catheter retained in the urethra. Of 8 cases so treated, 3 recovered. The recoveries were cases which had gone on to abscess formation, and all that was done was to open the abscesses. In 1845, Walker, of Boston, first employed lateral perineal cystotomy in a case of ruptured bladder, and drainage through this incision was successful and the patient recovered. After that perineal incision with drainage was the favorite method, and in 16 cases there were 4 recoveries. Abdominal incision was employed 5 times with 1 recovery, and then suprapubic cystotomy with or without a counter incision in the perineum took its place and has been up to the present time the ordinary method of dealing with this injury ; but of 8 patients treated in this way only 3 recovered.
 +
 +
In three cases, including the present one, the continuous bath has been used to prevent absorption and for better drainage, and all of these have recovered. While the bath treatment of wounds is in itself old and has been much used both in this country and abroad, its application to such cases as the present one seems to have been gradual, and its great value
 +
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 +
 +
January, 1898.]
 +
 +
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 +
JOHNS HOPKINS HOSPITAL BULLETIN.
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should be insisted upon. In 1878 Bartels speaks of "giving baths" to a case in which there was extensive suppuration, and the patient got well, but he does not go into particulars as to the time in which the patient remained in the bath. In 1891 Rose after doing a suprapubic operation for rupture found that ordinary dressings were not sufficient, and says that " therefore the patient was every day put in a continuous bath for several hours without any dressing." This was continued for 20 days, and then the bath was used only every 3nd or 3rd day. The second case in which it was employed was in 1896 by Wiesinger. Here on the 17th day an abscess was opened over the seat of fracture and the patient put in a continuous bath. The abscess was healed on the 42nd day.
 +
 +
It would seem then that whether there be merely incisions for extravasation, or whether suprapubic cystotomy or perineal section be performed, the best results can be secured by placing the patient in a continuous bath. In view of a forthcoming report we will not go into the particulars of the management of the bath, but as far as the comfort of the jiatient is concerned little can be said against it. While at first patients may object to the bath, probably more from the thought of it than from actual discomfort, they soon grow to like it. As has been said, the present patient when removed from the tub cried to be returned.
 +
 +
Dr. Bloodgood has already reported a case of ruptured urethra with fractured pelvis in which the bath was used with excellent result. It has been used by Schede in cases of extravasation of urine, and last year Puzey, in London, reported two cases of ruptured urethra which recovered under the bath ; so that it would seem to be especially adapted to this class of injuries, where efficient drainage is so important and so difficult.
 +
 +
Analysis of Cases.
 +
 +
Sex. — Males 84 = 94.4 per cent. Females 5 = 5.6 per cent.
 +
 +
Age.— 1-10 years, 4 ; 10-20 years, 8 ; 20-30 years, 20 ; 30-40 years, 18; 40-50 years, 10; 50-60 years, 11 ; 60-70, 4; total, 75. Total from age 20-60= 59 = 78.7 per cent.
 +
 +
Cause. — Crushed by weight falling on body, 23; run over, 25; fell from a height, 22; struck by engine or car, 4; crushed between wagons or cars, 9 ; total, 83.
 +
 +
Result. — Whole number of cases, 90; whole number of deaths, 75 ^ 83.3 per cent.; whole number of recoveries, 15 =: 16.7 per cent.
 +
 +
. Time of Death.— iBt day, 9; 2nd day, 14; 3rd day, 7; 4th day, 10 ; 5th day, 5 ; 6th day, 5 ; 7th day, 3. 1st week, 53.
 +
 +
8th day, 2 ; 10th day, 1 ; 12th day, 3 ; 14th day, 3. 2nd week, 9.
 +
 +
3rd week, 2; 4th week, 4; 5th week, 1; 6th week, 2; 6th month, 1 ; 14th month, 1.
 +
 +
Time of Operation. —
 +
 +
 +
 +
Time after Accident.
 +
 +
Within 24 hours.
 +
 +
 +
Total. 11
 +
 +
 +
Deaths.
 +
 +
7
 +
 +
 +
Recoveries. 4
 +
 +
 +
Mortality.
 +
 +
63.7 per cent.
 +
 +
 +
« 48 "
 +
 +
 +
3
 +
 +
 +
2
 +
 +
 +
 +
 +
 +
100.0
 +
 +
 +
" 4 days, " 2 weeks.
 +
 +
 +
5
 +
 +
7
 +
 +
 +
5 2
 +
 +
 +
 +
5
 +
 +
 +
100.0 " 28.6
 +
 +
 +
3 "
 +
 +
 +
1
 +
 +
 +
1
 +
 +
 +
 +
 +
 +
100.0
 +
 +
 +
 +
Bones Fractured. — Multiple fracture, 42 ; os pubis, 49 ; sacrum, 9; ischium, 9; ilium, 6; separation of symphysis pubis, 31 ; separation of sacroiliac synchondrosis, 10 ; penetration of bladder by bone, 20.
 +
 +
Position of Rupture. — Anterior wall, 41^63.2 per cent.; posterior wall, 1 ; neck, 13 ; side, 5 ; fundus, 3 ; base, 3.
 +
 +
 +
 +
Unoperated.
 +
 +
 +
 +
and catheterized
 +
 +
hot applications. . . retained catheter .
 +
 +
 +
 +
Incision for extravasation.
 +
 +
 +
 +
and retained
 +
 +
 +
 +
catheter.
 +
 +
 +
 +
Perineal incision
 +
 +
" " and retained catheter.
 +
 +
" " " drainage tube
 +
 +
" " " incision for extravasation
 +
 +
Perineal incision and incision for ex travasation and retained catheter. . . Perineal incision and abdominal incision " " " suprapubic incision
 +
 +
 +
 +
lithotomy tube and drainage.
 +
 +
 +
 +
Abdominal incision
 +
 +
" " and retained catheter
 +
 +
" " '• suprapubic inci
 +
 +
sion
 +
 +
 +
 +
Suprapubic incision
 +
 +
" " and retained catheter
 +
 +
 +
 +
Bath and incision for extravasation. . . " " suprapubic incision
 +
 +
 +
 +
Whole number operated upon.
 +
 +
 +
 +
"5.0
 +
 +
 +
 +
00.0 64 9
 +
 +
 +
 +
17
 +
 +
 +
 +
65.4
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 +
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THE JOHNS HOPKINS HOSPITAL BULLETIN.
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The Hospital Bulletin contains announcements of courses of lectures, programmes of clinical and pathological study, details of hospital and dispensary practice, abstracts of papers read and other proceedings ot the Medical Society of the Hospital, reports of lectures, and other matters of general interest in connection with the work of the Hospital. It is issued monthly.
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Volume IX is now in progress.
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The subscription price is $1.00 p«fr year.
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 +
Complete set (Vols. I-VIII), bound in cloth, for $13.00.
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 +
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 +
DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL.
 +
 +
By John S. Billings, M. D., LL. D.
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 +
Containing 56 large quarto plates, phototypes, arid lithographs, with views, plans and detail drawings of all buildings, and their interior arrangements— also woodcuts of apparatus and fixtures ; also 116 pages of letter-press describing the plans followed in the construction, and giving full details of heating-apparatus, ventilation, sewerage and plumbing. Price, bound in cloth, $7.50.
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10
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 82.
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THE PHYSIOLOGICAL AND PATHOLOGICAL RELATIONS BETWEEN THE NOSE AND THE
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SEXUAL APPARATUS OF MAN/^=
 +
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By John Noland Mackenzie, M. D., of Baltimore, Clinical Professor of Laryngology atul Rlmiology in the Johns Hopl-ins Medical School and Laryngologisl lo the Johns Hopkins Hospital.
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" Balnea, vina, Venus corrumpunt corpora nostra, Set vitam faciunt, l)(aluea), v(ina), V(enus)."t
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Olvog Kal ra '/joETfja kol ij Trept KvTTfiiv Ipuij
 +
 +
Mr. President and Oetitlemen. — The limited time at my disposal this moruiiig precludes an elaborate discussion of the propositions which form the text for these remarks. I shall, therefore, content myself with a brief statement of the conclusions which I have reached after a careful study of the subject, and shall not weary you with the arid narrative of individual cases.
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The injurious effects of undue excitation or disease of the generative apparatus upon the organs of sight and hearing are matters of ancient recognition. That immoderate indulgence in venery may lead to derangements of the former was familiar to Aristotle,§ and that the fathers of medicine recognized some mysterious connection between the ear and the rejM'oductive functions is evident from the testimony of Hippocrates.|| Over two centuries ago Eolfinc^ wrote: "Qui partihus genitalibus aiutitur, et sexto ptraccepto vim infert, male audit," a proposition which has been fully established by the clinical exj^erience of to-day.
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The intimate relationship between the genital organs and those of the throat and neck seems to have attracted the special attention of the ancients. Thus Aristotle** clearly defines the changes iu the voice at puberty, and the effect of castration on its qualities. ff Its harsh, irregular and discordant character during the maturation of the sexual functions was furthermore affirmed to be more conspicuous in those who attempted the early gratification of the sexual appetite. The
 +
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 +
Remarks made before the British Medical Association at its
 +
Montreal meeting, September, 1897.
 +
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t An old inscription found in the Campus Florae in Rome. See Buecheler's Antbolog. Latin. Carmen. Epigraphic, Fasc. II, p. 705, No. 1499, Teubner edition, 1897. Also Corpus Inscript. Latin. VI, 15258, Gruter 615, 11, Orelli 4816, etc. It is attributed, however, by Scaliger to a modern poet.
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X The supposed Greek original. See Antbolog. Palatin. X, 112.
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§ Aristot. Opera omnia giaeco-latin. Parisiis, 1834. De animalium generatione, lib. ii, cap. 7.
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 +
II Opera omnia. Ed. Kiihn, Lipsiae, 1827, torn, i, p. 562.
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H Ordo et methodus generatione dicatarum partium, per anatomen, cognoscendi fabricam. Jenae, 1664, part i, cap. vii, p. 32.
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0p. cit., De animal, historia, lib. vii, cap. i.
 +
Choking sensations in the throat and other hysterical manifestations have from time immemorial been regarded as signs of pregnancy. Shakespeare, in King Lear (sc. ii, act iv) thus gives expression to this idea :
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 +
" O, how this mother swells up towards my heart I Hysterica passio ! down, thou climbing sorrow, Thy element's below.*'
 +
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ttOp. cit., De animal, generatione, lib. v, cap. 7.
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observation that, during coitus, the voice becomes rougher and less acute, led tlie phouasci or voice-trainers to infibulate their pupils, or confine the penis with bauds and fetters, to preclude indulgence in wantonness,* whilst the popular idea of the injurious effect of repeated coition upon the singing voice is reflected in the epigram of the Roman satirist:
 +
 +
" Cantasti male, dum fututa es, Aegle, Jam cantas bene ; basianda non e8."t
 +
 +
The supposed influence of sexual excitement upon the external throat is likewise apparent from the ancient nuptial ceremonial. Before the virgin retired on the wedding night it was customary to measure her neck with a tape and again on the following morning. If the neck showed an increase in size it was taken as a certain indication of defloration, whilst if the two measurements were equal she was supposed to have retained her virginity. This curious test, which has also been utilized to establish the fact of adultery, has been transmitted to us iu the Epithalamium of Catullus:
 +
 +
" Non illam nutrix, oriente luce revisens, Hesterno collum poterit circumdare filo."t
 +
 +
Whilst, therefore, the above historical facts point to the early i-ecognition of the relationship between over-indulgence of the sexual powers and morbid conditions of the eye, ear and throat, the special part which it plays in the production of nasal disease seems to have been heretofore overlooked.
 +
 +
My attention was first attracted to the investigation of the physiological and pathological relations between the nose and
 +
 +
 +
 +
J. Riolani Anthropographiae, lib. ii, cap. 34, p. 303, Francofurti, 1626. Riolanus quotes from the Musaeum of Albertus Magnus
 +
the case of a girl, sent to fetch wine from a public house, who was seized and ravished on the road, and who found in attempting to sing on her return that her voice had changed from acute to grave.
 +
 +
See also Martial (lib. ix, Epig. 28) :
 +
 +
"Jam paedegogo liberatus etcujus Reflbulavit turgidum faber penem."
 +
 +
Also lib. xiv, Epig. 215:
 +
 +
" Die mihi, simplicitur, comoedis et cithaedis Fibula quid praestet ? Carius ut futuant,"
 +
 +
See also Juvenal, sat. vi, 73.
 +
 +
The gladiators and athletes were also subjected to infibulation :
 +
 +
"Dum ludit media, populo spectante, palaestra, Delapsa est misero fibula ; verpus orat."
 +
 +
Martial, lib. viii, Epig. Ix-t-Tii.
 +
 +
f Martial, Epig. lib. i, xcv, ad Aeglen fellatricem.
 +
 +
} Epitbal. Pelei et Thetidos, Ixiv. Catulli op. omn., Lond., 1882, p. 230. This phenomenon was variously attributed to the dilatation of the vessels of the neck by the semen, a portion of which, according to the Hippocratic doctrine, flowed down from the brain during intercourse, and to the general agitation of the vascular system, and especially the arterial and venous trunks of the throat, during the excitement of the sexual act.
 +
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 +
 +
January, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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11
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the genital orgians by the case of a patient in London, in 1879, wlio invariably suffered from coryza after sexual indulgence.
 +
 +
Stimulated by this observation I began the study of the subject, and five years later published the results of my investigations in the American Journal of the Jledical Sciences for April, 1881, in an essay entitled " Irritation of the Sexual Apparatus as an Etiological Factor in the Production of Nasal Disease." In this thesis, which was the first attempt to reduce this curious relationship to, as far as possible, a scientific basis, I advanced the series of propositions which you will find embodied in the text of these remarks.
 +
 +
Several years later there appeared in France a thesis by Arviset,* a critical review by Isch-Wallf and an excellent article by Joal,| which dealt in a most interesting way with the topic under consideration. In Germany, Peyer§ in Munich, Eudrissll in Goeppiugen, and, in the present year, Fliess^l in Berlin, have enriched its literature with their contributions. Fliess's elaborate monograph, written in apparent ignorance of the work done by me in this special field before him, is a model of painstaking labor, and is valuable as an independent contribution to the study of this important subject.
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 +
Before submitting for discussion the propositions which form the text for these remarks, let me briefly call attention to certain matters of historical interest which have seemed in olden times to have foreshadowed the physiological relationship between the nose and the genital apparatus.
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 +
In the Ayurveda, the sacred medical classic of the ancient Hindus, a work of fabulous antiquity, the causes of common catarrh are thus tersely defined :
 +
 +
"Uxoris concubitus, capitis dolor, fumus, pulvis, frigus, Vehemens calor, retentio urinae soecumque statim Catarrhi causae dictae sunt."**
 +
 +
Although indulgence in venery heads the list, it is highly probable that its real influence was unrecognized, and that it is given as an etiological factor simply in accordance with the seemingly prevalent idea that pervades the Indian Shastras, that venery and confinement of the bowels lay at the root of most diseases.
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The earlier physiognomists laid great stress upon the size and form of the nose as an indication of corresponding pecu
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Contribution a I'etude du tissu erectile des fosses nasales.
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These de Lyon, aoiit, 1887.
 +
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t Progres Medical, Sept. 10 et 17, 1887. Du tissu erectile des fosses nasales.
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t Revue mensuelle de laryngologie, d'otologie et de rhinologie, fevr. et mars, 1888. De I'epistaxis gt'-nitale.
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gUeber nervijs. Schnupfen u. Speicheliluss u. den iitiologischen Zusammenhang derselben mit Erkrankungen desSexualapparates. M'inchener Med. Wochenschrift, Jahrgang 1889, No. 4.
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jUeber die bisherigen Beobachtungen von pliysiologischen u. pathologisehen Beziehungen der Oberen Luftwege zu den Sexualorganen. Inaug. Diss. Wiirzburg, 1892.
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T^Die Beziehungen zwischen Nase u. weiblichen Geschlechtsorganen. Berlin, 1897.
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Siisrutas Ayurvedas: id est Medicinae Systema, a venerabili
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D'hanvintare demonstratum a suo disoipulo compositum. Translated from the Sanscrit into Latin by Franciscus Hessler, Erlangen, tom. iii, cap. xxiv, p. 44, 1850.
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liarities in the penis.* The nose, for example, that was large and firm was looked upon as an index of a penis acceptable to women, and hence it was that the licentious Emperor Heliogabalus only admitted those who were nasuti, i. e. who possessed a certain comeliness of that feature, to the companionship of his lustful practices. t
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Johanna, Queen of Naples, a woman of insatiable lust, seems also to have selected, as her male companions, men with large noses, with a similar end in view. J Sterne, in Tristram Shandy, depicts with consummate humor the supposed sexuality of the nose in " Slawkenbergius's Tale," in which the city of Strasburg was captured by a handsome nose. Every one remembers the closing lines of that intensely amusing production : "Alas ! alas ! cries Slawkenbergius, making an exclamation— it is not the first, and I fear will not be the last fortress that has been either won — or lost by noses."
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While the efforts of those who have selected men who were nasuti for sexual purposes were doubtless often crowned with success, history, alas ! records some cases of bitter disappointment. Thus Henry Salmuth§ relates with great solemnity a case in point.
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Christian Francis Paullini in his curious work]] devotes a chapter, under the caption Nasuti non semper hene vasati,\ to the subject. After alluding to the prevalent impression that a large nose indicated a corresponding increase in volume of the virile organ, he goes on gravely to state that he has known several "noble and pious" men in whom the rule did not hold good, and relates the following mournful tale : " Nobilissima ac venustissima Virgo, sed valde petulca, duos simul habebat procos, alteram bonae vitae, fortunataeque hominum, sed macileutum; alteram quadratum, et tws/^rwi.' ?irt>o conspicuum, hirconem, ac fruges consumere natum. Ilia, temto isto, hunc sibi elegit ob peculium, quod sperabat, magnum et conditionem strenuam. Sed egregie decepta est. Hinc domi jurgia, foris risae et sunima viri aversio, ob sterilitatem quae thorum perpetuo comitatur."
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It was possibly the supposed influence of an elegant and handsome nose as an incentive to illicit amours that led to the well-known custom of amputation of that organ in adulterers, " truncas inliomsto vulnere nares,"** whilst in women detected in the actft the disfigurement thereby produced was intended as a perpetual reminder of their shame.
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In astrology Venus was supposed to govern the nose.
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 +
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See especially Ludwig Septalius : De Naevis tractatus, sect. 26,
 +
p. 18, in Bonel's Labarynthi medic, extricati, etc. Genevae,
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I'JS.
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f Vide Aelius Lampridius in vita Antonii Heliogabilis, in Hist. August, etc. Beponti.
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JGuidonis PanciroUi rerum memorabilium sive deperditarum pars prior, etc. Francofurti, 1646, lib. 2, tit. 10, p. m. 176.
 +
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gibid.p. 177.
 +
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llObservat. medico-physiog. Cent, i, obs. xcvii, p. m. 141 ; Lipsiae, 1706.
 +
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IF Vasatus, post-classical.
 +
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Virgil, Aeneid, vi, 497.
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ffVide Diodorus Siculus in Bibliothecae Historicae, Paris edition, 1854, tom. i, lib. i, cap. Ixxvii (5), p. 04. On the customs and laws of the Egyptians.
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12
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 82.
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According to all the astrologers, the gentry who
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"... feel the pulses of the stars, To find out agues, coughs, catarrhs,"
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Venus presides over generation and all the parts pertaining thereto. De la Chambre in his work UArt de Gonnoisfre les Homines* in alluding to this supposed influence, says that nothing is more convincing, at least to those who admit the influence of planets on the affairs of men, than that there is an intimate relationship (astrologically) between the genital organs and the nose. As the result of this sympathy the nose must receive the same influence which the planet Venus communicates to the genital organs and must submit to the same empire to which they are subjected. The astrological signs of the nose are reproduced in the genital organs, which, like the nose, occupy a prominent part in the center of the body.
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The charlatans of those days pretended to establish the fact of virginity or defloration by astrological signs. William Lilly, the celebrated English astrologer and impostor of the seventeenth century, claimed never to have made a niistake.f It was doubtless this method of imposture that inspired the line of Butler in Hudibras, "detect lost maidenheads by sneezing,"! ill the famous poem in which he smiled the pretensions of this fraternity of quacks away.
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The idea of some occult relationship between the nose and the virile member seems, in days gone by, to have crept even into the darkness of teratology. Thus we find Palfyn§ describing cases in which in place of the nose were found masses resembling the male organs of generation.
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To render the relationship to which I wish to call attention more intelligible it is necessary to recall the anatomical fact that in man, covering the whole of the inferior, the under surface of the middle, the posterior ends of the middle and superior, and, what is not sufficiently insisted upon by many writers, a portion of the septum, is a structure which is essentially the anatomical analogue of the erectile tissue of the penis. Like it, this body is composed of irregular spaces, or so-called erectile cells, separated by trabecule of connective tissue containing elastic and muscular fibers, the latter element being not as prominent and well-marked as in the cavernous bodies of the generative organs. Under a multitude of various impressions erection of this tissue takes place, the dilatation of its cells being, in all probability, under the direct dominion of vaso-motor nerves derived through the spheno-palatine ganglion. It is the temporary dilatation of these bodies that constitutes the anatomical explanation of
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L'Art de Connoistre les Hoinmes. Amsterdam, cliez Jacques
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le Jeune, 1660. De la metoposcopie, p. 259.
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t Life and Times of William Lilly, written by himself. London, 1829.
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tPart ii, canto iii, 285. Bartholini (Anatomica Reformata, de naso ; also Lond. ed., bk. iii, chap, x, p. l.W) tells us that Michael Scotus pretended to be able to diagnosticate virginity by touching the cartilage of the nose.
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§Fortunus Licetus (Jean Palfyn), Description anatomique des parties de la femme, etc., avec un traite des monstres. Leiden, 1708, lib. ii, chap. 30, p. 142 and 144.
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the stoppage of the nostrils in coryza and allied conditions, and their permanent enlargement is the distinctive feature of chronic inflammatory states of the nasal passages. This erectile area is, moreover, especially concerned in the evolution of the many curious "reflex" phenomena which are observed in connection with nasal affections. Indeed, the changes which it undergoes seem to lie at the foundation of nasal pathology, and furnish the key not only to the correct interpretation of nasal disease, but also to many obscure affections in other and remote organs of the body. For practical purposes we may consider this erectile, or contractile, area, consisting, as it does, of myriad blood-vessels and blood spaces in wonderfully exquisite correlationship, bounded on the one side by mucous membrane, and on the other by periosteum, as an important organ, certainly of respiration and probably of other physiological functions, using the term organ in its highest physiological sense. Call these bodies by whatever name we may, erectile bodies, corpora cavernosa, nasal lungs, we have a definite, peculiar anatomical arrangement of tissues endowed with specific physiological function and serving a manifest and manifold destiny in the organism.
 +
 +
Physiological.
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That an intimate physiological relationship exists between the sexual apparatus and the nose, and especially the intranasal erectile tissue, is sufficiently evident from the following facts :
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I. — (a) In a certain proportion of women whose nasal organs are healthy, engorgement of the nasal cavernous tissue occurs with unvarying regularity during the menstrual epoch, the swelling of the membrane subsiding with the cessation of the catamenial flow.
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(b) In some cases of irregular menstruation, in which the individual occasionally omits a menstrual period without external flow, at such times the nasal erectile bodies become swollen and turgid as in the periods when all the external evidences of menstruation are present.
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(c) The monthly turgescence of the nasal corpora cavernosa may be bilateral, or confined to one side, the swelling appearing at first in one side and then in the other, the alternation varying with the epoch.
 +
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{(l) The periodical erection may be inconsiderable and give rise to little or no inconvenience, or, on the other hand, the swollen bodies may occlude the nostril and awaken phenomena of a so-called reflex nature, such as coughing, sneezing, etc.
 +
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{e) In some cases there seems to be a direct relationship between this periodical engorgement of the nasal erectile bodies and the phenomena referable to the head that so often accompany the consummation of the menstrual act.
 +
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(/) As a natural consequence of the phenomena above described, the nasal mucous membrane becomes, at such periods, more susceptible to reflex-producing impressions, and is therefore more easily influenced by mechanical, electrical, thermic and chemical irritation.
 +
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{(j) The conditions (engorgement and increased irritability of the nasal mucous membrane) indicated above, together with the phenomena that accompany them, are also found
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Jaxuary, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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13
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during pregnancy at periods correspouding to those of the menstrual flow. There is also reason to believe that similar phenomena occur during lactation and the menopause.
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During the period of my original investigations I was unable, from poverty of material, to come to any definite conclusions in regard to the behavior of the nasal apparatus during pregnancy. I was familiar with the fact that in some women the presence of pregnancy was proclaimed by a cokU in the head. Isolated cases, too, had led me to the belief that the changes such as I described in my first article occurred in some women, at least, during that period at intervals corresponding to those of the menstrual flow, but at the time of publication of my essay I was not as sure of the fact as I am now. Since my work first appeared I have been so busied with other things that I have given little or no time to the subject. Several cases have, however, offered themselves to me which have confirmed me in the belief that sometimes, at least, the phenomena described by me as occurring during menstruation also occur iu pregnancy at periods corresponding to those of the monthly flux. Not to mention others, I have, for example, at present under my care a young pregnant married woman, without any disease of the nasal passages, who with great regularity during the time at which her menses are due (from the 13th to the 17th of every mouth) suffers from acute and complete obstruction of both nostrils, intense sensitiveness of the nasal mucosa and violent paroxysms of sneezing. These phenomena commence on the 13th, reach their acme by the 15th, and gradually subside, to disajjpear on the 17th of the month. During the intervals between the periods there is no abnormal condition of the nose present. Indeed, it was for this peculiar, disagreeable feature of her pregnancy that she consulted me, with a very accurate voluntary description of her symptoms. This condition of affairs has continued during three pregnancies. If other proof were wanting of the fact that menstrual phenomena referable to the nose occur during pregnancy, the question has been definitely settled by Fliess, who has shown that they not only occur during that period, but also during lactation. This author also reports several cases iu which abortion was accidentally produced by galvano-caustic operations on the nose. In this connection I would call attention to the fact that Pliny* observes that the smell of a lamp which has been extinguished will often cause abortion, and that the latter ensues should the female happen to sneeze just after the sexual congress.
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II. — The presence of vicarious nasal menstruation.
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(rt) It is a familiar fact that women are occasionally found iu whom the menstrual function is heralded or established by a discharge of blood from the nostrils. This hemorrhage, which may be accompanied by other phenomena referable to the nose, such as sneezing, etc., may be replaced afterwards by the uterine flow, but sometimes continues throughout the menstrual life of the individual. In the latter case, some malformation or derangement of the sexual apparatus seems to be, usually, though not always, responsible for the nasal flow.
 +
 +
 +
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Nat. His. lib. vii, cap. 7.
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(b) Epistaxis also occurs, now and then, from the suppression of the normal flux. This was considered as a favorable sign by Hippocrates,* and by Celsus,twho followed closely in his footsteps.
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(c) Hemorrhage from the nose may occur as the vicarious representative of menstruation during pregnancy ; towards the close of menstrual life as the premature or normal herald of the menopause ; or it may be observed as a recurring phenomenon after the establishment of the change of life or after the removal of the uterus or its appendages.
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(d) These vicarious hemorrhages are, moreover, not confined to women, but make their appearance not infrequently in boys at or near the age of puberty, upon the full development of their sexual powers.
 +
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III. — The well-known sympalhy between Ihe erectile portions of the generative tract and other erectile structures of the body.
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There is uo reason why the sexual excitement that leads to congestion and erection of these organs, as for example in the case of the nipple, may not, under similar circumstances, cause engorgement of the nasal erectile spaces.
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IV. — The occasional dependence of phenomena referable to the nose during sexual excitement (such as, for example, nose bleed, stoppage of the nostrils, sneezing and other reflex acts), either from the operation of a physiological process, the erethism produced by amorous contact with the opposite sex or during the consummation of the copulative act.
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 +
The nasal symptoms most commonly found associated with sexual excitement are sternutation, occlusion of the nasal passages (from erection of the corpora cavernosa), and epistaxis.
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Sneezing is sufficiently common, particularly during coitus. Quite a number of such cases have come under my personal observation in persons in robust health and whose nasal organs were apparently free from disease. The reflex may occur before (from erotic thoughts), during, or after the consummation of the act. Many like cases have been since reported to me. Thus one physician of large practice, who became interested in the subject, found twelve cases among his clientele. It may be interesting to know that this form of sexual consensus, or sympathy, has been recognized for centuries. Thus in the sixteenth century, Amatus LusitanusJ reports a case of sneezing from the sight of a pretty girl ; Bonet§ and Thomas Bartholini,|| and later, Stalpart Vanderwiel,T| relate cases of sneezing during coitus. In the last century Schurig,**
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 +
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0p. omn. EJ. Ktilin. Lipsiae, 1827, toui. ii, p. 174. De
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morbis lib. i, and Aph. sect. 5, art. 33.
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t De medicina. Rotterodami, 1750, lib. ii, cap. S.
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j:Curationum medicinalium cent, iv, cur. 4, Venet. 1557. See also Rahn. Exercit. phys.de causisphyeicis mirae illiustum in homine, turn inter homines, turn denique inter cetera naturae corpora sympathia, xvii, Turici 1788.
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§Sepulchretuni. L. I, s. xx.
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II Historiarum anatomic, et meilic. rariorum, cent, v et vi, ed. Hafniae, 1761, v, p. 184.
 +
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H Gynaecologia historico-medica, etc. Dresden and Leipsic, 1730, p. 429.
 +
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Observations rares de medecine etc. (quoted by Deschamps,
 +
Traite des maladies des fosses nasales et leur sinus. Paris, 1804, p. 88.)
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14
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 82.
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following Bartholini, and at the commencement of the present, Gruner,* give sneezing as one of the sigus of pregnancy. Grunert states that the nose becomes warm and red in the hysterical, in women at the menstrnal period and in the victims of onanism.
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Isolated cases of sneezing at the menstrual period arefonnd scattered here and there in older medical literature. Thus GarmauusJ and Lauzonus§ report cases of this kind, Delius|| a case of sneezing following the suppression of the menses, while Petzoldlf relates one in which sneezing occurred every day during the whole of pregnancy. Paullini** records a case in which the menses were brought on by sternutatories, and quotes Fabricius Hildanus as having noted copious menstruation follow violent and immoderate sneezing.
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Sudden and complete occlusion of both nostrils sometimes occurs with regularity during coitus. This phenomenon, which may be accomjjanied by so-called "reflex" phenomena, such as, for example, asthmatic attacks, is doubtless due to sudden dilatation of the erectile bodies from paralysis of their vaso-motor nerves; for as Anjelft has shown, during coitus the nervous shock is distributed to the whole vaso-motor system of nerves and is not confined to the erection center.
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Cases have also been reported in which the act of coitus was accompanied by hemorrhage from the nose (Isch-Wall, Joal).
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V. — The reciprocal relationship between the genital organs and the nasal apparatus is furthermore illustrated by the occasional dependence of genito-urinary irritation upon affec
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Physiologische u. pathologische Zeichenlehre, etc. Jena, ISOl,
 +
p. 122.
 +
 +
tibid., p. 327. Several of the older writers refer to a case of " pituitous and serous catarrh " from coitus, reported by Georg Wolfgang Wedel (see Schurig, Spermatologia historico-medica etc., Francofurti ad Moenum., 1720, p. 280), but I have been unable to obtain the original account of the case. John Jacob Wepfer, Observationes medico- practicae de affectibus capitis internis et externis, Schaphusii, 1728, obs. Ivii (see my essay. The Pathological Nasal Reflex, an Historical Study. Transactions of the American Laryngological Association, 1887 ; also N. Y. Medical Journal, August 20th, 1887), mentions a case of hemicrania, tinnitus aurium and vertigo associated with uterine trouble, sneezing and a nasal discharge, but few particulars are given.
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It is interesting in this connection to recall the admonition of Celsus to abstain from warmth and women at the commencement of an ordinary catarrh. (Op. cit., lib. iv, cap. 2, § 4, " ubi aliquid ejusmodi sentimus, protinus abstinere a sole, a balneo, a venere deberaus.") Hippocrates, on the otlier hand, relates the following case : " Timochari liieme distillatione in nares praecipue vexato, post veneris usum cuncta ressicata sunt, lassitudo, calor et capitis gravitas successit, sudor ex capite multus manabat." Op. cit., De morbis vulgaribus, lib. v (torn, iii, p. 574). The expression " bride's cold " would seem to indicate on the part of the laity the suspicion of a causal connection between repeated sexual excitement and coryza.
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t Ephemerid. nat. cur. Dec. ii, An. viii, obs. 152.
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§Ibid., Dec. iii. An. ii, obs. 32.
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II Act. nat. cur., vol. viii, obs. 108.
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TEphem. nat. cur. Dec. iii, An. v, vi, obs. 183. See also Rahn, op. cit., p. 34.
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0p. cit., cent, iv, cap. xlviii.
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tt Archiv fur Psych., Bd. viii, Heft 2.
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tioiis of the nasal passages. Ketarded sexual developmeut, too, may possibly depend upon the co-existence of nasal defect* Unfortunately there are no authentic cases in literature in support of this latter hypothesis, but in this connection I would like to call attention to the remarkable case reported by Heschel (Wiener Zeitschrift fiir pract. Heilkunde, Miirz 23, 1861), in which imperfectly developed genital organs were associated with absence of both olfactory lobes. The man was well developed, with the exception of the testes, which were the size of beans and contained no seminal canals, and the larynx, which was of feminine dimensions. All trace of olfactory nerves was absent, as were also the trigona olfactoria and the furrow on the under surface of the anterior lobes. There was scant perforation of the cribriform plate which transmitted the nerveless processes of the dura mater. There was also an absence of nerves in the nasal mucosa.
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VI. — It is, finally, quite possible that irritation and congestion of the nasal mucous membrane precede, or are the excitants of, the olfactory imjiression that forms the connecting link between the sense of smell and erethism of the reproductive organs exhibited in the lower animals and in those individuals whose amorous propensities are aroused by certain odors that emanate from the person of the opposite sex.
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Through all the centuries the season of flowers — the springtime — has been celebrated in amatory song and story as the season of love and of sexual delight. This conceit, handed down to us from the poets of antiquity, finds modern expression in the glorious verse of Tennyson:
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" In the Spring a fuller crimson comes upon the robin's breast ; In the Spring the wanton lapwing gets himself another crest ; In the Spring a livelier iris changes on theburnish'd dove ; In the Spring a young man's fancy lightly turns to thoughts of love."
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Woman, in all the ages, from the perfumed courtesan of ancient Babylon to her reflected image in the harem of the Sultan to-day, has appealed to the olfactory sense to bring man xrnder her sexual dominion and to fire his passionate desire.
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In the Song of Solomon, in the Aries amoris of the older writers, in the fetich worship of odor, in the picture of Eichelieu surrounded by an atmosphere of dense perfume in order to stimulate his amorous feeling, is reflected the idea of the m possible power of olfactory perception in awakening sexual I thoughts. If you doubt that modern man has not forsakeh this idea, read Zola,t Lombroso, Tolstoi, Nordau.
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Rousseau has aptly termed olfaction the sense of the imagi- nation, and if we reflect how intimately related it is to the I impressions we form of external objects, how it affects our emotions and influences our judgment, the clever definition of the French philosopher becomes all the more striking and felicitous. J
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See Elsberg, Archives of Laryngology, Oct., 1883.
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f See especially a work by Leopold Bernard, Les odeurs dans lea romans de Zola. Montpellier, 1889.
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tOf great interest is the influence which civilization exerts upon the development and impressibility of the olfactory sense. With
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January, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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15
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While it is iindonbtedly true that olfactory impression iu man, under natural conditions, plays a subordinate part in the excitation of sexual feeling, while it may be also true that such intensification or perversion of the odor sense may indicate an abnormal condition and a reversion to the purely animal type, still the fact is incontestable that many persons are attracted sexually to each other through the sense of smell. Both history and fiction are full of such examples.
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In connection with this part of the subject it is interesting to note the extraordinary degree of nervous sympathy that may be developed through the sense of smell. Millingen,* for example, relates the case of a pensioner iu the Hospital for the Blind in Paris, called Les quinze Vingt, who by the touch of a woman's hands and nails and their odor could infallibly assert if she were a virgin. A number of tricks were played on him and wedding rings were put on the fingers of young girls, but he never was at fault.
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As in the lower animals it is possible or even probable that the alternate inflation and collapse of the erectile bodies is, to some extent at least, the means by which the grateful or ungrateful odorous particles are excluded from, or admitted to contact with, the apparatus of special sense, so in men in whom this sense is sexually excited or perverted, either normally, or from defect in the subjects themselves, the reception or rejection of the sensuous odors may be accomplished by a similar mechanism.
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These facts point conclusively to an intimate physiological association between the nasal and reproductive apjjaratus, which may be partially explicable on the theory of reflex or correlated action, partially by the bond of sympathy which exists between the various erectile structures of the body. That a relationship exists by virtue of which irritation of the one reacts upon the circulation and possibly nutrition of the other, is accordingly rendered highly probable by the evidence of clinical observation.
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If this excitation be carried beyond its physiological limits there comes a time sooner or later when that which is a normal process becomes translated into a pathological state, according to a well-known law of the economy. Hence it is
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out enumerating, much less elaborating, the myriad conditiona that conspire to produce such a result, we may safely lay down the general proposition that the physical and moral forces of civilization — the social and intellectual environment of the subject — exert a marked effect upon the olfactory faculty by inviting or encouraging disturbance of the sentient and perceptive apparatus ; that the higher we ascend in the social scale, the more readily our judgments are unnaturally influenced or perverted by impressions derived through tlie sense of smell, and that the more we recede from the inferior orders, the less perfect and acute this faculty becomes, the more susceptible to irritation and the more predisposed to disease. In view, therefore, of the importance of olfaction as an avenue through which our mental impressibility is influenced — our imagination perverted — and in view of the relations of civilization to the sense of smell, we can readily understand why it is that this faculty is found more frequently deranged among the superior orders than in those lower down in the social scale and in the savage state.
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•Millingen. The Passions, or Mind and Matter, etc. London, 1848, p. lOli.
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a priori conceivable and eminently probable, not only that stimulation of the generative organs, when carried to excess, may become an etiological factor in the production of congestion and transient inflammation of the nasal passages, and especially of their cavernous tissue, but that repeated and prolonged abuse of the function of these organs may, by constant irritative influence on the turbinated tissue, become the starting point of chronic changes iu that structure.
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Pathological.
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The following data, derived from personal clinical observation, may possibly throw some light upon the subject.
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I. — In a fair proportion of women suffering from nasal affections, the disease is greatly aggravated during the menstrual epoch or when under the influence of sexual excitement.
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II. — Cases are also met with in which congestion or inflammatory conditions of the nasal passages make their ajipearance only at the menstrual period, or, at least, are only sufficiently annoying at that time to call for medical attention.
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III. — Occasionally the discharge from a nasal catarrh will become offensive at the menstrual epoch, losing its disagreeable odor during the decline of the ovarian disturbance. In many cases of ozoena, the fetor is much more pronounced at times corresponding to those of the menstrual flow.
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IV. — Excessive indulgence invenery sometimes seems to have a tendency to initiate inflammation of the nasal mucous membrane, or to aggravate existing disease of that structure. There are those, for example, who suffer from coryza after a night's indulgence in venereal excesses, and the common catarrhal affections of the nose are undoubtedly exaggerated by repeated and unnatural coition.
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V. — The same is true in regard to the habit of masturbation. The victims of this vice in its later stages are constantly subject to nose-bleed, watery or mucous discharge from the nostrils, and perversion of the olfactory sense.
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VI. — The co-existence of uterine or ovarian disease exerts sometimes an important influence on the clinical history of nasal disease. This fact has been shown in practice in cases in which the nasal affection has resisted stubbornly all treatment and in which it has only been relieved upon the recognition and appropriate treatment of the disease of the generative apparatus.
 +
 +
The recent researches of Fliess seem to indicate that the converse of this proposition is true.
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The most commonly found conditions of the nasal apparatus following perverted sexual excitement, either from excessive venery or onanism, are: (1) coryza (generally of vaso-motor type), with or without reflex manifestations, such as asthma, paroxysmal sneezing, etc., (2) epistaxis, and (3) various forms of perversion of the sense of smell. In addition to these, Peyer has observed abnormal dryness of the nasal and pharyngeal mucous membrane, indicated by a feeling of dryness and burning in these regions and by complete cessation of secretion.
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The coryza that follows intemperate venery resembles iu character that seen in the disease falsely called "hay fever,"
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16
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 82.
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and, like it, is generally associated with more or less prouounced neurasthenia, or shall we say, localized hysteria. In other cases the nervous system is not apparently involved. The predominant temperament, however, in individuals thus affected is the neurotic. While they may not necessarily in some instances belong to the so-called "nervous " or "hysterical " individual, while they may give no outward and visible sign of a deranged nervous system, there will generally be found, on careful examination, a delicacy or sensitiveness of the nervous apparatus either in whole or in part.
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It is conceivable that this sexual coryza may be associated with almost any of the so-called reflex neuroses. In one of my cases asthma was the central symptom. A young married woman, twenty-three years old, in otherwise apparently perfect health, consulted me for the relief of attacks of asthmatic breathing associated with stoppage of the nostrils. I could find nothing wrong at the time of consultation with the respiratory apparatus, and her other organs were in perfect condition. Keluctantly she confessed that every night for five years she and her husband had indulged in intemperate venery. Moderation in their sexual relations caused rapid disappearance of the symptoms, and in the nine years that have elapsed since she consulted me there has been no return of the disorder.
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Interesting cases of asthma of nasal origin associated with, and due to sexual excitement have also been reported by Joal and Peyer. In this connection I would recall a case of periodic vaso-motor coryza reported by me at length elsewhere,* in which the attacks invariably appeared and were most severe at the menstrual period, appearing sometimes at its commencement, sometimes at its close. In the attacks coming on in the interval between the monthly periods pain was always felt in the left ovary. Residence at the seashore invariably gave relief, except during menstruation, when the attacks were as bad as when at home. The outbreak of the disease at the menstrual epoch in this case is readily explained by the physiological erection of the corpora carveruosa which occurs at that period. In this particular case the chief, and under certain circumstances the sole excitant of the paroxysm was the utero-ovarian excitement of the menstrual epoch.
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Nose-bleed is not infrequently the result of onanism. Years ago Du Saulsayf called attention to the fact that enormous quantities of blood can be lost from the nose from the practice of this vice, and the accuracy of his observation is borne out by the experience of subsequent observers. Among others, Joal| has collected several such cases and reports three of his own. One of his patients informed him that he masturbated to excess to provoke nose-bleed, which relieved him from violent headaches from which he suffered.
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AVhether the hemorrhages in these cases — which by the way are not confined to the male sex§— come from simple acute
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A contribution to the study of coryza vasomotoria periodica, or
 +
so-called " hay fever." N. Y. Med. Rec, July 19, 1884.
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t Comment, de rebus in med. etc., vol. xviii, p. 213. Michell, in Schlegel's "Sylloge selectiorum opusc. de mirabile sympathiae quae partes inter diversas corporis humani intercedit." Lipsiae, 1787. Jl. c.
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§See case of Lemarchand de Trigon (girl of 10), quoted by Joal.
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distension of the intra-nasal blood-vessels, or whether definite chronic structural changes have taken place in the mucous membrane and in the vessel walls, are points which are as yet undetermined. The probability is that some intra-nasal lesion is responsible for them, for, as I have pointed out elsewhere,* the discharge from the nostrils and the perverted olfactory sense found in the later stages of onanism are often simply the outward expression of chronic nasal inflammation.
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The nature of the perversion of the olfactory sense in onanists will vary with the character of the nervous condition produced by the vice — hyperosmia, hyposmia, parosmia andallotriosmia have all been observed in cases of immoderate sexual excitement.
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The investigations of Fliess would seem to indicate that painful, profuse and irregular menstruation may in some instances depend upon an intra-nasal cause. He cites a number of cases to show that the pain of certain forms of dysmenorrhcea may be temporarily dissipated by the application of cocaine to the nasal mucous membrane, or permanently controlled by cauterization. According to him, only the inferior turbinated body and the tuberculumsepti possess a special relation to the dysmenorrhoeic pains. These two localities he accordingly designates as xar' i^nyrj-, genital zones (Genitalstellen). If the tuberculum septi be cocainized, the sacral, if the inferior turbinated bodies be cocainized, the hypogastric, pains disappear. Cocainization of the right nostril causes disappearance of the pain on the left side of the body and vice versa.
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In answer to the objection that these phenomena may be due to the general auassthetic action of the drug, he points out the fact that cocaine absorbed into the blood does not produce a general analgesic effect, as is produced in the case, for example, of morphia. On the contrary, in small doses it acts as a stimulant. The fact that the pain ceases 07ily when the genital zones are cocainized and that it may be permanently dissipated by cauterization of this area, does away, he thinks, with the assumption that the subsidence of the pains is a part of the euphoria produced by the drug. The fact alluded to above, that in cocainization of certain parts of the genital zones only individual pains disappear from the symptom complex, militates against the supposition of a simple, general narcotic effect.
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I cannot vouch for or deny the accuracy of the above statements, as Fliess's monograph has just come into my possession and I have had neither time nor opportunity to put them to the test. Curiously enough, the genital zones of Fliess correspond exactly with the most sensitive portions of the sensitive reflex area mapped out by me in ISSS.f
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•1. c.
 +
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tOn Nasal Cough and the Existence of a Sensitive Eetlex Area in the Nose. American Journal of the iMedical Sciences, July, 1883. The results of these experiments were first brought before the Baltimore Medical Association in the early part of 1SS3, and subsequently before the Medico-Chirurgical Faculty of Maryland (April, 1883, vide Transactions), and the American Laryiigological Association (May, 1883, vide Transactions). The conclusions reached from these investigations were as follows :
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"(1) That in the nose there exists a definite, well-defined seusi
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January, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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17
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I have ou innumerable occasions* shown that phenomena widely different in character and anatomical sphere of opera
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tive area, whose stimulation, either through a local pathological process, or through the action of an irritant introduced from without, is capable of producing an excitation which finds its expression in a reflex act or in a series of reflected phenomena.
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(2) That this sensitive area corresponds in all probability with that portion of the nasal mucous membrane which covers the turbinated corpora cavernosa.
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(3) That reflex cough is produced only by stimulation of this area, and is only exceptionally evoked when the irritant is applied to other portions of the nasal mucous membrane.
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(4) That all the parts of this area are not equally capable of generating the reflex act, the most sensitive spot being probably represented by that portion of the membrane which clothes the posterior extremity of the inferior turbinated body and that of the septum immediately opposite.
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(5) That the tendency to reflex action varies in different individuals, and is probably dependent upon the varying degree of excitability of the erectile tissue. In some the slightest touch is sufiicient to excite it ; in others, chronic hypersemia or hypertrophy of the cavernous bodies seems to evoke it by constant irritation of the reflex centers, as occurs in similar conditions of other erectile organs, as for example the clitoris.
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(6) That this exaggerated or disordered functional activity of the area may possibly throw some light on the physiological destiny of the erectile bodies. Among other properties which they possess, may they not act as sentinels to guard the lower air passages and pharynx against the entrance of foreign bodies, noxious exhalations and other injurious agents to which they might otherwise be exposed ?
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Apart from their physiological interest, the practical importance of the above facts from a diagnostic and therapeutic point of view is sufiiciently obvious. Therein lies the explanation of many obscure cases of cough which heretofore have received no satisfactory solution, and their recognition is the key to their successful treatment."
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In calling attention to this area as containing the spots most sensitive to reflex-producing impressions, I did not, nor do I now (as lias been wrongly inferred), desire to maintain that pathological reflexes may not originate from other portions of the nasal mucous membrane. Indeed, wherever there is a terminal nervous filament it may be possible to provoke sneezing, lachrymation and other reflex movements. My contention is simply this, that the area indicated in my original paper represents by far the most sensitive portion of the nasal cavities, and that pathological reflex phenomena are in the large majority of cases related to diseased conditions of some portion of this sensitive area. That all pathological nasal reflexes arise from irritation of this particular area is a proposition which I do not, and never have maintained. The determination of these sensitive areas is of special importance and interest in the solution of the pathology of the so-called nasal reflex neuroses. Whether a special sensitiveness in certain portions of the nasal mucous membrane exists or not, the agitation of the question has led to more rational methods of procedure in the treatment of a large class of nasal affections, and to more conservative methods in intranasal surgery. Before the location of the sensitive area or areas, the nasal tissues were destroyed with an almost ruthless recklessness that bade fair to bring intra nasal surgery into the worst repute. (For an elaborate discussion of this whole subject see article by the author in Wood's Reference Handbook of the Medical Sciences, edited by Buck, Wm. Wood & Co., N. Y., 1887, vol. V, pp. 222-242.)
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My views upon this subject may be found in the following
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publications: A contribution to the study of coryza vasomotoria
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tiou may be produced at will by artificial stimulation of this area, and that they may be dissipated by local applications to, or removal of, the membrane covering the diseased surface. It is therefore not difficult to conceive that the phenomena referable to the uterus and ovaries during menstruation may be influenced in a similar manner. The specific relations of the two zones and the crossed action of the reflex, if such it be, are much more difficult of explanation. If such a condition of affairs exists, it is certainly a remarkable phenomenon.
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These observations, therefore, encourage the belief, if they do not establish the fact, that the natural stimulation of the reproductive apparatus, as in coitus, menstruation, etc., when carried beyond its normal physiological limits, or pathological states of the sexual apparatus, as in certain diseased conditions, or as the result of their over-stimulation from venereal excess, masturbation, etc., are often the predisposing, and occasionally the exciting causes of nasal congestion and inflammation and perversion of the sense of olfaction. Whether this occur through reflex action, pure and simple, or as a sequel of an excitation in which several oi' all of the erectile structures of the body participate, the starting point of the nasal disease is, in all probability, the repeated stimulation and congestion of the turbinated erectile tissue of the uose. It is highly probable that this erectile area, or organ, so sensitive to reflexproducing impressions, is the correlative of certain vascular areas in the reproductive tract, and that the phenomena observed may therefore be explained by the doctrine of what we may call, for want of a better name, reflex, correlated action.
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In these remarks I have attempted no thoroughgoing exposition of the subject, but simply laid before you the results of my personal labors. These no longer represent, I am glad to say, the result of solitary observation and isolated experience. I have not attempted, as Fliess has done, to touch upon the biological side of the question.
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The study of the relations between the nose and the sexual apparatus opens up a new field of research, of pleasing landscape and almost boundless horizon, which bids to its exploration not only the physiologist and pathologist, but also the biologist. Above all it brings us face to face with a serious problem of life, an interesting enigma, whose significance it will be the task of the future to divine.
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periodica, or so-called " hay fever," N. Y. Med. Record, July 19, 1884. Coryza vaso-motoria periodica in the negro, with remarks on the etiology of the disease, N. Y. Med. Record, Oct. 18, 1884. Rhinitis sympathetica, essay read before Clin. Soc. of Md. ; see brief abstract in Md. Med. Journal, April 11th, 1885, and in Internationales Centralblatt f. Laryngologie, etc., Sept., 188.5. Observations on the origin and cure of coryza vaso-motoria periodica. Trans. Medico-Chir. Faculty of Maryland, 1885. Review of Morell Mackenzie's essay on hay fever, etc.. The American Journal of the Med. Sciences, Oct., 1885, pp. 511-528. See also discussion of the subject before the American Laryngological Association (May 14th, 1884, vide Transactions, p. 113 et seq.). See also cases of reflex cough due to nasal polypi, Trans, of the Medico-Chirurgical Faculty of Md., 1884, and articles in Wood's Handbook already referred to
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18
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 83.
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PROCEEDINGS OF SOCIETIES
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THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.
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Meeting of October 18, 1897.
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On the Hiematozoan Infection of Birds.— Dr. W. G. MacCallum.
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(See Bulletin, Vol. VIII, p. 235.)
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Discussion.
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Dr. Welch. — Everybody familiar with the literature of the subject knows that this communicatiou is of the very first importance, not only of interest with reference to this particular organism, but of general biological interest. It clears up one of the most obscure questions in the biology of the malarial parasites. I have had the opportunity of seeing Dr. MacCallum's demonstration of the phenomena which he has described in the blood of the crow. I should like to ask Dr. MacCallum if he has any evidence that in the regular sporulating cycle of development any differences can be observed between male and female organisms.
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Dr. Thayer. — Dr. MacCallum's communication is most refreshing. For nearly 20 years the question of the nature of the flagellate bodies has been one of the most keenly studied points in connection with the malarial parasite, and that this important discovery should have come from our laboratory is an honor to the institution.
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Owing to my absence from America I have not seen the whole process as it takes place in birds, but a part of the process I have been able to follow out in man. The specimen was that which Dr. MacCallum has described, and the body which I observed was one which had just been penetrated by a free flagellum. This body was a large round form of the aistivo-autumnal parasite without evidence of any surrounding corpuscle. It contained a central ring of pigment. About this body there were two flagella which, though actively motile, did not disturb or agitate the round body. On careful observation, however, it was easy to observe that the flagella were quite free from the organism. These flagella which were very active would draw away from the parasite and then attack it, butting their heads against its periphery, struggling around it, and apparently making every effort to jjenetrate into the interior. Now this parasite represented a form which we have been looking at quietly off and on for these last seven years, considering it to be a flagellate body which for some reason or other was not agitated by the surrounding filaments, as is ordinarily the case. And yet after being taught by Dr. MacCallum to observe the picture before us, how perfectly simple it was to realize that the organism was not really possessed of motile filaments, but was a separate body attacked by free flagella.
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These observations are, as I said, most refreshing and encouraging, and may well lead us to hope for more. It is particularly satisfactory to realize that Dr. MacCallum's discovery was not accidental, but was the result of intelligent and well-directed observations. It bids fair to be the most important contribution to our knowledge of the malarial parasite since the discovery by Golgi in 1885 of the ordinary cycle of development.
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Dr. Barker. — The observations reported by Dr. MacCallum are of interest not only as settling the fact that fertilization occurs in connection with the life-history of the malarial parasites, but they also give ns some information concerning the exact nature of the fertilizing process in its different stages. The processes of fertilization in the protozoa have been studied by many observers, and one naturally inquires in how far does the phenomenon as observed in the malarial parasite agree with the findings heretofore recorded concerning protozoan organisms in general. All zoologists believe that the important material substances underlying the process of fertilization are situated in the nuclei of the cells concerned. It would seem very likely then that the flagella of the malarial parasite contain nuclear substances, a view which is quite in accord with the ideas of Sacharov.
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If the flagella do contain nuclear substances we have beautifully exemplified in the process of fertilization in the malarial parasite the well-known phenomenon of reduction-division. In the fertilization of all animals and plants, as far as the process has been studied exactly, reduction-division of some sort appears to be constant. Dr. MacCallum has shown that one only of the flagella of the aggressive organism enters the passive parasite. It will be of very considerable interest to find out whether or not any analogous process of reduction of nuclear substances occurs in the parasite into which the flagellum goes. In most instances in other organisms the reduction-division in the female element occurs before the entrance of the spermatozoon. In a few instances it is stated that the directive corpuscles are extruded after fertilization. Dr. MacCallum tells me that thus far he has been unable to make out any bodies resembling directive corpuscles thrown off from the passive parasite.
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Dr. MacCallum. — I can hardly answer Dr. Welch's question because in the particular form which I examined, segmentation takes place only in the bone marrow, I believe. I recorded the temperature of an infected crow every three hours day and night for three weeks and found a rise in temperature of three to five degrees daily. There is, however, a similar daily rise in temperature in the normal crow. There seemed to be a higher rise about every fifth day in the infected crow, but I could not determine this definitely. The temperature of the crow is from 103° to 109°.
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The Presence in the Blood of Free Grannies derived from Leucocytes, and their Possible Relations to Immunity.— Dr.
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W. R. Stokes and Dr. A. Wegefaeth. (See Vol. VIII, p. 246.)
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Discussion. Dr. Welch. — This has been a very painstaking research. Dr. Stokes' view that free granules in the blood are identical with or derived from the specific granules in the leucocytes is very suggestive, and he brings valuable, although not wholly conclusive, evidence in its support. Especially significant is his observation that free granules exist in the horse's blood apparently identical with the unusually large and characteristic granules in the eosinophiles of this animal. Dr. Stokes,
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January, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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19
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it will be observed, does not identify with the granules which he has studied the blood-plates, concerning whose structure and origin there is still much difference of oj^iniou.
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As to whether the bactericidal properties of blood are in fact derived from the free granules cannot be said to be demonstrated beyond all doubt. It is well known that tiltratiou through porcelain not only filters out particulate matter, such as these granules, but likewise affects the composition of the fluid. Still the theory of immunity proposed by Dr. Stokes is supported by other observations, such as those of Kanthack and Hardy, and is a legitimate one to use as a working hypothesis.
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Dr. Barker. — When Dr. Stokes replies I should like him to state whether or not he has observed the granules in rows outside of the leucocytes. Many histologists believe that the granules in the leucocytes are really the cytomicrosomes embedded in the cytolinin threads of the cytoplasm.
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Dr. Stokes. — In answer I would say that you can stain the free eosinophilic granules both by eosin and the triple blood stain in horse's and frog's blood. We have found numerous large granules in the horse's blood, but have not been very successful in staining the free granules of either variety in human blood. I have not seen the granules in rows.
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I simply used the term neutrophilic to designate a leucocyte containing fine granules and having a polymorphous nucleus.
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NOTES ON NEW BOOKS.
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An Epitome of the History of Medicine. By Koswkll Park, M. D.
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(Philadelphia : F. A. Davis Co., 1896.)
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As Dr. Park in his introduction states, "the following pages represent an effort to bring the most important facts and events comprised within such a history into the compass of a medical curriculum, and at the same time to rehearse them in such a manner that the book may be useful and acceptable to the interested layman,— J. e. to popularize the subject." The work represents a series of lectures delivered to the medical students at Buffalo, and is interesting and thoughtful, as are all the writings of this author. There is no satisfactory history of medicine in the English language — perhaps there is none in any language — for the difficulties in writing it are very great. In this epitome Dr. Park has succeeded in presenting his subject in as attractive a way as possible, we think, and we have found it agreeable reading, although frequently, from the very necessity of the case, it is too encyclopedic in form to be altogether easy reading. To cover the entire history of medicine in 350 octavo pages and make it readable at all is a task in itself, but Dr. Park has done more than this. He has not only given us a history of medicine, but has shown us its connections with the other arts, and the influences brought to bear upon it through all time. And in addition he has set the example to other medical schools of giving a course in medical history, which, spite of the many branches of medicine that have to be studied, should certainly not be left by the leading medical schools entirely out of their curriculum. The only unsatisfactory part about the book is its index, which should be more complete.
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It is perhaps in just such an epitome of history that one can grasp the whole subject better than in a larger history ; in a certain sense it brings the different periods in the development of medicine into closer union, and one is able to judge more readily of the advances made in medicine since our earliest knowledge of it. There are many points of similarity between the conditions of medical prac
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tice to-day and those of the middle ages and later — we are no more free of false schools now than then — even to-day when the hold of pure science on the minds of men is greater than ever before, we find schools of homeopathy, osteopathy, bone-setters, faith-curists and Christian-scientists. Then again we have no doubt that when the history of medicine of the present era is written several hundred years hence, it will be shown that we shall have missed making discoveries, to which we are as close, as those discoveries made by us, which the practitioners of the 16th, 17th and 18th centuries almost made— they helped us to them. In fact most of our discoveries are not due to greater intellectual discernment, but to added tools of trade, which make the study of medicine easier for us every day, and at the same time tend to make most of us superficial thinkers — we rely on our instruments and not on our brains. It may fairly be argued whether we have any as great men-thinkers as existed during the middle ages. The breadth of knowledge attained by the leading men of those times is something very remarkable. True, there was not so much to know, not so many book* to read, but nevertheless the great men were better informed for their times than those of today. Their very breadth of knowledge may have made them less able practitioners than are the physicians of to-day ; it is certain that great knowledge in many branches of science often leads to a questioning spirit of mind, to one of less positiveness and directness, and thus to less readiness to act. We have advanced far in medicine during the past ICO years, but with all our new tools is the advance so great after all when in addition we take into consideration the enormous increase in workers? It is certainly an interesting comment that in the past 2500 years only two specifics for diseases have been found, quinine and mercury, and the latter is not so sure a specific as the former. Let us hope for better times to come in therapeutics.
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Unscientific as Rademacher's doctrine was of three primary diseases with three universal medicaments, in its development it came closer than appears at first sight to a doctrine of the present day. He and his followers believed that besides universal diseases there were diseases of organs to be diagnosed by the efficacy of organ remedies, "thus abdominal diseases must be relieved by corresponding abdominal remedies," head diseases with "head remedies," etc. Are we not to-day doing just this with such remedies as cerebrine, ovarine, thyroidine, pancreatine, pepsin and many others, and, what is more, do we not believe to a greater or less extent in their efiicacy, and are we not justified in our belief? Is it quite fair when Dr. Park says : "What is the most surprising about this absurd doctrine is that it found followers, some even quite capable in their way." Rademacher may have been a "quack," so to speak, but oftentimes the difference between the " quack " and the " regular practitioner " is rather in words than in deeds.
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Have we any much better definition of hysteria than that of Thomas Willis (l(i22-1675), who accounted for this condition "by the union of the spiritus with imperfectly purified blood "; a most accurate definition of the cause in many cases of hysteria.
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We cannot go further on this line. We merely wish to show how nearly connected we are with the past in many respects, and . how interesting it is to follow the steps which have led us on so far ; there are few broken links in the chain of gradual growth in medicine, although its development has been hindered at all times by various false doctrines.
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Before we close this review there are still one or two points to which we would like to draw attention. The easiest way, we think, to make such an epitome interesting is to connect as many stories or discoveries with the names of the men introduced. Dr. Park has given us many, but there are others we miss which would add to the value and attractiveness of the volume without increasing its length materially. Although Scarpa, Pott, and Bigelow are mentioned, there is no mention of the triangle, disease of the spine, and y-ligament so closely associated with these names. The
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20
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 82.
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discovery of the y-ligament is one which has quite revolutionized the treatment of dislocations of the hip and shouKl certainly not be omitted. Other omissions of a like character might be spoken of, but these are enough to mark our point. One of the most striking stories in medicine, itseemstous, is theone connected with Boerhaave's name, of which we find no mention in Dr. Park's work. When he died he left behind him an elegant volume, the title-page of which declared that it contained all the secrets of medicine. On opening the volume every page except one was blank. On that one was written : " Keep the head cool, the feet warm, and the bowels open." We miss also the amusing verse connected with I. Lettsom's name (there are a number of variations of this stanza) :
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" When patients come to me I physics, bleeds, and sweats 'em. If after that they choose to die, Why then of course
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I. Lettsom."
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We are surprised, too, at the slighting mention of Sir Thomas Browne, who is one of the very few literary lights in medicine. His work, the " Religio Medici," should be read by every student of medicine, and is a book which will always live ; there is none other like it ; it is a classic. Surely, too, the student of medicine should know that Thomas Dover (Dover's powder) was a buccaneer, and the discoverer of Alexander Selkirk, the original of Robinson Crusoe. There is a delightful paper by Dr. Osier on Thomas Dover. And, finally, the name of James Cesdaile, M. D., should not be entirely omitted. He wrote two works, one entitled " Mesmerism in India," 1850, and the other, "Clairvoyance and Practical Mesmerism," 1852. He peiformed a large number of major operations in India on patients under the influence of mesmerism or hypnotism, and had it not been for the discoveries of ether and chloroform just at this time, his work, which was admirable, would have obtained greater reputation than it has. He was an able surgeon and used mesmerism merely as a means of doing away with pain. He was not a believer in mesmerism in any false sense ; he used it purely from a humanitarian point of view, and more extensively than any one who preceded him, and with very brilliant results.
 +
 +
In final conclusion we wish only to congratulate Dr. Park on this last work of his, which deserves much praise.
 +
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Practice of Medicine. By James M. Anders, M. D. {Philadelphia :
 +
 +
W. B. Saunders, 1898.)
 +
 +
Witliin the past eigliteeu months three books on the practice of medicine have appeared written by Philadelphia physicians ; first came Dr. Tyson's, then the combination work of Drs. Wood and Fitz, and finally this one by Dr. Anders. In addition to these volumes from Philadelphia, a number of systems of medicine have appeared, so that there is at present no lack of text-books on medicine. These are the days of cheap printing and of superabundant writing. Tliere have been many advances in the past ten years in diagnosis and treatment of diseases, but we do not think there is any call for this multiplicity of books on practice ; and we hope that there will soon be a reaction against the production and publication of works all treating the same subject.
 +
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This last book compares favorably with its predecessors; it is about the same size as Dr. Tyson's, but larger than that of Drs. Wood and Fitz. Every author necessarily has views of his own on diagnosis, prognosis, treatment, etc., but these may not be either truly novel or suggestive. Much space in this work — too much, we think— is given to treatment ; and with it all we have found important matters left out, and treatment suggested that we do not believe to be good. For instance, in typhoid fever Dr. Anders seems to be a strong advocate of rectal feeding and rectal irrigation, in spite of the fact that, as he states, ulcerations in the large intestine are found in nearly 33 per cent, of all cases; the dangers of perforating
 +
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an ulcer with a rectal tube are not slight, and we believe such treatment should only be resorted to in the very gravest cases. We find no mention of the use to which the Roentgen rays may be applied in the diagnosis of obscure thoracic cases ; the value of these rays has been ably demonstrated by Dr. Francis H. Williams, of Boston, and others. And again the author does not speak of the use of antistreptococcus treatment in ulcerative endocarditis. The value of this last method of procedure may be questioned, but it deserves to be noted, and has already proved eflScacious in certain cases. Nothing is said also of the palliative treatment by hypodermoclysis in diabetic coma. This brings up one of those subjects of perennial interest to all practitioners, and one which was much discussed at the late meeting of the British Medical Association in Montreal, that is, the treatment of diabetes mellitus. Anders' treatment is practically that advised by the men who took part in the discussion, to cut off all starches at first, and then to admit them little by little to the dietary as the patients prove that they can digest them without harm, or prove as in some cases to be doing worse without them. We are glad to note that he advocates the free use of fats, which oftentimes are readily digested in large quantity, while the patient gains in strength and weight.
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Another subject which was much discussed at Montreal was that of arthritis deformans ; and here Dr. Anders differs from the general consensus of opinion as expressed at that meeting. He believes in the neuro-trophic theory as a cause of this disease, which it seems to us is a theory which does not stand a very thorough examination. As Dr. James Stewart, of Montreal, said in closing his paper on this subject, " the result of recent investigations points very strongly to its infectious nature." He also very strongly advocated the Tallerman method of treatment, i. e. baths of superheated dry air. This means is not spoken of by Dr. Anders.
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In the chapter on malaria there are several confusing statements ; speaking of the evolution of the aestivo-autumnal parasite the author saj'S, p. 83 : " For the differences in the period of evolution there is no satisfactory explanation, though the variation may be connected with the circumstance that it frequently (though by accident) penetrates into the red blood corpuscle." We do not understand what the author means by this. Again on p. 91, in speaking of malarial hsematuria, he states : " The blood shows non-pigmented parasites (forming rosettes)"; the rosette-shaped figures are always pigmented, and we do not comprehend exactly what form of organism he means. On p. 93 we regret to note the term typho-malaria, — the author says " remittent fever must not be confounded with typho-malaria "; it is the use of this word which has already led to so much distracting confusion between typhoid fever and malaria, and it ought not to be used any longer. There is no mention in the differential diagnosis of malarial and other diseases of syphilis. Every now and then cases of syphilis will develop intermittent chills, almost identical to those seen in malaria. We have lately had under observation a very interesting case of right apical lobar pneumonia ; the patient had contracted syphilis about a year previously for which he had received irregular treatment. On three successive occasions, on alternate days, during the height of the pneumonic fever, at about 4 o'clock in the afternoon there was a rise of from one to two degrees in the temperature, and this wasseenon twooccasions after the temperature was practically normal. The blood was examined on two occasions for malarial parasites, but none were found ; the patient was treated with both quinine and mercury, so that no conclusions can be drawn from the effects of the medicine. It yet remains in doubt as to whether these peculiar rises of temperature were due to syphilis or malaria. We are inclined to attribute them to the former.
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On page 602 it is stated of the diastolic murmur heard in aortic incompetency, that "from the xyphoid it is transmitted to the left as far as the spinal column." We believe there is some slip here.
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January, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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There are many other points we should like to iliscuss in this review, but they would take up too much space. It seems to us that the prognosis of valvular lesions of the heart is too favorable as given by Dr. Anders, and that the relationship between increased tension in the arterial system, arterio-sclerosis following it, and disease of the valves of the heart is not clearly stated.
 +
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There are a few typographical errors, and while most of the illustrations seem to us satisfactory, yet there are some which might quite as well be omitted, for instance those on pp. 467, 472 and 476.
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 +
Notwithstanding all our criticisms the book is a good one, and for the average general practitioner will be of distinct service from its detail of treatment. It is not a great book. We could have got on without it, but we are glad to have it on our shelves. There is little that is new in it, but it is well to have the opinions of any man of large experience. The reliance of the author on Osier's work is marked by numerous references to his practice of medicine.
 +
 +
A Text-Book of Diseases of Women. By Charles B. Penkosk,
 +
 +
M. D., Ph.D. 8vo, 529 pages. {W. B. Saunders, Philadelphia,
 +
 +
1897.)
 +
 +
After a brief introductory chapter, the author treats in detail the methods of examining the uterus and bladder, and in the examination of the rectum lays especial stress on the value of the kneechest posture.
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 +
The illustrations demonstrating Emmit's operation for repair of a lacerated perineum are the best that have yet appeared, but theuse of silk ligatures and shot instead of catgut in the angles is rather antiquated, as there is usually considerable danger of a breaking down of the external portions of the perineum during the removal of the deeply-seated sutures in the angles.
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It is pleasing to see the word of warning against the stem pessary noted on page 119. On page 127 it is said, " in all old cases of retrodisplacement, endometritis is an accompaniment." This is very doubtful. In a number of cases of retroflexion where the uterus was densely adherent posteriorly and where both tubes were the seat of pyosalpinx, we have found a perfectly normal endometrium. On page 137 a very opportune warning is given against the use of pessaries where the uterus is bound down or the appendages are the seat of inflammation.
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The operation for suspension is accurately described, and the author fully agrees with the lines previously laid down by Kelly when he says, " we do not wish to make a fixation of the uterus to the anterior abdominal wall."
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 +
Figure 98, labeled " left lateral laceration of the cervix with erosion," is misleading, resembling much more a typical early carcinoma of the cervix. It is refreshing on page 166 to note: "If the advice here given — to seek for the primary cause of the cervical catarrh and to cure it — is followed, it will be found that there are very few cases that depend for a cure upon local applications."
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The articles on cancer of the uterus are well written, but we cannot agree with the writer when on page 212 he says that cancer of the body is rare in comparison with cancer of the cervix. Figure 118, which is marked Glandular Endometritis, shows an intact surface epithelium, typical glands lined by characteristic epithelium, and a normal stroma between the glands. Although this might according to general usage be called endometritis, there is not the slightest sign of any inflammation.
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On page 205 one is advised to carefully wash out the uterus with a bichloride solution should the organ be perforated by the curette. This is hardly to be recommended, as the fluid would naturally flow out into the abdominal cavity. The author on page 247 claims that myomectomy is a dangerous operation and that it is applicable only when one fibroid is present. The experience of others has shown conclusively that several may be removed with little danger, and Kelly has removed as many as eighteen at one time.
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The chapters on diseases of the tubes are clear and forcible, especially chapter xxvi, on tubal pregnancy.
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 +
Ovarian tumors are well handled, but it is surprising to learn that ovarian fibromata are very rare, as the literature contains reports of numerous cases ; also to learn that the majority of solid tumors of the ovary are sarcomatous in character, in view of the fact that they are sparsely scattered throughout the bibliography.
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Primary carcinoma of the ovary is by no means a rarity. Diseases of the urethra and bladder are brought up to date and due credit is given to Kelly for the work he has done.
 +
 +
The chapters on technique are to the point, but we believed that the glass drainage tube was a thing of the past.
 +
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The majority of operators will fully agree with the author when he says " more discomfort may be experienced after ventrosuspension of the uterus than after a hysterectomy," and with a subsequent remark, "catheterization should never be performed under any circumstances by the aid of the tactile sense alone. The nurse should always see what she is doing."
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Preceding the discussion of each organ, a brief review of its anatomy is given. The illustrations both of the gross and microscopical specimens are well executed and the text concise and clear. The book was written for students and to them it can be recommended as the best we possess. T. S. C.
 +
 +
Crimeand Criminals. By J. Saxdersox CnnisTisoN, M. D. (Chicago:
 +
 +
W. T. Keener Co., 1897.)
 +
 +
It is very seldom that a series of newspaper articles are worth reprinting in book form, and this work is no exception to the rule. It is composed of a series of articles which appeared in the Chicago Tribune under the caption of "Jail Types," and we believe that they were undoubtedly meant to be " popular" articles. They are certainly not in any strict sense " scientific" papers, and are practically of no value to the thorough student of criminology. The histories of the cases as presented are very superficial, and no fair deductions can be made from the majority of them. We think that the book is practically useless, and that the moral tendency of such papers in daily journals is bad.
 +
 +
Transactions of the Chicago Pathological Society, from December, 1895, to April, 1897. Vol. II. [Chicago: American Medical Association Press.)
 +
 +
There are many cases of interest to both physicians and surgeons reported in this volume — too many, one may fairly say. The mere collection of cases or specimens at the present time is of comparatively little value; both must be "worked up" by all the many methods we have at our command. Especially is this true of pathological specimens, which without a most thorough microscopical examination are practically worthless. The value of such volumes of transactions lies wholly in their being books of reference for strange and rare cases. We have no doubt Volume II is an improvement on Volume I, but if the editors of Volume III would use more supervision in the selection of cases to be published next time, the third volume would be an improvement on its predecessors. Fewer cases should be reported, and more in greater detail ; then the volume would become of permanent value.
 +
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Transactions of the Indiana State Medical Society. Forty-sixth Annual Session held in Indianapolis, Ind., June 6th and 7th, 1895. {Indianapolis : Carlon and Uollenbeck.) This is a large volume of over 500 pages, nearly 400 of which are devoted to papers on medical and surgical topics, but there is little of permanent value to be found in this mass of material. A number of interesting cases are reported, but few of them with sufficient detail to make them of real value, and the papers on general topics, such as litha;mia, immunity, hypnotism, alcoholism, etc., present no original ideas. The volume can only be of importance to the members of the society and their immediate friends.
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22
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 82.
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Compatibilities in Prescriptions. By Edsel A. Ruddiman, Ph. M.,
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M. D. {New York : John Wiley & Soiis, 1897.)
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This work is divided into two parts as described by the author in his preface : " The object of the first part of this book is to present to liim [the busy practionist] in a convenient and condensed form the more common incompatibilities .... The second olg'ect of t' e writer is to furnish the student of pharmacy with a list of incompatible prescriptions in such form that he may find out for himself what the trouble is and the best means of avoiding or overcoming it." The book is well arranged, the more ordinary drugs being taken up in alphabetical order, and in fact no fault can be found with it. But it requires very careful study, and is hardly adapted for the general practitioner unless he has a well-grounded knowledge of chemistry. As an exercise book for the student it will undoubtedly prove itself of value. We doubt whether any one but an expert pharmacist or chemist would recognize the errors in a number of the prescriptions given, which only go to show the numberless difficulties to be met with in combining drugs, and the gratitude which the ordinary practitioner should have for the makers of tablet triturates and other compounded drugs, which we believe have eaved many errors in prescription writing, and also many lives. The multiplicity of new chemical compounds has added immensely to the probabilities of making errors in combining two or more drugs in a prescription, and we rejoice that it is becoming less and less the fashion to use more than two or three medicines in combination. It is better to use the active principles alone, if possible.
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Exercises in Practical Physiology. By Augustus D. Waller, M. D., F. R. S. Part III. Physiology of the Nervous System. ElectroPhysiology. (New York: Longmans, Oreen cC Co., 1897.)
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 +
In this volume, which forms the third in a series of exercises and demonstrations in physiology for medical students, the author has dealt with that difficult branch of medicine, the " electrophysiology " of the nervous system. The experiments are only intended foraJvanced students, and seem to us to coverthe ground well. Every instructor would probably modify these exercises, or build up a new series for himself, but any student who has done these experiments should have a good understanding of this subject. The author takes up in order first some of the ililferent kinds of electric cells and their adjuncts, as commutators, galvanoscope, rheostat, etc. ; then follow a number of experiments on the stimulation of the muscle, its fatigue and contractions ; on muscle and nerve currents ; on the secondary currents ; and these experiments in turn are followed by others on reflex time and action. In this manner Dr. Waller covers a broad ground with a comparatively small number of well-chosen exercises.
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Rheumatism and its Treatment by the Use of the Percusso-Punctator. By J. Brindley James. {London : Rebman Publuhiitg Co. Ltd., 1897.)
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 +
The title of this work is both misleading and ambiguous. We opened the book thinking that the author had found a new treatment for acute articular rheumatism, but found ourselves entirely mistaken. The treatment is not new, and by " rheumatism " the author means all those vague pains which are included in such terms as " lumbago," "vertigo," " hemicrania," " brow-ague," etc. The " percusso-punctator " is nothing more nor less than a modified form of acupuncture, and an instrument very like many of the old "wet-cups." The cures which the author professes to have wrought by means of this tool are frequently obtained by other physicians with simpler methods ; we have seen the insertion of a long hat-pin in the lumbar muscles rapidly relieve an attack of lumbago. Another chapter in this superficial work is taken up with the treatment of sciatica by hypodermatic injections of sulphuric ether; the writer states that he has cured a number of cases by this
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method, and we have no doubt of its use in certain cases, but bis treatment was supplemented by the daily use of salicylate of soda, so that it is quite impossible to judge to which of these two drugs the honor is due. There are two chapters given to " nevrose" or neurasthenia which deserve special condemnation ; the use of numerous French words and italics is resorted to most unnecessarily and lends no strength to an otherwise feeble production.
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The conceit of the author is astonishing, as may be judged from the following: "It is, however, only in strict accordance with this sublunary world's order of things that the discoverer and inventor, from Galileo with his telescope to Stephenson with his locomotive, should at first — often a terribly prolonged 'at first' — resign themselves to encounter, not active persecution in our times, but at all events hostile opposition, scepticism and contemptuous derision." The author believes he has been most unjustly treated by the world at large, but when he compares his discovery (?) to those of Galileo and Stephenson we can but smile and leave him to his merited fate.
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Transactions of the Jlichigan State :Medical Society. 1897. Vol.
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XXI. {Grand Rapids : Published by the Society.)
 +
 +
Were it not for the address on surgery in this volume by Roswell Park, these transactions might be laid on a back shelf. But this address, like all of Dr. Park's, contains thoughts of more than passing value. The subject of it is " the problems which most perplex the surgeon," but it is devoted almost entirely to a very interesting discussion of the question of cancer in many of its various relations. Besides this paper there are only two or three to which attention might be drawn — one on a case of purulent pericarditis, by F. AV. Garber ; a second on cancer of the stomach, by J. H. Kellogg, and thirdly, report of a case of lead-poisoning, by H. Gibbes; but except as cases they deserve no special mention — the histories are meagre.
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The Diseases of Women. A handbook for students and practitioners. By J. Bland Sutton, F. R. C. S. Eng. , and Arthur E. Giles, M. D. {Philadelphia: W. B. Saunders. London : Rebman Publishing Co. Ltd., 1897.) This little book of 436 pages is written in a way to be " useful to
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students for examination purposes," and is not calculated to increase
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the reputation of its distinguished authors. It contains nothing
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new. It is well printed and profusely illustrated.
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BOOKS RECEIVED.
 +
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Crime and Criminals. By J. Sanderson Christison, M. D. 1897. 12mo. 117 pages. The W. T. Keener Co., Chicago.
 +
 +
Rheumatism and its Treatment by the Use of the Perciisso-Pnnctatur.
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 +
By J. Brindley James, M. R. C. S. Eng. Second edition. 1897.
 +
 +
12mo. 39 pages. The Rebman Publishing Co. Ltd., London. Transactions of the Michigan Slate Medical Society for the Year 1897.
 +
 +
Vol. XXI. Svo. 526 pages. Published by the Society, Grand
 +
 +
Rapids.
 +
 +
A Practical Treatise on Scvual Disorders of the Male and Female. By Robert W. Taylor, A. M., M. D. 1S97. Svo. 451 pages. Lea Brothers & Co., New York and Philadelphia.
 +
 +
Selected Essays and Monographs. Translations and reprints from various sources. 1897. Svo. 436 pages. The New Sydenham Society, London.
 +
 +
Thirty-third Report of the Trustees of the Boston City Hospital, with Report of the Superintendent, etc., for the year Feb. 1, 1896, to Jan. 31, 1S97, inclusive. Svo. 194 pages iMunicipal Printing Office, Boston.
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 +
 +
 +
January, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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23
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PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.
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THE JOHNS HOPKINS HOSPITAL REPORTS. Volume I. 423 pages, 99 plates.
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 +
Report In Fntliologrr The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
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 +
Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the
 +
 +
Vena Fortae and its Influence upon the Circulation. By F. P. Mall, M. D. A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis
 +
 +
(Atrophy). By Henry J. Berkley, M. D, Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.
 +
 +
Mall, M. D.
 +
 +
Report in Dermatology. Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
 +
 +
T. C. Gilchrist, M. D., and Kmmet Risford, M. D. A Case of Blastomj-cetic Dermatitis in Man; (Tomparisons of the Two Varieties of
 +
 +
Protozoa, and the Blastomyces found in the preceding Cases, with the so-called
 +
 +
Parasites found in Various Lesions of the Siiin, etc. ; Two Cases of MoUuscum
 +
 +
Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By
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 +
T. C. GiLCBKIST, M. D.
 +
 +
Report in Pathology. An Experimental Study of the Thyroid Gland of Dogs, with especial consideration
 +
 +
of Hypertrophy of this Gland. By W. S. Halsted, M. D.
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 +
 +
 +
Volume II. 570 pages, with 28 plates and figures.
 +
 +
Report in Metliclne.
 +
 +
On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
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 +
Gallstones. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D. On Pyrodin. By H. A. Lafleur, M. D. Cases of Post-febrile Insanity. By William Osler, M. D, Acute Tuberculosis in an Infant of Four Slonths. By Harry Toitlmin, M. D. Rare Forms of Cardiac Thrombi. By William Osler, M. D. Notes on Endocarditis in Phthisis. By William Osler, M. D.
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 +
Report in Medicine.
 +
 +
Tubercular Peritonitis. By William Osler, M. D.
 +
 +
A Case of Raynaud's Disease. By H. M. Thomas, M. D.
 +
 +
Acute Nephritis in Typhoid Fever. By William Osler, M. D.
 +
 +
Report in Gynecology.
 +
 +
The Gynecological Operating Room. By Howard A. Eellt, M. D.
 +
 +
The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard
 +
 +
A. Kelly, M. D., and Hunter Robb, M. D. The Report of the Autopsies in Two Cases Dying in the Gjrnecological Wards without Operation; Composite Temperature and Pulse Charts of Forty Cases of
 +
 +
Abdominal Section. By Howard A. Kelly, M. D. The Management of the Drainage Tube in Abdominal Section. By Hunter Robd,
 +
 +
M. D. The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;
 +
 +
Ovarian Tumor; General Gynecological Operations from October 15, 1889, to
 +
 +
March 4, 1890. By Howard A. Kelly, M. D. Report of the Urinary E.xamination of Ninety-one Gynecological Cases. By Howard
 +
 +
A. Kelly, M. D., and Albert A. Ghriskey, M. D. Ligature of the Trunks of the Uterine and Ovarian Arteries as a Means of Checking
 +
 +
Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D. Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D. Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D. Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment
 +
 +
of Ureteral Stricture; Record of Deaths following Gynecological Operations. By
 +
 +
Howard A. Kelly, M. D.
 +
 +
Report in Snrgery, I.
 +
 +
The Treatment of Wounds with Especial Reference to the Value of the Blood Clot in the Management of Dead Spaces. By W. S. Halsted, M. D.
 +
 +
Report in Nenrolosy, I.
 +
 +
A Case of Chorea Iiisanicns. By Henry J. Berkley, M. D. Acute Angio-Neurntic Oedema. By Charles E. Simon, M. D. Haematomyelia. By August Hoch, M. D.
 +
 +
A Case of Cerebrospinal Syphilis, with an unusual Lesion in the Spinal Cord. By Henet M. Thomas, M. D.
 +
 +
Report in Pathology, I.
 +
 +
Amoabic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleue, M. D.
 +
 +
 +
 +
Volume III. 766 pages, with 69 plates and figures.
 +
 +
Report in Pathology.
 +
 +
Papillomatous Tumors of the Ovary. By J. Whitridqe Willlaus, M. D. Tuberculosis of the Female Generative Organs. By J. Whitridqe Williams, M. D.
 +
 +
Report in Pathology.
 +
 +
Multiple Lympho-Sarcomata, with a report of Two Cases. By Simon Flexner, M. D.
 +
 +
Tlic Cerebellar Cortex of the Dog. By Henry J. Berkley, M. D.
 +
 +
A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.
 +
 +
Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.
 +
 +
Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.
 +
 +
Report in Gynecology.
 +
 +
The Gynecological Operating Room; An External Direct Method of Measuring the Conjugata Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retroflexed Uterus. By Howard A. Kelly, M. D.
 +
 +
Potassium Permanganate and Oxalic Acid as Germicides against the Pyogenic Cocci. By Mary Sherwood, M. D.
 +
 +
Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stately, M. D.
 +
 +
 +
 +
Gynecological Operations not involving Coeliotomy. By Howard A. Kelly, M. D. Tabulated by A. L. Stavely, M. D.
 +
 +
The Employment of an Artificial Retroposition of the Uterus in covering Extensive Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdominal Pelvic Operations. By Howard A. Kelly, M. D.
 +
 +
Photography applied to Surgery. By A. S. Murray.
 +
 +
Traumatic Atresia of the Vagina with Hxmatokolpos and Haematometra. By Howard A. Kelly, M. D.
 +
 +
Urinalysis in Gynecology. By W. W. Russell, M. D.
 +
 +
The Importance of employing Anaesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D.
 +
 +
Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D.
 +
 +
One Hundred Cases of Ovariotomy performed on Women over Seventy Years of Age. By Howard A. Kelly, M. D., and Mary Sherwood. M. D.
 +
 +
Abdommal Operations performed in the Gynecological Department, from March 5, 1890, to December 17, 1892. By Howard A. Kelly, M. D.
 +
 +
Record of Deaths occurring in the Gynecological Department from June 6, 1890, to May 4, 1892.
 +
 +
 +
 +
Volume IV. 504 pages, 33 charts and illustrations.
 +
 +
Report on Typhoid Fever.
 +
 +
 +
 +
Report in Nenrology.
 +
 +
Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver: The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of ihs musculiis; The Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berelet,
 +
 +
Report In Snrgery.
 +
 +
The Results of Operations for the Cure of Cancer of the Breast, from June. 1889. to January, 1894. By W. S. Halsted, M. D.
 +
 +
Report in Gynecology.
 +
 +
Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic PeritonitisTuberculosis of the Endometrium. By T. S. Collen, M. B.
 +
 +
Report in Pathology.
 +
 +
Deciduoma Malignum. By J. Whitridqe Williams, M. D.
 +
 +
 +
 +
Volume V. 480 pages, with 32 charts and illustrations.
 +
 +
==CONTENTS==
 +
The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D. A Study of some Fatal Cases of Malaria. By Lewellys F. Barker, M. B.
 +
 +
Stndies in Typhoid Fever. By William Osler, M. D., with additional papers by G. Blumer, M. D., Simon Flexner, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.
 +
 +
 +
 +
Volume VI. 414 pages, with 79 plates and figures.
 +
 +
Report in Nenrology.
 +
 +
Studies on the Lesions produced by the Action of Certain Poisons on the Cortical Nerve Cell (Studies Nos. I to V). By Henry J. Berkley. M. D.
 +
 +
Introductory.— Recent Literature on the Pathology of Diseases of the Brain by the Chromate of Silver Methods; Part I.— Alcohol Poisoning.— Experimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol) ; Part Il.-^erum Poisoning.— Experimental Lesions induced by the Action of the Dog's Serum on the Cortical Nerve Cell; Part III.— Ricin Poisoning.— Experimental Lesions Induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic Ricin Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the Cortical Nerve Cell produced by the Toxine of Experimental Rabies; Part V.— Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.
 +
 +
Report in Pathology.
 +
 +
Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.
 +
 +
Cullen, M. B. Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Jligration of
 +
 +
Ovum and Spermatozoa. By Thomas S. Cdllen, M. B.. and O. L. Wilkins. M. D. Adeno-Myoma Uteri Diifnsum Benignum. By Thomas S. Cullen, M. B. A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. By
 +
 +
William D. Booker. M. D. The Pathology of Toxalbumin Intoxications. By Simon Fle.xner, M. D, Tlie prirf of a si-t hrmnil in riolli [Tnls. I-VT] of the TTospittil Ittports is
 +
 +
$30.00. Vols. I, II and III are not sold senai-atelii. Tlir price of
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 +
Vols. IV, r and TI is $B.O0 each.
 +
 +
 +
 +
Monographs.
 +
 +
The following papers are reprinted from Vols. I, IV, V and VI of the Reports, for those who desire to purchase in this form : STUDIES IN DERMATOLOGY. By T. C. GiLCiiRisT, M. D.. and Emmet Rixforo,
 +
 +
M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,
 +
 +
$3.00. THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, M. D., and J.
 +
 +
Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.
 +
 +
By Lewellys F. Barker, M. B. 1 volume of 280 pases. Price, in paper, $2.7.5. STUDIES IN TYPHOID FEVER. By William Osler. M. D., and others. Extracted
 +
 +
from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481
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 +
pages. Price, hound in paper. $a.00. THE PATHOI.OOr OF TOX.M.ItUMIN INTOXICATIONS. Rv Simon Flexner, M. I). 1
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 +
volume of 150 paees with I full-paKe lilliricraphs. I rice, bound in paper, J'i.OO. Subscriptions for the above publications may be sent to
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 +
The Johns Hopkins Press, Baltimore, Md.
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24
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 82.
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THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.
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FACULTY.
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Daniel C. Oilman, LL. D., President.
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William H. Welch, M. D., LL. D., Dean and Professor of Pathology.
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Ira Rehsen, M. D., Ph. D., LL. D., Professor of Chemistry.
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William Osler, M. D., LL. D., F. U. C. P., Professor of the Principles and Practice
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 +
of Medicine. Henrt M. Hurd, M. D., LL. D., Professor of Psychiatry, William S. Halsted, M. D., Professor of Surgery. Howard A. Kelly, M. D., Professor of Gynecology and Obstetrica. Franklin P. Mall, M. D., Professor of Anatomy. John J. Abel, M. D., Professor of Pharmacology. William H. Howell, Ph. D., M. D., Professor of Physiology.
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William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology. John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine. Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoology. Robert Fletcher, M. D., M. R. C. S., Lecturer on Forensic Medicine. William D. Booeer, M. D., Clinical Professor of Diseases of Children. John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology. Samdel Theobald, M. D., Clinical Professor of Ophthalmology and Otology. Henry M. Thomas, M. D., Clinical Professor of Diseases of the Nervous System, Simon Flexner, M. D., Associate Professor of Pathology. J. Whitridge Williams, M. D., Associate Professor of Obstetrics. Lewellvs F. Barker, M. B., Associate Professor of Anatomy. William S. Thayer, M. D., Associate Professor of Medicine. John M. T. Finney, M. D., Associate Professor of Surgery.
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Georoe P. Dreter, Ph. D., Associate in Physiology.
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William W. Russell, M. D., Associate in Gynecology.
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Henry J. Berkley, M. D., Associate in Neuro-Pathology.
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J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.
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T. Caspar Gilchrist, M. R. C S., Associate in Dermatology.
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Robert L. Randolph, M. D., Associate in Ophthalmology and Otology.
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Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.
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Thomas B. Futcher, M. B., Associate in Medicine.
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Joseph C. Bloodgood, M. D., Associate in Surgery.
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Thomas S. Cullen, M. B., Associate in Gynecology.
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Ross G. Harrison, Ph. D., Associate in Anatomy.
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Frank R. Smith, M. D,, Instructor in Medicine.
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George W. Dobbin, M. D., Assistant in Obstetrics.
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Walter Jones, Ph. D., Assistant in Physiological Chemistry.
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Adolph G. Hoen, M. D., Instructor in Photo-Micrography.
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Sydney M. Cone, M. D., Assistant in Surgical Pathology,
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Louis E. Livingood, M. D., Assistant in Pathology.
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Henry Barton Jacobs, M. D., Instructor in Medicine.
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Charles R. Bardeen, M. D., Assistant in Anatomy.
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Stewart Paton, M. D., Assistant in Nervous Diseases.
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Norman McL. Harris, M. B., Assistant in Pathology,
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Harvey W. Cushing, M. D., Assistant in Surgery.
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J. M. Lazeab, M. D., Assistant in Clinical Microscopy,
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J. L. Walz, Ph. G., Assistant in Pharmacy.
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GENERAL STATEMENT.
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 +
The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1803. This School of Medicine is an integral and coordinate part of the Johns Hopkins Universit}', and it also derives great advantages from its close affiliation with the Johns Hopkins Hospital.
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The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.
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Men and women are admitted upon the same terms.
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In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital. While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. The first two years of the course are devoted mainly to practical work, combined with demonstrations, recitations and, when deemed necessary, lectures, in the Laboratories of Anatomy, Physiology, Physiological Chemistry, Pharmacology and Toxicology, Pathology and Bacteriology. During the last two years the student is given abundant opportunity for the personal study of cases of disease, his time being spent largely in the Hospital Wards and Dispensary and in the Clinical Laboratories. Especially advantageous for thorough clinical training are the arrangements by which the students, divided into groups, engage in practical work in the Dispensary, and throughout the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.
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REQUIREMENTS FOR ADMISSION.
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As candidates for the degree of Doctor of Medicine the school receives :
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1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.
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3. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (ft) That they have such knowledge of physics, chemisti'y, and biology as is imparted by the regular minor courses given in these subjects in this university.
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The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in each subject.
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3. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientific school, and the knowledge of French, German, Latin, iihysics, chemistry, and biology above indicated.
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Applicants for admission will receive blanks to be filled out relating t p their previous courses of study.
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They are required to furuish certificates from officers of the colleges or scientific schools where they have studied, as to the courses pursued in physics, chemistry, and biology. If such certificates are satisfactory, no i xamination in these subjects will be required from those who possess a degree in arts or science from an approved college or scientific school.
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Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass, at the beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (2) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory ti'aining as specified above. It is expected that only in very rare instauces will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.
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Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.
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ADMISSION TO ADVANCED STANDING. ; ,
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Applicants for ailinlsslon to advanced standing must turnish evidence II) that the foregolug terms of admission as regards prellmluary training have been fulOUed, 1 (2) that courses eqiilvaleut In kind and amount to those given here, preceding that ye.ir of the course tor admission to which application Is made, have been satisfactorily ' completed, and (3| must pass examinations at the beginning of the ses.slou In October In all the subjects that have been already pursued by the class to which admission Is sought. Certificates of standing elsewhere cannot be accepted in place of these exainlnationa.
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SPECIAL COURSES FOR GRADUATES IN MEDICINE.
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 +
Since the opening of the Johns Hopkius Hospital in 1880, courses of instruction have been offered to graduates in medicine. The attendance upon these courses has steadily increased with each succeeding year and indicates gratifying appreciation of the special advantages here afl'orded. With the completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the majority of those desiring to take the courses than the former one. The special courses of instruction for graduates in medicine are now given annually during the months of May and June. During April there is a preliminary course in Normal Histology. These courses arc in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended to meet the requirements of practitioners of medicine, and is almost wholly of a practical character. It includes laboratory courses, demonstrations, beside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the several instructors that they are prepared to profit by the opportunities here offered. The ntimber of students who can be accommodated in some of the practical courses is necessarily limited. For these the places are assigned according to the date of application.
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The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the
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KEGISTR.\R OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.
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The Johns Hopkins Hospital BiiJIrtins fire issued monthly. They arc printed by THE FRIEDENWALD CO., Baltimore. Single coplet may he procured from Messrs. GUSHING <f CO. and the BALTIMORE NEWS COMPANY, Baltimore. SubsaHptions, $1.00 a vear, may be addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; sinyle eopie^ uHll be sent by mail for fifteen cents each.
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BULLETIN
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OF
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THE JOHNS HOPKINS HOSPITAL.
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Vol. IX.- No. 83.]
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BALTIMORE. FEBRUARY, 1898.
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co:N"TEisrTS
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Inflated Rubber Cylinders for Circular Suture of the Intestine. By W. S. Halsted, M. D., - - - 25
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Cerebro-Spinal Meningitis. By W. T. Councilman, M. D., - 27 The Diaphragm Phenomenon— The So-called Litten's Sign.
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By NoEMAN B. GwYN, M.B.,
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35
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PAGE.
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Proceedings of Societies :
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Hospital Medical Society, - - - ZS
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Cases of Aneurism [Dr. Hunner] ;— Diabetes in the Negro [Dr. Pancoa.st] ; Exhibition of Specimen of Round Ulcer of the Stomach. Erosion of Gastric Artery ; Post-mortem Perforation [Dr. Flexner].
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Notes on New Books, 42
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Books Received, ---------- 44
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INFLATED RUBBER CYLINDERS FOR CIRCULAR SUTURE OF THE INTESTINE.*
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By W. S. Halsted, M. D., Professor of Surgery in the Johns Hopkins University.
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Until ten years ago every oue who had written on the subject of intestinal suture believed that the Lembert stitches, which were then almost universally used in circular and other sutures of the intestine, included only the jjeritoneal coat of the intestine ; and many surgeons evidently still believe this. The notions of Jobert and Lembert as to the structure of the intestinal wall were still accepted by all surgeons. The submucous coat of the intestine, the coat which, I am convinced, should most concern the surgeon when he is sewing the intestine, was ignored or unknown. In my first article on suture of the intestinef in 1887 I quoted from MadelungJ as follows: " The needle now penetrates in the usual manner the two ends of the intestine, passing between serosa and muscularis"; and from Reichel,§ who insists upon the " accurate adaptation of the two edges of the wound, particularly of the two serous coats," and having described the mannerof taking the first row of stitches, continues, "over this then comes the external suture, which includes only the serosa." Maydl, Kocher, Czerny and others were quoted to show that the submucous coat had not been recognized, and how universal was the opin
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Remarks before the Johns Hopkins Hospital Medical Society,
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December 13, 1897.
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t Halsted: Circular Suture of the Intestine. An Experimental Stuily. Am. Jour. Jled. Sciences, October, 18S7.
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X Madelung : Arch. f. klin. Chirurgie, Bd. xxvii, p. 321.
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§Reichel: DeutscheZeitschr.f. Chirurgie, Bd. xiv, pp. 268 and 270.
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ion that intestinal suture should be performed by stitches which included only the peritoneal coat. When we know that the wall of the intestine must be magnified to a thickness of 4 cm. to enable us to represent the peritoneal coat by a fine pencil-stroke, we find it hard to understand that surgeons should ever have supposed that they were including nothing but peritoneum in their stitches. Hardly less remarkable is the fact that the intestinal wall had, for the surgeon, only three coats : the serous, muscular, and mucous coats. Not only were the qualities of the submucosa unknown to surgeons, it was also an unknown quantity. Only five years ago Schimmelbusch,* describing with some detail the manufacture of the so-called catgut, tells us that it is made from the longitudinal muscular coat. He says, " If the intestine be laid ou a towel and scraped with a dull instrument like the back of a knife, the muck (' Schmutz '), so called by the artisans, is removed. This is nothing else than the mucous membrane of the gut. In the same manner the circular muscular coat is rubbed off, so that only the very thin tube composed of longitudinal muscle-fibres remains, an intact, very delicate and pipelike structure which may be distended with air. The threads are manufactured from this by twisting, and conformably to the thickness desired, either the entire tube or only strips of
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Schimmelbusch: Anleitung zur aseptischen Wundbehandlung
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Berlin, 1892, p. 104.
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20
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 83.
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it are twisted together like heuiiieu cords." The muscular pipe referred to is, of course, the tube of the submucosa, the sausage-skiu, etc.
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The following suggestions, emphasized among others, in my article on intestinal anastomosis,* are equally relevant to circular suture of the intestine :
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"1. It is bad surgery to employ stitches which enter the lumen of the intestine.
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" 2. It is impossible to suture the serosa alone.
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"3. It is impossible to suture unfailingly the serosa and niuscularis alone, unless one is familiar with the resistance offered to the needle by the submucous coat of the intestine; furthermore, stitches which include nothing but the serous and muscular coats tear out easily and are not to be trusted.
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"4. Each stitch should include a bit of the submucosa. A fine thread of this coat is much stronger than a considerable shred of the entire thickness of the serosa and muscularis. It is not difficult' to familiarize one's self with the resistance offered to the needle by the submucosa, and with a very little practice one learns to include a bit of this coat in each stitch.
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" 5. The mattress-stitches are to be preferred to Lembert's, because one row of them is siifficient, because they tear out less easily, oppose larger surfaces and more evenly, and constrict the tissues less than the Lembert stitches do."
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6. lu circular suture of the intestine, only one row of stitches should be taken, and the entire row should be applied before a single stitch is tied ; othej-wise it is impossible to preserve a straight line in the taking of the stitches, and the stitches taken last may be never so much farther from the cut edge than those taken first, and the flange turned in may be so broad as to occlude the intestine's lumen.
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7. Before the intestine is resected, its blood-supply should be most carefully studied, with reference not only to the placing of ligatures, but also of the stitches, and the stitches should be so placed that the circulation, up to the very edge of the parts to be sewed, shall be as perfect as possible.
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The results obtained by adhering strictly to the foregoing rules have been so perfectf that we have employed no other methods in our practice.
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Edmunds aud Ballance in their valuable coutributionj to intestinal surgery, give the results of their measurements to determine the relative thickness of the submucous and muscular coats in the dog and in man. They state that the muscular coat is very much thicker in the dog than in man, but that the submucous coat is somewhat thicker in man than in the dog, and they too find it perfectly feasible to engage a thread of the submucosa in each stitch without perforating the lumen of the intestine.
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Halsted : I otestinal Anastomosis. Demonstration at a meeting
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of the Johns Hopkins Hospital Meiiical Society, December 1, 1890. Johns Hopkins Hospital Bulletin, January, 1891.
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fAmer. Journ. Med. Sciences, October. 1887.
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t W. Edmunds and Charles A. Ballance: Observations and Experiments on Intestinal and Gastro-intestinal Anastomosis. Medico-Chirurg. Trans,, Vol. 78. London, 1S9G.
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The objection to Neuber's* decalcified bone-bobbins, Senn's decalcified bone-plates, and Murphy's button, probably the best of the mechanical aids to intestinal suture, I will not dwell upon at this time. The method of each of these surgeons has its advantages, particularly in the hands of those who have not practised the intestinal sutures on animals.
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I believe that the license to practice general surgery should be withheld from those who have not practiced on animals the operations for circular suture of the intestine and intestinal anastomosis.
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Not so very long ago a surgeon requested me to assist him to perform a circular suture of the intestine (end to end anastomosis) upon one of his patients. He readily consented to practice the ojjeration upon dogs. At first his dogs died. He finally succeeded in saving more than 50 per cent, of the dogs operated upon. The operation upon his patient required five hours, but was successful. It is not difficult to predict what the result would have been if the practice on dogs had been omitted.
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Experts in intestinal surgery, almost without exception, prefer to jserform circular suture of the intestine without the use of mechanical devices.
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But my operation was not by any means a satisfactory one, notwithstanding the very perfect results which attended its employment in the bands of others as well as myself.
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The disadvantages of my original method aud of all similar methods (methods without mechanical aids) were as follows:
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1. They required about twenty minutes to perform the operation.
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2. One or two assistants at the wound were indispensable.
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3. Clamps or the fingers of an additional assistant were necessary to prevent the escape of intestinal contents.
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4. The vermicular action of the intestine (particularly in dogs) was a great annoyance, for it prevented an accurate disposition of the stitches; stitches applied as near together as possible during intestinal contraction might be too far apart in the stage of relaxation.
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5. If the j)ieces of intestine to be united were not of the same size their adjustment might be very difficult.
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6. The rolling out of the cut edges of the intestine prevented in places recognition of the precise edges, and hence
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A few weeks ago Dr. ^Mitchell discovered in the Medical and
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Surgical Iieporter for July, 1S96, a description b}- Dr. A. J. Downes, of collapsible rubber bobbins for all forms of intestinal approximation. These bobbins resemble Neuber's bobbins very closely and were designed with the same end in view, viz. to accommodate the inverted ends in circular suture of the intestine. My rubber cylinders were made in June, 1S97, and were suggested to me by the success attending the employment, experimentally, of aluminum rods in suture of the common bile-duct. I intend to describe these rods at another time. Dr. Downes' bobbins have spherical ends, which are filled with water. When a larger is to be sutured, end to end, to a smaller intestine he uses a bobbin especially designed for the purpose, with a large sphere at one end and a small sphere at the other end of the connecting shank. I should suppose that this modification of the bobbin would defeat the very end for which it was constructed.
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Presection-siitches —Left.
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Prese^tioQ-stikhes — Right.
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Presection-siitches.
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The Johns Hopkins Hospital Billetix No. 83. See page
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FIG. 3
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FIG.
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FIG. 5
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FIG. 6.
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FIG. 7.
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The Johns Hoprivs Hn
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February, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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27
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the operator might not know just how far from the edge he was phicing his stitches nor just how much intestine he was turning in.
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7. The handling of the intestine by assistants who act as clamps or who hold parts in place during the stitching must be injurious to the tissues and predispose to infection.
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Every one of these objections is disposed of by the employment of the rubber cylinders in the manner indicated in the plates. The drawings are so excellent and illustrate the method so graphically and accurately that a description of the procedure is almost superfluous.
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Figs. 1 and 3 show the presection-stitches applied. It is immaterial whether these stitches perforate the wall of the intestine or not, for they are cast off eventually into the bowel. The method of ligating the mesenteric vessels is also accurately shown in Figs. 1 and 2, which were drawn from life. The intestine should be divided carefully with scissoi-s as close to the presection-stitches as possible. No visible blood-vessels are occluded by these stitches.
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Fig. 3. The rubber cylinder inflated. For the human small intestine the diameter of the cylinder is from li to IJ inches. It would be better to have cylinders larger than necessary rather than too small.
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In Fig. 4 two of the presection-stitches have been tied, and the collapsed rubber cylinder is being pushed into the bowel with a forceps.
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Fig. 5. The three presection-stitches have been tied. They are supplemented by a fourth stitch, b, which is removed later to facilitate the withdrawal of the bag. The bag has been inflated with air by the syringe. Water might, of course, be used instead of air ; but a bag distended with air would, perhaps, more quickly reveal a prick from a faulty stitch than a bag distended with water.
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The stitch a (Fig. 6 and also Figs. 5, 7 and 8) is the first and most important of the mattress or permanent stitches. The submucosa is picked up four times by this as by all the mattress stitches, and the mesentery is twice perforated by it (Fig. 6). This stitch insures the proper turning in of the mesenteric border. It was devised by Drs. Mitchell and Huuner, and I shall call it the Mitchell-Hunner stitch.
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Fig. 7. The bag is still distended, and all of the mattress stitches have been placed. From seven to nine of these
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stitches suflBce in operations upon the small intestine of the dog, and from ten to twelve in operations upon the human subject. The first stitch to be drawn home and tied is a. The mesenteric border is turned in by it infallibly. Not.a single visible vessel is occluded by the stitches (Figs. 7 and 8). On the right side the stitches pass under one vessel and over another, without interfering with either, and on the left side a vessel lies under the stitches, uninjured.
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Fig. 8. Two mattress stitches drawn aside on a hook ; the temporary stitch has been removed and the collapsed bag is being withdrawn.
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Fig. 9. The circular suture is completed; the slit in the mesentery is being sewed in such a way that its circulation is not interfered with.
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Advantages of the Inflated Eubbeu Cylinder in Circular Suture of the Intestine.
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1. The vermicular action of the bowel is arrested over the bag, and the stitches can, consequently, be placed at regular and proper intervals.
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2. The distended bag unrolls and spreads out to a fine edge the everted raw edge of the intestine (Fig. 4), and enables the operator to place the stitches with great precision at the desired distance from this edge.
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3. If distended intestine is to be sutured to collapsed intestine (in strangulated hei-nia, ilius, etc.), or intestine of larger to intestine of smaller lumen (jejunum to ileum, duodenum to esophageal end of the stomach, etc.), the smaller may easily be expanded to fit the larger piece.*
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4. Very little handling of the intestine itself by the operator is necessary. The tube from bag to syringe is used as a handle to rotate and elevate the parts to be united.
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5. The cylinder takes the place of at least two assistants. The operation could readily be performed without an assistant.
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6. It prevents escape of intestinal contents and hence dispenses with the injurious clamps or the fingers of assistants.
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7. The entire operation, exclusive of suture of the abdominal wall, can be performed on dogs in five or six minutes and probably in less time.
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The results should, I believe, be better than by any method hitherto devised.
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CEREBRO-SPINAL MENINGlTIS.t
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By W. T. Councilman, M. D., Harvard University.
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Cerebro-spinal meningitis has prevailed in Boston iu the form of an epidemic during the past winter and spring. One hundred and eleven cases of the disease were treated in the Boston City Hospital, the Massachusetts General Hospital, and the Children's Hospital, between June, 1896, and October 1, 1897. At the time of the appearance of the first case in June there had been no case of this form of meningitis in the hospitals for a number of years. The first case occurred in June, 1896, one in the following September, and three cases in December. In 1897 there was one case in January, ten in
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February, 33 in March, 39 in April, 21 in May, 14 in June,
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I have recently had occasion to unite a distended paper-thin
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jejunum to a collapsed ileum. The rubber cylinder worked like a charm. The patient, a very old and feeble woman, convalesced without interruption for 16 days. She died quite suddenly from peritonitis due to complications which cannot at this time be discussed. So far as the stitching was concerned the result was perfectly satisfactory.
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t Presented to the Johns Hopkins Medical Society, November 15, 1897.
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28
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 83.
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7 iu July, aud 3 in September. At the present time the disease contiunes to prevail aud many more cases have been seen this autumn than in the autumn of 189G.
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The disease has been epidemic iu Boston a number of times. The first appearance of the disease iu Massachusetts was in 180G, one year after its apjjearance in Geneva in 1805. It has been generally supposed that this was its first appearance, but it is more than possible that many of the early epidemics were this disease, although iu the absence of clear clinical records aud post-mortem examinations it is impossible to be certain of this. The first epidemic of the disease prevailed in the New England States and lasted until 1816. There was another epidemic between 1864 aud 1860, and still another in 1874.
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A table of the ages of the 111 cases shows that the disease prevailed principally in young adults. Only oue case was seen iu a child under one year of age. A table of ages of our 111 cases agrees almost exactly with the table of the same number of cases given by Leichtenstern in his report of the epidemic in Cologne in 1885. A great deal of stress should be laid on the rarity not only of epidemic meningitis but of all forms of meningitis in children under one year of age. Nothing more clearly shows the inaccuracy of general mortality tables than the ages given iu the cases of meningitis. In nearly all of these tables a large percentage of cases are attributed to children under one year of age. In looking over these mortality tables one receives the impression that errors iu the diagnosis of meningitis are not uncommon.
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The mortality of the 111 cases was 68 per cent., which is comparatively high. Hirsch gives the mortality as varying from 20 to 75 per cent. The greatest actual and relative mortality was found iu the cases iu April aud May. Most of the epidemics of cerebro-spinal meningitis reported in the literature have appeared in the late winter and spring, although there have been a number of exceptious to this general rule. A map of the city giving the distribution of the cases shows them to have been pretty well scattered over the city, there being only two localities where they were esjjecially numerous. Generally but a single case came from the same family, although there were several exceptions to this, in oue case three coming from the same family, and in another two.
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A great deal of interest attaches to sporadic cases of cerebro-spinal meningitis. We can only be certain that these sporadic cases are the same as the epidemic form when the organism associated with the epidemic form has been found in them. So far we have only been able to find one instance in which the diplococcus intracellularis of Weichselbaum, the organism of epidemic cerebro-spinal meningitis, was found in a sporadic case. In most of the sporadic cases no cultures have beeu made, but so far as we can judge from the clinical and anatomical descriptions many of these represented the true epidemic form. Almost all observers who have been acquainted with the epidemic form of the disease speak of the presence of spoi-adic cases occurring both before and after the epidemics. The single cases seen here in June and September may be considered as sporadic. We think it maybe generally assumed that cases of sporadic meningitis which recover are of the epidemic variety. So far we have not beeu able to find
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a case which from its association with other conditions could be regarded as dne to the pneumococcus or streptococcus which has recovered. Certainty with regard to the sporadic cases can only be known by careful anatomical and bacteriological investigation. The bacteriological examination of the fluid removed by spinal puncture is of special importauce.
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The first description of an organism which might be regarded as the diplococcus intracellularis was given by Leichtenstern in 1885. He found in the exudation iu the meninges a few diplococci, sometimes single, sometimes in group?, similar in arrangement togonococci, enclosed iu white corjiuscles. Schwabach found diplococci in the pus cells in a case of otitis media secondary to meningitis.
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Most of the bacteriological examinations made on cases of meningitis up to the past few years have seemed to show that the pueumococcus was the cause both of the epidemic aud most of the sporadic cases. This was probably due to the fact that the pueumococcus is very frequently found in sporadic meningitis, aud in the ejiideniic form the diplococci may either be mistaken for the pueumococci, or an accompanying pneumococcus infection mask the diplococci.
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The first definite description of this organism was given by Weichselbaum in 1887. The organism was described by him as a diplococcus which in the lesions is found almost solely vvithiu the cells. In cultures the organisms grow singly, in pairs and in tetrads. Both in cultures and in the tissue they were decolorized by Gram. There were few confirmations of the discovery of Weichselbaum until 1895, when Jiiger found the same organism in 13 cases of epidemic cerebro-spinal meningitis which occurred iu the garrison at Stuttgart. Jiiger's description added but little to the previous description of Weichselbaum.
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Post-mortem examinations were made iu 35 of the 111 cases, aud the diplococcus intracellularis was found in cultures, on microscopic examination of the exudation, or in sections of the tissues, iu all but four cases. In most of the cases they were found iu all three methods of examination.
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In one of the four negative cases they had previously been found iu the fluid withdrawn during life by spinal puncture. Two of the other cases were very chronic, aud the fourth was a chronic case of mixed infection with tuberculosis. In a certain number of cases cultures failed to give the organisms, | although they were abundantly present, as shown by cover-slip B examination of the meninges and microscopic sections. The organism is very difficult to grow, and from a number of tubes inoculated, in many cases only one or two tubes would show a | few single colonies. We have found the Loeftler's blood serum | mixture best adapted for its growth. Hud agar been used for the primary cultures there is no doubt that iu nuiuy cases no growth would have beeu obtained. There is considerable irregularity in staining, some organisms being brightly stained, others more faintly. Sometimes these differences in staining tl are seen in a single pair of organisms, one being more brightly I stained than the other. There may also be considerable variation in size, and the larger organisms stain more imperfectly. In these swollen organisms there is often a brightly stained point iu the centre, while the remainder of the cell is but slightly colored. This condition may have been mistaken by
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February, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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29
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Jiiger for a capsule around the organism. These variations in size aad staining appear to be due to degeneration and are more common in old than in fresh cultures. In the tissues the diplococcus is almost strictly confined to the interior of polyuuclear leucocytes. It has no definite position in the cell and is never found in the nucleus. The number of organisms found in the cells varied from a single pair to such numbers that the nuclei of the cell were frequently obscured. In no case were the diplococci found except in connection with the lesions of the disease. So far as could be learned from cultures of the blood, liver, spleen and kidneys, the organism does not produce septicffimia.
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Lumbar puncture was iierformed in 55 cases, and in a few cases several punctures were made in the same individual. In the fluid obtained diplococci were found on microscopic examination or in cultures in 38 cases; in 17 of the cases they were absent. The average duration of time from the onset of the disease before spinal puncture was made was 7 days in the positive cases and 17 days in the negative. The longest time after onset in which a positive result was obtained was 29 days.
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The character of the fluid obtained by spinal puncture varied greatly. In some cases, even when diplococci were found in it, it was almost clear, showing only a slight turbidity when examined against a dark background. In most cases where the puncture was made early in the disease the fluid was turbid, and in 3-1 hours a large amount of sediment formed at the bottom of the tube. The amount of fibrin in the exudation varied greatly. In a few cases so much was present that the fluid coagulated and the tube could be inverted. In one chronic case of marked intermittent character three punctures were made, one before, one after and one during the exacerbation. In the fluid obtained before and after the exacerbation no diplococci were found. The fluid obtained during the exacerbation was more cloudy and contained diplococci. This would seem to show that in the intermittent cases the exacerbations are due either to a fresh, growth of the organisms or to a fresh invasion of the j^arts which had been previously comparatively free. In the fluid obtained in the early punctures almost the only cellular elements were polynuclear leucocytes. Later, large epithelioid cells and lymphoid cells were found among the pus cells. No ill effects were seen from spinal puncture.
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Too much cannot be said of the importance of spinal puncture in making the diagnosis of the disease. As a diagnostic measure it ranks in value with the examination of the sputum. A microscopical and bacteriological examination of the fluid should always be obtained in order to ascertain what organism is present. In no other way will it be possible to arrive at certainty with regard to the nature of the sporadic cases.
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In all of the post mortem examinations careful microscopic examination was made of the tissues. For general histological purposes portions of the brain and cord and other organs were hardened both in Zenker's fluid and in alcohol. For the study of nerve degeneration small pieces of tissue were hardened in Jliiller's fluid, or in formaldehyde followed by Miiller's fluid, preparatory to staining by Marchi's method. The amount of the exudation varied in the acute and chronic cases.
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In the most chronic cases there was general thickening of the meninges and only small masses of degenerated cells were found in the place of the former exudation. In cases dying two or three days after the onset but a slight amount of purulent exudation was found. The amount of fibrin in the exudation varied and was never so great as is found in cases of meningitis due to the pneumococcus.
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In addition to the acute inflammation found in the meninges of the brain and cord, lesions of the tissue were found. In places there was a circumscribed infiltration of the tissue with pus cells which extended from the infiltration in the meninges. The vessels were dilated, and the spaces around the vessels filled with pus cells which extended into the surrounding tissue. In two cases there was extensive softening with purulent infiltration and hemorrhage in the cortex of the cerebellum, l^esions were foiind in both the white and gray matter, consisting principally in foci of fine hemorrhages with some purulent infiltration. There was a definite increase in the cells of the neuroglia both in connection with the acute lesions and at a distance from them. The neuroglia cells were swollen, their nuclei large and vesicular and contained much chromatin. Around these large nuclei there was a faintly stained irregular mass of granular protoplasm. Many of the cells contained two nuclei, and in places thei'e were groups of four or more nuclei with a considerable amount of protoplasm around them. In all of these places nuclear figures were found. They presented the same form as other nuclei, and in some cases both spindles and centrasomes were distinguished. In addition to the changes in the neuroglia, proliferation was found in the connective tissue of the brain and cord around the blood-vessels. The inflammation of the meninges extended along the cranial nerves and along the anterior and posterior spinal nerve roots.
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The cranial nerves most affected were the 2nd, 5th and 8th. The examination of the eyes in two cases showed a choroidoiritis which was due to a direct extension along the sheath of the optic nerve. Diplococci were found here and in the purulent exudation within the eye. The same thing was true of the ear. Secondary otitis media was found in a number of cases, some of which recovered. In all of these nuntliers of diplococci were found in the pus.
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The nasal secretion in 19 of our cases was examined, by means of cover-glass preparations, the material being taken from high up in the nasal cavities with the aid of a platinum loop. Of the 19 cases 10 showed the presence in the nasal secretion of diplococci, decolorized by Gram's method and identical in morphology with the diplococcus from the brain. Similar Gram decolorizing diplococci were also found within leucocytes in the nasal secretion of two cases of convalescing meningitis. Attempts were made to isolate this organism in cultures in 10 cases in which microscopic examination showed them to be present, but without success.
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With reference to the occurrence of this organism in the nasal secretion of patients not affected with meningitis twelve hospital patients chosen at random were examined. In the nasal secretions of two among these twelve, diplococci like the preceding were found by cover-glass examination. They were not cultivated. From the results of these examinations it
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30
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 83.
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would seem either that the diplococcus intracellularis may be met with in the nasal secretion of patients who have not meningitis, or that other species of diplococci identical with this morphologically and in staining peculiarities may be found.
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It is greatly to be regretted that it was not possible to obtain cultures of the organisms from this locality, for their identity can only be established by this method combined with inoculations. At any rate it is impossible to regard the presence of diplococci in the nose, decolorizing by the Gram stain, as of much diagnostic value as claimed by Scherrer.
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Degenerations were shown by the Marchi method in the nerves of both the brain and cord. The spinal ganglia were affected iu all cases, and in four cases in which the Gasserian ganglion was examined an acute inflammation, sometimes to an intense degree, was found in this. Degeneration was shown by the Nissl method in the ganglion cells of the brain and cord. The studies of this degeneration have not been completed.
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The condition of the lung is interesting on account of the relation which has very generally been supposed to exist between epidemic cerebro-spinal meningitis and pneumonia. In 13 cases there was merely congestion with more or less adema. In 7 cases there was broncho-pneumonia, more marked in the lower posterior portion of the lung. In two cases there was characteristic croupous pneumonia ; one in the stage of red hepatization bordering on gray. Pueumococci were found in these cases in cultures and on microscopic examination. In 8 cases pneumonia due to the diplococcus intracellularis was found. Nearly all of these cases came from the last part of the epidemic. It is very possible that some of the earlier cases in which the lesions were described simply as broncho-pneumonia, were really due to the diplococcus intracellularis.
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These lesions consisted microscopically of areas of consolidation in various parts of the lung, more particularly in the lower lobe, and they were most numerous beneath the pleural surface. The foci varied in size from a pin's head up to that of a pea, and on section some of them resembled small hemorrhages in the tissue. In other cases the periphery of the area was distinctly hemorrhagic and the centre opaque and yellowish. In one case the consolidation of the lung was so extensive that it might easily have been regarded as croupous pneumonia, particularly as the pleura over it was covered with a definite fibrinous exudation. On section this large area was composed of a number of irregular grayish foci, with softened centres, and with hemorrhagic and cedematous tissue between them. The lung tissue in the yellowish centres was frequently broken down and pus oozed from it. On microscopical examination the central areas showed in most cases a purulent infiltration of the tissue, with beginning abscess formation. The alveoli contained large numbers of pus cells ; their walls were found infiltrated with pus and iu places entirely broken down. The foci of consolidation did not appear to be bronchial in origin. The bronchi in the vicinity often contained pus cells, but their walls were not infiltrated.
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The duration of the disease in the cases in which diplococcus pneumonia was found was: iu 2 cases, 3 days; in 2
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cases, 2 days ; in 2 cases, 5 days ; in 1 case, 9 days ; in 1 case, 23 days, and in 1 case, 74 days. It will be seen from this that the lung complications due to the pneumococcus can take place in almost any period of the disease. In the case of 74 days' duration the lesions in the brain and cord could be regarded as almost completely healed and the lesions in the lungs were acute. In one case in which the apparent history of the disease was of only two days' duration, the lesions were so advanced that they seemed possibly to antedate those of the brain, providing the history as given by the patient's relatives was correct. Immense numbers of diplococci were found in the pus cells in the lung. They were most numerous in the cells in the centres of the foci where softening was taking place. In the centre of one of the foci a small branch of the pulmonary artery occluded by a thrombus formed of pus cells containing large numbers of diplococci was found. It seems probable that this thrombus may have come as an embolus from the meninges and may have produced an infection of the surrounding tissue.
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There was great variation in the size of the spleen. In general it was not much enlarged and was probably smaller than in most of the acute infectious diseases. In only three cases it was found considerably enlarged. The average weight in the adult cases was 163 grms. The lymphatic glands in the uncomplicated cases were never found enlarged.
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The liver presented no change beyond acute degeneration. In two cases extensive acute lesions were found in the kidneys. In one of these the acute lesions had no connection with the meningitis, but were due to an accompanying infection with diphtheria. In the other case there was an acute hemorrhagic nephritis. In this there was an accompanying acute pericarditis, the organism causing which could not be ascertained. The only lesions found in the kidney which could be properly attributed to the meningitis were acute degenerative lesions which were always present.
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The intestinal canal was found normal iu every case.
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In two cases there was acute pericarditis, accompanied in one case with foci of necrosis and jjuruleut infiltration of the myocardium. In several other cases in which the myocardium was examined histologically it was found normal.
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Lesions of the skin were found in but one of the cases on which an autopsy was made. In this case, over upper and lower extremities, chest and abdomen, there were numerous small dark purplish spots in the skin, varying in size from a pin's head up to that of a pea. On microscopic examination of these areas there was intense congestion and dilatation of the blood-vessels of the skin, with small and diffuse hemorrhages immediately beneath the epithelium. In some of the larger areas there was some purulent infiltration in the centre. No diplococci were found in these lesions.
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There is no doubt that acute meningitis may be produced by the entrance into the meninges of a number of infectious organisms. These forms are rarely primary. The organisms enter the meninges either by the formation of a communication between the meninges and some cavity where they may be accidentally present (as in the middle ear and nose), or by the extension to the meninges of an infectious process in the vicinity (mastoiditis, erysipelas), or they are brought to the
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February, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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meuinges by the blood from some other focus iu the body (pneumonia, endocarditis). In tuberculous meningitis we have never found a single case in which the lesions iu the meuinges could be regarded as primary. We believe that all infections of the meninges other than the diplococcus intracellularis are fatal, but this cau only be determined by microscopic and bacteriological examination of the exudation obtained during life by spinal puncture. If tubercle bacilli, pneumococci or streptococci are found with the evidences of meningitis iu a case which recovers, it would settle the point; clinical evidence, without spinal puncture, will not.
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Discussion.
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Dr. Welch. — It is a great pleasure to have Dr. Councilman with us upon this occasion, and we are all very much indebted to him for his instructive presentation of this subject and the report of his extensive and valuable studies. As he has not dwelt upon the historical development of our knowledge concerning the meningococcus iutracellularis, I maybe permitted to say a few words about the steps leading to the recognition of this organism as the cause of epidemic cerebro-spiual meningitis.
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It is not a little remarkable that the organism first described by Weichselbaum in 1887 as the diplococcus iutracellularis meningitidis did not come to be accepted as associated especially with epidemic cerebro-spinal meningitis until the publication of Jaeger's article iu 1895. This was not due to an imperfect or faulty description of this micrococcus by Weichselbaum, for its essential morphological and biological characters were fully and correctly described by him. Weichselbaum, iu the article referred to, reported the results of his bacteriological examination of eight cases of cerebro-spiual meningitis not secondary to pneumonia. All of these cases he regarded as sporadic forms of meningitis. In two he found the lanceolate pneumococcus and in the remainiug six the diplococcus iutracellularis meningitidis. He concluded that each of these two bacterial species may be the cause of primary acute cerebro-spinal meningitis, but he expressed no definite opinion as to whether either was concerned with epidemic cerebro-spinal meningitis, although he thought it probable that the jjueumococcus might cause epidemic forms of cerebro-spiual meningitis with or without pneumonia. With the exception of the confirmation in 1887 in a single case by Goldschmidt of Weichselbaum's discovery, and of Edler's microscopical examinations in 1888, nothing more is heard of the presence of the meningococcus iutracellularis of Weichselbaum in meningitis until Jaeger's report already mentioned.
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During these eight years the results of bacteriological examinations of cases of meningitis were reported by a number of observers. In 60 to 70 per cent, of these cases the pneumococcus was reported as present, and in about 13 per cent, the streptococcus pyogenes. Some of the cases in which the pneumococcus was reported as present were of epidemic cerebrospinal meningitis. The attempts of Bouome and of FoA to separate as distinct varieties or species from the pneumococcus cocci which they found in cerebro-spinal meningitis received merited criticism from Bordoni-Uffreduzzi, who
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showed that these organisms were in all probability genuine pneumococci. Bordoni-UfEreduzzi at the same time expressed the opinion that not only Bonome's streptococcus meningitidis and Foa's meningococcus, but also Weichselbaum's diplococcus iutracellularis meningitidis, are varieties of the diplococcus pneumouise. This opinion acquired support as we became familiar with the remarkable variations in all of the characters, morphological, cultviral aud pathogenic, of the pneumococcus. Hence the view came to be generally entertained that, although various species of bacteria may be the cause of cerebro-spiual meningitis, the pneumococcus is the most common cause not only of meningitis secondary to pneumonia but also of primary cerebro-spinal meningitis, including the epidemic form.
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The great merit of Jaeger's publication in 1895 lies, not in adding materially to Weichselbaum's description of the meningococcus iutracellularis, but in directing attention to the special association of this coccus with epidemic cerebro-spinal meningitis. He denies any relationshij) between the pneumococcus and this disease. Most of those who have investigated the subject during the two years following the appearance of Jaeger's article have come to the same conclusion, and the confirmation of this view by Dr. Councilman in his report of a larger number of cases of epidemic cerebro-spinal meningitis than have been previously studied bacteriologically by a single observer is an importaut contribution to our knowledge.
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The question naturally arises whether those who before Jaeger's publication reported the presence of the j)neumococcus in the exudate of epidemic cerebro-spinal meningitis have all been mistaken in the diagnosis of the organism. As some of these reports are by highly competent bacteriologists, it is difficult to admit this supposition. Several possibilities suggest themselves : (1) It is possible that the meningococcus iutracellularis is not the sole specific cause of epidemic cerebro-spinal meningitis, but that the pneumococcus is likewise the cause of a certain number of cases. (2) There may have been mixed infection or secondary infection with the pneumococcus; the intracellular meningococcus, on account of its scarcity or failure to grow iu the cultures, or absence of pathogenic power by subcutaneous inoculation, being overlooked. (3) It is probable that in some cases at least the intracellular meningococcus has been mistaken for the pneumococcus. Further investigations are needed in order to determine how much value attaches to these various suppositions.
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Another question of interest is as to a possible relationship between the meningococcus iutracellularis and the micrococcus lauceolatus, in the sense that the former may be a variety of the latter. All of those who have worked with the meningococcus appear to agree upon the independence of this organism as a bacterial species, and especially upon its separation from the micrococcus lauceolatus. This view seems to me probable. Nevertheless, the great variability of the lanceolate coccus as to form, cultural characteristics and pathogenic properties renders this question still a debatable one, as is shown by the position assumed by Lubarsch in his discussion of the relations of this organism to the streptococcus pyogenes
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[No. 83.
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on the one hand and to the meningococcns intracellularis on the other hand.*
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Baltimore seems to have enjoyed remarkable immunity from epidemic cerebro-spinal meningitis. In New York I used to see every year at least a few sporadic cases of primary cerebrospinal meningitis.
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It may not be out of place if I say a word in this connection concerning the disease in horses commonly called cerebrospinal meningitis. Through the kindness of Dr. Clement I have had the opportunity of making autopsies upon horses in Maryland which have died with the symptoms commonly attributed to this disease, and I have been informed by him of his investigations upon the same disease which has prevailed in this State during the past summer and autumn. In none of the cases which we examined was there any meningeal exudate. The disease was not cerebro-spinal meningitis in the anatomical sense, nor were we able to find any lesions competent to explain the symptoms. While I would not be understood to deny the occurrence of genuine cerebro-spinal meningitis in horses, I believe that the disease which usually passes by that name among veterinarians is not a true meningitis. We did not obtain evidence even of a meningitis serosa, as claimed for these cases by Siedamgrotzky and Schlegel.
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Dr. Flexner. — One appreciates all the more what the investigations of Dr. Councilman have involved if he has had an opportunity of studying an epidemic of cerebro-spinal meningitis. Many of you will recall that Dr. Barker and myself, through the courtesy of the State Board of Health, were permitted to study an epidemic of this disease which prevailed in the year 1893 at Lonacouing and other places in the George's Creek valley in this State. As Dr. Councilman proceeded to develop the symptomatology and the pathological anatomy of his cases I was impressed more and more with the idea that we had been working with the same disease-process. In one respect only do onr results differ; Dr. Councilman has become convinced through the study of the large material at his command that the causative micro-organism is the meningo-coccus inti-acellularis of Weichselbaum, while we believed that we isolated from our cases the diplococcus pneumoniiE. In regard to this disparity, of which I shall speak more at length, it is worth while noting that Dr. Councilman stated that he did not distinguish the two organisms in his first post-mortem examinations.
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The epidemic at Lonaconing was perhaps larger than the one at Boston, but its investigation was much more difficult. Dr. Barker and I spent some days in this place and the adjacent country in which the disease' prevailed, at a time when the epidemic was on the decline. We had therefore to rely for our statistics upon the reports of the local profession scattered over twenty miles of rough mining country. Our conclusions were that there had occurred within this area about 200 cases of cerebro-spinal meningitis and the mortality had been about 48 per cent., a figure somewhat lower than the Boston epidemic and somewhat higher than some of the reported European epidemics.
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Lubarsch-Oestertag. Ergebnisse der allg. Pathologie u. path.
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Anat., 3ter Jahrg. I, p. 169.
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Our studies were both clinical and pathological. While we had the opportunity of visiting many cases, we succeeded in obtaining two autojjsies only. These were of great interest to us as they were examples of two different types of the disease. I wish to recall to you briefly these cases.*
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Case 1. Girl 9 years of age; died on 3rd day of disease; autopsy two hours post mortem. There were no adhesions between the dura and skull-cap, the dura and pia arachnoid were free from adhesions to each other. The soft meninges were swollen, but no considerable quantity of fluid escaped from them ; they were opaque, especially over the convexity of the brain, and in the depressions between the sulci heavy opaque white streaks and bands were visible. The exudation into the meninges was confined to the convex surface of the brain, the base being free from it ; but the ventricles were dilated and contained an excessive amount of clear serum.
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The dura covering the spinal cord, especially in its inferior part, was wide and bulging. On incising it near the middle of the lumbar region about 40 cc. of turbid fluid escaped. In the meshes of the pia arachnoid was an exudate which was not uniformly distributed, but was most abundant posteriorly, and corresponded for the most part with the lower cervical and dorso-lumbar region. The exudate resembled that present in the brain.
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The bacteriological examination by means of cover-slips showed the presence of what was regarded as the micrococcus lanceolatus without admixture with any other organism. The micrococci occupied pus cells and were also present in the fluid among the cells.
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Case 2. Girl 16 years old; death in third week of disease; autopsy 12 hours after death. The dura was strongly adherent to the skull-cap, and on removing it about 200 cc. of turbid fluid containing white flakes escaped from the posterior fossa. The fluid in the pia over the cortex, which was increased in amount, was turbid. In the membrane covering the pons and upper part of medulla was a firm white deposit which was intimately adherent to the underlying tissues. Over the base, from the pons to the optic chiasm inclusive, there was a turbid fluid exudate. The fourth ventricle and the lateral ventricles contained greenish-yellow, gelatinous pus; indeed the former was completely filled with it. Both the lateral ventricles were dilated, and the choroid plexuses covered with an opaque exudate. A similar exudate extended along the sheath of the auditory nerve into the bony canal. The pia arachnoid, throughout the whole length of the cord on the posterior surface, contained an opaque exudate fully two millimetres in thickness, the exudate on the anterior surface I being less marked. From the pus in the ventricles and from the exudate over the base of the brain diplococci were obtained on cover-slips. The organisms were present in much smaller numbers than in the previous case. I
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The cultures made from the brain and other organs did not ' grow. Those made from the first case, which was most promising, included the cerebro-spinal exudate and organs
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Ab8tracted from report in American Jourual Jledical Sciences,
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1S94.
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February, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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33
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generally. Cultures from the exudate were made at once on exposing it by drawing back the dura. Additional cultures were made an hour or so later. It is necessary to state that the second set was made in a carriage-house next a stable in which horses were kept. The first cultures, made at the time of the autopsy, showed a very feeble growth of diplococci ; but on transplantation no further growth could be obtained. All other tubes from the brain or cord showed either no growth or an abundant one, a tolerably coarse bacillus, doubtless a contamination. Culture tubes from the organs remained sterile with the exception of those from the spleen. From this a pure growth was obtained of streptococci. The cultures from the second case could not be made until Baltimore was reached, 14 hours after the autopsy. Various media inoculated from the exudate and solid organs remained without growth ; mice and rabbits were inoculated without effect. In view of the negative results in cultivations and animal experiments, we regarded it as questionable whether the organism found by us in the exudate was really the micrococcus lanceolatus. But as it is regarded as characteristic of the lanceolate diplococci to show a variable vitality and great variation in pathogenic effect on animals, we were therefore the more disposed to consider the bacteria found by us as probably identical with this organism. In interpreting the studies of Dr. Councilman and comj^aring them with those of Dr. Barker and myself, it must be remembered, as Dr. Welch has just pointed out, that it was not until Jaeger's studies, which appeared in 1895, that the meningococcus intracellularis was sharply differentiated from the pneumococcus. There remains, moreover, the disparity in behavior of the bacteria found by us and the organism obtained by Dr. Councilman towards Gram's stain. Kecent studies have shown the Gram's method of staining to be a feeble reed and one perhaps unworthy of the confidence placed in it as a means of differentiation of bacterial forms. All these facts taken together, and especially the histological details of Dr. Councilman's study, which agree so well with our findings, dispose me to the belief that the Lonaconing and Boston epidemics have not improbably been caused by the same micro-organism.
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In our studies of the histological changes in the central nervous system. Dr. Barker and myself were impressed with the large phagocytic cells which Dr. Councilman also found, and we regarded them as forming a considerable portion of the exudate in the acute case. The figure No. 3 in the reprint (passed around) which I brought with me will show you the relative size and numbers of these cells in a portion of the exudate in the meninges of case 1. These cells were regarded as being derived by proliferation from the pia mater. In the chronic case the exudate looked more like the caseation of a tuberculous meningitis than an ordinary inflammatory exudate, and the stained preparations showed extensive degeneration of all the morphological elements composing the exudate. We found in our cases a tendency for the exudate to pass along the sheaths of the nerves (optic and auditory ; spinal nerves) leaving the cerebro-spinal cavity, and we attributed the disturbances of sensation in part to the involvement of the posterior roots of the spinal nerves. Dr. Councilman has not mentioned the occurrence of abscesses within
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the substance of the brain and spinal cord; we encountered several small accumulations of leucocytes in the spinal cord, and it maybe recalled that Zenker, Klebs and Striimpell have shown that abscesses of comparatively large size may exist.
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I have been most interested and instructed by Dr. Councilman's presentation of the subject, and I desire to add to the sentiments already expressed my sense of obligation to him.
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Dr. Barker. — I was much impressed with what has been said with reference to the presence in the nose in cerebrospinal meningitis of the organism which gives rise to the disease. It is certainly anatomically proven that relatively free communication exists between the nose and the intracranial cavity, but it is just as reasonable to assume that the organisms pass from the cerebral meninges to the nose as to believe that the path followed is in the opposite direction.
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Concerning the lesions in the nervous system Dr. Councilman states that he has found marked alteration in the ganglion cells and in the white matter of the spinal cord and brain. In the report made by Dr. Flexner and myself of the autopsies at Lonaconing, considerable attention was paid to the nerve lesions. Since then better methods of studying alterations in the nerve tissues have been developed. In view of this fact I undertook last year to restudy the spinal cords of our cases, some portions of which had been preserved, and in them it has been possible to make out some interesting changes not referred to in our article. The results were communicated to the Pathological Section of the British Medical Association, held this autumn in Montreal, but it may not be out of place to refer briefly to the main points.
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As is now well known, the cells of the anterior horn of the spinal cord, when stained by the method of Nissl, show inside them what appear to be three distinct substances: (1) In the dendrites and cell body (except in the area whence the axone arises) the stainable substance of Nissl, here arranged chiefly in the form of spindle-shaped masses, the latter in turn tending to be arranged in stripe-like rows; (2) the achromatic substance occupying the regions between the Nissl bodies, and constituting the whole of the axis cylinder process and its hillock of origin ; (3) the so-called " pigment " of the anterior horn cells.
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In the Lonaconing material, though the tissue was not. perfect for work with Nissl's method, it was easy to make out two distinct types of change. The first, briefly stated, consisted in a disintegration in the stained section of the individual Nissl bodies, especially in those of the dendrites and of the periphery of the cell body. In the second tyjie the anterior horn cell presented an entirely different appearance. Whereas the Nissl bodies at the perijjhery of the cell and in the dendrites were sometimes tolerably well preserved, in the centre of the cell the achromatic substance was entirely broken down, this portion of the cell being either pale in sections stained by Nissl's method, or pervaded by minute dust-like particles of the stainable substance. In addition, the nucleus of the cell was displaced to the periphery, sometimes to such an extent as to cause a distinct bulging at the margin of the cell.
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In the light of the more recent work bearing upon the patholoo-y of the nerve cells it is not difficult to bring forward plausible
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34
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 83.
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explanations of these lesions. The researches of Nissl, Marinesco, Flatau, Liigaro, van Gehuchten and others have demonstrated that in many forms of poisoning the action of the toxic snbstauces upon the cells tends to be exerted chiefly upon the periphery. It is but natural that poisonous substances circulating in the blood and lymph should affect the dendrites and periphery of the cell before leading to alterations in its central portion. My own studies on ricin poisoning and diphtheric intoxication support the observations just mentioned. On the other hand Nissl was the first to call attention to the fact that if a given axis cylinder be severed or seriously injured, the cell body of the neurone to which it belongs undergoes curious and typical alterations, and the nucleus is dislocated from its usual position. Thus if the root of the n. facialis be cut, the cells in the nucleus of origin of the same side situated in the pons undergo the alterations described; the nucleus is displaced to the side of the cell ; the Nissl bodies in the ceil, more particularly in the central regions and especially near the axone hillock, are disintegrated or even wiped out. Nissl further proved that the application of common salt to the nerve trunk without actual section of the fibres would yield the same result. The experiment has been repeated by many neurologists and in the Anatomical Laboratory here by J. Erlanger. Nissl's results have received manifold confirmation.
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It is obvious, if you compare the two types of changes which I have described as occurring in the anterior horn cells in cerebro- spinal meningitis, with the two classes of changes mentioned in the bibliography, that there is a striking agreement. The first type corresponds to the primary alteration consequent upon direct insult of the cell bodies and dendrites by a poisonous solution bathing them, while the second type corresponds to the secondary changes occurring in the cell body after insult to its axone at any point between the cell and the peripheral ramifications of the nerve fibre — in other words, to the "reaction at a distance" of Mariuesco.
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The first series of lesions, not strongly marked in the specimens, are probably to be accounted for by the slight tox£emia which we may assume accompanies a meningitis ; for although the causative micro-organism does not lead to a severe general .intoxication of the body, at least under ordinary circumstances, there is evidence (from the occurrence of leucocytosis and changes in the urinary secretion) that some poison is absorbed. That the lesions of the first type are so little marked is probably directly attributable to the fact that the disease is relatively non-toxic.
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The other lesions, those designated as " secondary," were in contrast with the "primary" or "toxic" lesions very marked in the anterior horns. The explanation is not far to seek. In the Lonaconing cases, and as Dr. Councilman has stated in those coming to autopsy in Boston, a very common finding was involvement, in the meningeal inflammation, of the anterior and posterior roots of the spinal nerves. Swollen axis cylinders, accumulations of small round cells and of leucocytes were met with, the changes varying in degree and extent in different nerve roots. That the cells in the anterior horns then should show the alterations so characteristic of axone lesion is not surprising; indeed, from what we now know their
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existence could have been prophesied, and their absence would have been extremely difficult to account for. The variation in the number of cells affected in different segments of the cord doubtless depends upon the varying degree of involvement of the corresponding nerve roots.
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The explanation of the condition of the cells of the nucleus dorsalis Clarkii met with on studying the thoracic cord was temporarily puzzling. An examination of sections showed that almost every cell in this nucleus on each side showed alterations quite like those following axone lesion. The axones of these cells enter neither the anterior nor posterior roots of the spinal nerves. Some other explanation than nei've root involvement had to be sought; for although the experiments of Warrington in England and van Gehuchten in Belgium make it seem probable that a lesion apparently precisely similar can be called forth in a nerve cell by depriving it of the cellulipetal impulses reaching it, it is scarcely conceivable that there could have been, through the irregular involvement of the posterior roots, sufficient interference with the passage of impulses along collaterals and terminals into the nucleus dorsalis to account for the involvement of almost every one of the cells contained within it. If, on the other hand, one inquires as to the course followed by the axones of the cells of this nucleus, there comes into view a much more plausible explanation for the lesions. While, so far as I know, no one has ever actually demonstrated the connection of the axones in the tract with the cell bodies of the nucleus by means of the method of Golgi, still the study of secondary degenerations by Mott and of the embryonic cord by Flechsig leave but little reason for doubting the view now generally held that the axones of the cells of the nucleus dorsalis Clarkii are also the constituent axis cylinders of the fibres in the fasciculus cerebellospinalis (direct cerebellar tract).
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The exact position of the direct cerebellar tract in the spinal cord, and in the medulla oblongata where it passes into the corpus restiforme, is well known. The fibres occupy an extensive area immediately adjacent to the surface of the cord, being intercalated between the lateral pyramidal tract and the periphery. A reference to the description of the gross appearances of the cord in cerebro-spinal meningitis will show that it is precisely in this region that the meningeal exudate is most abundant. Is it any wonder then that axones running practically on the surface of the cord all the way from the thoracic region to the corpus restiforme, exposed throughout this whole distance to the direct action of the meningeal inflammation, should undergo inj ury ? AVould it not be more surprising to learn that some fibres had escaped insult? I am of the opinion therefore that the lesions of the second type met with in the nucleus dorsalis in cerebro-spiiuil meningitis are in reality "secondary" to injuries of the axones in the direct cerebellar tract, and afford another example of the so-called " reaction at a distance."
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Dr. Theobald. — There are two points I would like to allude to. Dr. Councilman has spoken of the belief that the disease is comparatively rare in young children. I have seen from time to time a great many cases of deaf-mutism from cerebro-spinal meningitis, at least the history indicated this, and most of these had the disease in infancy or early childhood. So it
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February, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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35
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would seem, if this view is correct, that when the attack occurs in early childhood it is more apt to affect the ears than it is later in life. Again, Dr. Councilman spoke of the labyrinth being involved through extension of the inflammatory process along the auditory nerve. While this is one way by which the labyrinth may be reached, another, not improbable, route would be through the aqueductuscochleas and the aqueductus vestibuli which connect the lymph spaces of the labyrinth with those of the brain.
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Dr. Randolph. — I had the opportunity of examining the eyes of about forty cases in the epidemic of cerebro-spinal meningitis which has just been described by Drs. Flexner and Barker, and of these the fundus was normal in only seven cases, and out of these seven cases one had divergent strabismus and dilated pupils, another had marked nystagmus, and still another had greatly dilated pupils. I found neuritis optica in six cases. There was one case of retinitis with which was associated thrombosis of the central vein of the right eye. The other cases were (as regards the fundus of the eye) characterized especially by great venous engorgement and tortuosity, and more or less congestion of the optic disk. In the eight cases of divergent strabismus it was the right eye that diverged. In four cases the right pupil was dilated and the left unchanged. In three cases the neuritis was more marked in the right eye. I can give no satisfactory reason why the right eye more often showed abnormal conditions than the left.
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The type of eye symptoms peculiar to this epidemic seems to have been a remarkable tortuosity and distension of the retinal veins and more or less congestion of the oj^tic disk. The degree of venous engorgement in some of the cases was, in my experience, a unique condition, the blood appearing almost black and as though actually stagnant. The tortuosity of the veins, too, was striking. The turning points of
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the veins were so abrupt that they resembled small hemorrhages, and as such I regarded them in one case till I was enabled later to make a more thorough examination, when I found that what I took to be hemorrhages were very abrupt tui-ns in the veins where the circulation must have been almost at a standstill. These conditions are quite analogous to what was discovered in the brain in every case where a post-mortem was made. I regard the existence of eye symptoms, especially those where the fundus is involved, as indicating a particularly grave case. Wherever I found the condition I have described very pronounced I felt justified in speaking positively as regards the prognosis. I think that this type of eye symptoms is of more value as indicating the condition of the brain than the symptoms described by other writers, such as panophthalmitis, suppurative choroiditis and keratitis, affections which in my opinion would be likely to have their origin in general infection, and not likely to be the direct result of purely cerebral changes.
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I have been interested in Dr. Councilman's account of the bacteriology of the disease, and it may be worth while mentioning that the Fraenkel-Weichselbaum diplococcus, which has been regarded till lately the specific organism of epidemic cerebro-spinal meningitis, has been identified as the causative agent in more than one eye affection. Recently Uhthotf and Axeufeld have reported 34 cases of serpent ulcer of the cornea, where they found this diplococcus in every case, and in the majority of cases in pure culture. These observers go so far as to call this affection of the cornea the pneumococcus ulcer. Not a year ago Gifford reported an extensive epidemic of "pink eye" in Omaha and its vicinity, and he was able to identify the pneumococcus of Fraenkel-Weichselbaum as the specific organism. In conclusion it may be said that this same organism is the predominating one in the majority of cases of chronic suppurative inflammation of the middle ear.
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THE DIAPHRAGM PHENOMENON-THE SO-CALLED LITTEN'S SIGN.
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By Norman B. Gwyn, M. B., Assistant Resident Physician.
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In an indirect way the movement of the diaphragm is well recognized by its displacement of underlying organs or masses, and in this direction its value in the diagnosis of certain conditions is thoroughly established ; but the fact that this movement normally gives indication of itself seems until lately to have escaped the observation of clinicians.
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Stokes first, in 1837, incidentally mentions that in some cases of emphysema the diaphragm stood so low that its line of contact could be seen as a transverse furrow, moving downwards with inspiration, between thew hypochondria, and that there was a similar occurrence in pleurisy.
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Gerhardt, in the second edition of his " Lehrbuch der Auscultation," quotes these words of Stokes, and adds that in similar cases at the beginning of a short and deep inspiration he has seen this furrow move first a little upwards, then downwards. Gerhardt further states that "occasionally the movement of the diaphragm at a higher level can be seen on the intercostal spaces of very wasted people, a slight horizontal furrow
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separates in these cases the upper concave part of the diaphragm from the lower flatter part, and moves up and down. Artificially overfed sucklings give the first sad examples for the demonstration of this occurrence."
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The deformity known as Harrison's groove, marking the early position of the point of contact of the diaphragm with the chest wall, may be mentioned as one way of determining by inspection alone where this muscle stands or has stood in earlier years.
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Except Stokes and Gerhardt, physicians do not seem to have observed any direct visible movement of the diaphragm, and they definitely limited it to certain abnormal conditions, and seem to have regarded it as an accidental occurrence. Stokes says " in some cases of emphysema." Gerhardt expressly says " in similar cases," and " in extremely wasted conditions." These references do not take into consideration a constantly visible movement, which was first recognized and described bv Litten in 1892.
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36
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[Xo. 83.
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His account appears under the title of "The visible movements of the diaphragm which are normally seen on the thorax with every respiration," and he states particularly that it is a description of a constantly visible movement of the diaphragm, which up to this time had been described as a very rare condition, or as one occurring only in pathological conditions. As a preliminary he dwells upon the action of the diaphragm, its position as determined by pei-cussion, and the extreme value of the ascending and descending movements of this muscle in the physical examination, and in contrast to all previous methods of estimating the movements he insists upon the possibility of so doing by direct inspection of the thoracic walls.
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Previous to a full description the references of Stokes and Gerhardt are discussed, which are altogether to pa(7wlogical conditions; then the statement is made that "in contradistinction to these the author has made this observation," namely, "that one can see the movements of the diaphragm as a constant physiological appearance, returning with every respiration on the thorax of every sound person, and also on those patients who have no grave respiratory disturbance."
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The phenomenon is described as an undulating movement or shadow which begins on both sides at about the level of the sixth intercostal sjDace, and descends with inspiration as a distinct line or furrow for several spaces, reaching sometimes the costal margin, returning to its point of origin with expiration, and crossing the ribs at an acute angle.
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With a deep inspiration the visible movement or play of the diaphragm travels 2-3 s^mces. In superficial, this is reduced to 1-1 J. The movement may cover the whole width of the side of the thorax, so that the visible line of departure of the diaphragm reaches from axillary line to the sternal margin on same side. In other cases one may not see it in this full extent, but perhaps only between the axillary and parasternal or mammillary lines, or only in one or other intercostal space. The movement on the right side is usually more marked than on the left, but often the reverse is true ; it can also be well demonstrated on the back. The costo-abdominal type of resjiiratiou seen in men favors the occurrence of the movement, which is not so constantly present or so well marked in women and children.
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To see well this movement of the diaphragm the recumbent position, either on back or abdomen, is required. The lateral position is unfavorable. A thick chest wall does not necessarily hide the movement. Pull daylight, with the bed near a window, the observer in front and to the side, complete the requirements. Artificial light is useless unless concentrated on the side examined.
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This comprises the description of Litten's sign, as it is now commonly called. Litten mentions that he has known of its occurrence for some time, and that so far he has not failed to find it in any case, provided there was no marked respiratory disturbance. The principal importance attached by him to this movement is that it gives an absolute method for determining at a glance the exact position of the diaphragm and its mobility, and having fixed the position of this muscle the inferior border of the lungs is also found. It gives also an idea of the depth of respiration, and finally in the left front the heart's lower limits can be mapped out by this movement.
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Chief among respiratory disturbances which interfere with the production of this movement are emphysema and pleural effusions; other processes are pericardial adhesions, tumor masses underlying the diaphragm, and paralysis of the diaphragm itself. Litten states that pleural effusions cause partial obliteration of the movement on the affected side, and in addition that the level of the effusion may be influenced by the rise and fall of the diaphragm. Emphysema and hypertrophy of the right ventricle, by depressing the diaphragm, may give indication of its visible movement as a transverse furrow below the xiphoid between the costal margins.
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A year after the appearance of Litten's article, Becher of Berlin admitted the normal character and value of the sign and sought to determine its cause. This was the first notice of Litten's original communication, which seemed to have attracted so little comment that in 1894 he again called attention to the subject. Following this second article came a statement from Martins that Litten had entirely overlooked the fact of Gerhard t's description several years before, to which Litten replied, pointing out the differences already referred to.
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In the Wiener Klin. Wochenschrift, 1895, Litten returned to the question, and deplored the fact that so little attention had been given to his original paper. In this article he added several points of interest. The cause is stated to be the peeling of the vertical portion of the diaphragm from the chest wall by the inspiratory contraction, and the subsequent replacement in expiration. In looking for the sign behind, the knee-elbow position is recommended. The observer should stand three or four feet away from the patient, at an angle of 45 degrees with his body. Both patient and observer should be turned from the light, which should come from a window directly adjacent to the bed. Three essential requirements are given : horizontal position, good light and full deep breath. From 6 to 7 cm. are given as the normal limit of descent of the movement ; anything less than this is considered abnormal. By comparing the descent of the abdominal organs during the descent of the diaphragm it is considered that we have a valuable confirmatory accessory sign. Should the diaphragmatic movement not be observed on one side or other, palpation should show that underlying organs are not depressed as they normally are.
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The sign is valuable in differentiating subphrenic abscess from a small pleural effusion. In the former the line at which the movement begins is elevated, while in the eft'usiou the line of movement, if present, is depressed. In the Verhandluug der Berliner Med. Gesellschaft a case of subphrenic abscess is reported in which the line of origin was pushed up to the third rib.
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According to Litten, small pleural effusions do not obliterate tlie movement entirely,-but show it at a lower level, which indicates that a small effusion does not sink into the complementary sjjace, or that it is unable to separate the adjacent diaphragm and chest wall. Tumors in the thorax also depress tlie line of origin, while abdominal tumors elevate it, but do not obliterate it; only one case of sarcoma of the liver, thirtysix pounds in weight, having been observed to do so. With tumors are included jiregnancy, tympanites, moderate ascites. Litten furtlu'r states tliat if the visible niovenieiit reaches thi
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February, 1898.]
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costal margin (an occurrence which is never normally the case) one must consider the existence of emphysema.
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Generally speaking, processes which limit the breathing to the costal type obscure the diaphragm phenomenon ; with these is to be included pneumonia of the lower lobe, a point not- mentioned in the first article. Pleural adhesions and retraction of the chest give an impaired or restricted movement.
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From this review of the 1895 article it is seen that Litteu not only confirms his previous views, but elaborates them, and insists on the physiological and clinical value of the sign. His observations, which dated from 1891, numbered nearly 6000, and he asserts that nothing has so far come up to disprove the occurrence of the diaphragm phenomenon in every normal chest.
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There are very few confirmatory references to Litteu's sign. Eichhorst* says "the movements of the diaphragm are often visible in people not too fat, as a light shadow which especially on the right side descends with inspiration, ascends with expiration; the extent of this shadow is 5-7 cm. Litten has called this the diaphragm phenomenon, and places much value thereon as marking the lower border of the lungs." In the second edition of Musser's diagnosis there is also a note upon it.
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Elkanf reviews the subject and insists on the value of the sign in diaphragmatic hernia ; its retention at a higher level than normal, and the tympany above it from the distended intestines being the marked features.
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Stabyl gives the diajihragm phenomenon considerable diagnostic value.
 +
 +
Rumpf § in studying the diaphragm phenomena in beginning pulmonary apical tuberculosis, shows that when the apex is involved to a certain extent the sign is lessened perceptibly on the affected side.
 +
 +
The diaphragm phenomenon is generally held to represent the peeling oif of the vertical part of the diaphragm from the chest wall and its subsequent replacement. This is Litten's view, and it seems most reasonable. Two other views are advanced in Becher's article of 1893. Gad thinks it due to the atmospheric pressure around the infundibula of the lungs, which is increased by the beginning descent of the diaphragm, the negative pressure not being immediately neutralized from the upper air passages. As the lungs descend, the diaphragm preceding them, this line of atmosjjheric pressure follows the line of the lower border of the lungs downward, and makes the shadow or undulation of descent. He does not explain the shadow of ascent.
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Becher holds that the abdominal contents, feeling the direct pressure of the diaphragm downwards, attempt to neutralize the negative pressure at the point where it is most marked, i. e. at the meeting of the horizontal with the vertical part of the diaphragm. The pressure to which the contents are subjected
 +
 +
 +
 +
Lehrbuch Klinische XJntersuchungen Methoden innere Krankheiten, Ed. 1896.
 +
t Berlin Thesis, Aug. 1896. t Berlin Thesis, February, 1896. § Berliner Klin. Wochenschr., Feb. 8tb, 1897.
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and their attempts to neutralize the negative pressure result in a protrusion against the point of meeting, making the visible sign descending with inspiration. As reason for this view Becher gives Hinke's description of the diaphragm. This is that the diaphragm has two parts, a vertical, rising from the attachment at the costal margin and lying in contact with the chest wall as high as the sixth or seventh rib, and a horizontal part stretching directly across, meeting the vertical at a distinct angle. The close apposition of the vertical to the chest wall allows the pressure results to be easily transmitted through it.
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We might well question whether, as Litteu supposes, the mere separation of one smooth surface from another is capable of producing the phenomenon. Could we include the influence of atmospheric pressure, Litten's view would be strengthened, for often the phenomenon is marked as a distinct narrow furrow, a depression which looks as if pressure were exercised from without. One can see in many chests on sudden stoppage of inspiration a similar furrow momentarily made along the lower pulmonary borders. Harrison's groove, which represents this in a chronic form, seems to jjoint to the occurrence of a negative pressure within and a counteracting external pressure.
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Against Becher's view it can be primarily said that the phenomenon does not appear in the form of bulging, but, as has been stated, is more to be compared to a furrow ; the result seen in sudden stoppage of inspiration and in Harrison's groove both seem at variance with his idea.
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The result of increased abdominal pressure on the right side must act directly through the liver. One would expect some modification therefrom ; the reverse, however, is more often found.
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The descent of the expanding lung is not considered especially as being a factor in producing the diaphragm phenomenon, though it must be in very close relation thei'eto; one could look for a sign produced thus wherever the free border of the lung is inflnenced by inspiration, as, for example, the covering of the cardiac area.
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The production of the shadow seen returning with expiration seems more in accordance with Litten's idea of the replacement of the diaphragm against the chest wall. Neither Gad nor Becher discusses this part of the phenomenon.
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To study and familiarize myself with the sign I have made observations upon 100 consecutive cases in the wards, seeking to confirm Litten's statements.
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The patients were all examined in the recumbent posture. Ths position in every case was such that daylight fell directly upon the side to be examined, forming an angle of 90 to 130 degrees with the line of the observer's vision. The observations were made on clear days before 4 p. m. There was no selection of the cases. In order to expose the sides fully the hands were placed on the head and the jiatient brought to the edge of the bed, and the examination made first during quiet breathing and then during deep inspiration. The limits of the movements were marked in pencil on the chest wall, and the depth of the excursion measured in centimeters. To clearly make out the movement an ordinary deep inspiration is necessary, as only in very thin subjects does a quiet respiratory movement bring out the sign. In very stout subjects
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38
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 83.
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deep iuspiratiou is always necessary. The following are the results in 100 cases examined :
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In every patient not too fat or excessively developed, or who had had no serious pulmonary disorder, the sign was fouud. In one very fat subject. Case 52, thei'e was only a suspicion of the phenomenon on one side. In five cases there was no indication of the sign on either side. In four cases the phenomenon was present on only one side. In the cases in which it was absent one was a colored boy of eleven, with double adhesive pleurisy, the autopsy showing a diaphragm firmly attached to chest wall on both sides. Case 62 was a short, stout, well developed man. Case 38 was a colored man with ascites and general anasarca. Case 49 was a man with extreme emphysema. Case 6, a very stout woman.
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Of those showing the sign on one side only, Case 39 was a well built negro with much effusion into the left pleura, on which side the sign was absent. Case 46 had pneumonia of the right lower lobe. Case 52 was the very stout man above referred to. Case 85 was a colored man with chronic pleurisy on the right side.
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The remaining 91 cases showed the phenomenon more or less equally on both sides. Thin subjects furnished the most satisfactory examples, giving usually more sharply defined and regular outlines to the shadow. The most favorable field of motion for the shadow lay between the parasternal and posterior scapular lines. It sometimes reached as far as the spine behind and the nipple line in front. In the axilla the sign was always the most marked. The extent of visible movement from behind forwards measured from 2 to 29 cm., the average being about 15 cm. In all instances it was a continuous line without interruption. The vertical excursion varied from 1 to 9 cm., the average distance being about 4* cm. It did not reach the costal margin in any case. The beginning of the descent does not coincide accurately with the beginning of the movement of inspiration. One can see the shadow begin a fraction of a second after one has perceived the inspiration to have begun. Erect posture occasionally gave a small sign, while the line of origin would often be seen as an oblique line approaching the costal margin behind, and sometimes reaching it at the finish, when the subject lay on his side. The light seems to be the essential condition. Two cases in which the absence of the sign on one side could not be explained showed on re-examination that the sign was present. Artificial light under some conditions of j)osition gave fair results.
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The shadow ascending with expiration moved accurately in the same field as the descending shadow, ending quite abruptly at the line of origin. It was never so marked as the descending shadow, and never showed the marked furrow-like appearance observed often in this.
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On either side the lines of origin as determined by insi^ection were at a very nearly equal distance from the costal margin ; a difference of J to 1 cm., however, was quite common. It was not apparent that the line stood higher on the right side over the liver. The descent on both sides was never so equally marked, differences of 2 to 3 cm. being quite often seen where no affection of respiration was suspected or found. This difference was noted both on right and left.
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The position and extent of the phenomena in a majority of the cases was within the same lines, but occasionally one side would show a sign several centimeters longer from behind forward, and perhaps situated more towards the back or front than the other.
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Litten's sign may be regarded as a normal phenomenon. The absence in 9 of the 100 cases in this series could be reasonably accounted for. Litten states that in his enormous number of observations, amounting now to many thousand cases, it was present in every normal thorax. It is certainly a matter of very great value to be able to see at a glance the inferior border of the lung, and it is certainly true, as Litten says, that the student has now a valuable and accurate method of proving the correctness of his percussion, and a rapid and easy way of ascertaining a fact that previously had to be laboriously and jjerhaps only indefinitely determined.
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As yet the value of the jihenomenou in diagnosis is unsettled. So long as one may see in apparently normal chests differences of several centimeters, it would be hard to say what might be considered abnormal. The complete absence of the sign in large effusions and emphysema is an interesting and natural fact, but the presence in small effusions might be misleading. Cases of subphrenic abscess and diaphragmatic hernia, in which rather striking modifications of the phenomenon have been observed, are rather few to establish any fixed rule. Only adhesions of the diaphragmatic and costal pleural layers directly below the infundibula of the lungs would interfere with the diaphragm's descent enough to obliterate the sisrn.
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PROCEEDINGS OF SOCIETIES,
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THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.
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Meeting of November 1, 1897.
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Dr. Baekee in the Chair.
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Cases of Aneurism.— Dr. Hunnee.
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Case I. — "W. T. G., a3t. 27, a printer, with a definite family history of tuberculosis, was sent to the hospital on October 26 by Dr. Norton of Washington, with the diagnosis of abdominal aneurism.
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Since a boy he has always been accustomed to holding type in his mouth. He has carried heavy " forms " of type resting against his abdomen, and has lifted heavy weights in the gymnasium. He has had several attacks of gonorrhcea, and about seven years ago an attack of acute arthritic rheumatism which he thinks was synchronous Avith one. No definite history of syphilis. He has been a pretty heavy drinker of alcoholics since a boy.
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His present trouble dates since May or June of this year, when he began having a "dull dragged-out feeling" and
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February, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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39
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occasionally sharj) pains across the abdomen, which caused him to lie doubled across his printer's stool for the pressure benefit. At this time he often vomited after eating, but has not vomited for the past two months.
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The paiu and weakness have increased since May and he has lost about forty pounds in weight. During the past mouth he has been obliged to sleep on the left side or in the erect posture, because of j)ain when in any other position. Pain is referred to the pelvic region, at times shooting into scrotum, at times extending even to the knees. In walking the street a sudden jar gives great pain. He walks slightly bent forward to avoid pain. He first noticed pulsation in abdomen one month ago.
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On physical examination he is found to have greatly sclerosed arteries ; a markedly accentuated second aortic sound ; no blue line on the gums or other evidence of plumbism.
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On inspection of the abdomen a diffuse pulsation over the whole upper abdominal region, most marked in the left epigastrium, is seen. This region is prominent, and the left costal margin over the sixth and seventh cartilages is bulged slightly forwards. The pulsation is felt to be limited to the upper half of the abdominal aorta, over which a globular exj^ausile mass the size of a very large orange can be outlined. A purring systolic and diastolic thrill is felt over the mass. Percussion gives dullness everywhere over the mass, but later, during observation, stomach tympany is found on percussion over its lower left quadrant. On auscultation a loud double murmur — a systolic, loud, harsh, and short — a diastolic, fainter, prolonged, and almost musical in character — is heard. In the back a soft blowing systolic murmur is heard over an area to the right of the vertebras extending from the eleventh dorsal to the first lumbar. The knee kick is greatly exaggerated.
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Case II. — 0. G., a German, set. 47, was first admitted to hospital, Oct. 23, 1896, complaining of pain in the back and left side. He has an excellent family history and has always been a healthy and hard-working man. He served through the Franco-Prussian war in the artillery ; has always been a steady drinker of alcoholics ; twenty years ago he had a hard chancre, and one year later was treated five weeks for secondary symptoms at the Konigsberg hospital. In 1894 he was at the Johns Hopkins dispensary for eye trouble; was told that it was syphilitic in origin, and after two or three weeks' treatment he was well.
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His present trouble began in March, 1896, with paiu in the right side under the costal margin extending down to hip. This grew gradually worse, and about August, 1896, the pain began in the mid-lumbar region, and on first admission in October, 1896, it was described as only on the left side, beginning ill the left iliac region and running back to the spine. The pain was of varied character, a dull aching being almost always present, and several times a day, lasting for a second or two, very sharp pains like the cutting of a knife ran across the abdomen.
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The patient improved greatly during a three months' rest in the Hospital, and in February, 1897, went to work, at first doing light work on a dairy farm, and then heavy work grading roads. He soon had to cease work because of great
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jjain in the left side beneath the ribs, and returned to the Hospital in March, 1897.
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His pains grew more severe and frequent during a second stay of three months, but being ambitious to get to work he left the Hospital in June and was able to work about halftime during the summer. He remained under supervision of the Hospital and kept up treatment with iodide of potassium, nitroglycerine, and cathartics, being obliged to take as high as four grains of morphia per diem for pain. He lost weight and grew weaker, and on October 23 was obliged to enter the Hospital for the third time.
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Physical examination on his first admission revealed an aortic and a mitral insufficiency. On careful inspection there was seen a good deal of throbbing over the manubrium. No localized pulsation. The epigastrium showed a marked pulsation, and on palpation a heaving up and down stroke with an occasional palpable thrill. No positive tumor could be outlined. On auscultation a very loud systolic bruit was heard over the course of the abdominal aorta. This thrill was intense and rough in the left upper quadrant of the epigastrium. In the back a murmur could be faintly heard about opposite the tenth dorsal vertebra and for a distance of six centimeters below.
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On his second admission in March, 1897, the pulsation, the thrill and bruit were all increased in intensity, and on deep pressure just below the ensiform it was thought that a throbbing expansile tumor could be f elt ; not, however, as a globular mass.
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Before his discharge in June a pulsation could occasionally be detected in the back ; and during a paroxysm of pain, with one hand under the ribs in front and one under the ribs behind, a definite expansile pulsation could be obtained. On his last admitsion in October a diffuse epigastric pulsation is seen, although the region shows a depression rather than an elevation as before. The pulsation and displacement of the hand is limited to the upper half of the abdominal aorta. On auscultation over this area a loud blowing systolic murmur is heard, followed at times by a higher pitched blowing diastolic.
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Inspection of back shows a widely diffuse pulsation at the outer edge of the erector spinte muscle just below the twelfth rib. This is more evident on palpation. On auscultation over this area a very faint distant systolic murmur, followed by a sudden diastolic shock, is heard. Examination of the tendon reflexes shows that of the right rectus femoris to be apparently normal, while the left seems diminished.
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Dr. Barker. — The possibility of the healing of aneurisms has interested me especially, for I have met with one case in which an aneurism of the aorta of considerable size healed spontaneously. In 1891 a colored man applied to the dispen sary for treatment, complaining of cough, shortness of breath and some swelling of the legs. His personal history showed that he had been a hard worker and had seen the rough side of life; he had indulged in alcohol to excess and gave some evidence of having had lues. On examination of the chest a globiilar swelling was found in the parasternal region on the right side, extending from above the sternal clavicular articulation to the level of the third rib. The swelling pulsated
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40
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 83.
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with the heart's beat, yielded a marked systolic impulse aud evident diastolic shock. It was dull ou percussion, aud the aortic second sound over the area was accentuated. Tracheal tugging was well marked. No difference could be appreciated in the pulse at the two wrists ; the radials were thickened. There was no distinct bruit over the tumor, nor was there any valvular lesion of the heart. A diagnosis was made of general arterio-sclerosis with aneurism of the ascending portion of the aortic arch. In*1893, a little less than two years after I had first seen him, he entered the medical ward with oedema of the legs, complaining of shortness of breath ; the urine was albuminous, and a few granular and hyaline casts together with blood corpuscles were present in it. In the thorax there was found an area of dulness, and ou deep palpation a firm resistant mass could be felt in the episternal notch. There was no pulsation of the tumor nor was there any distinct tracheal tugging. The character of the thoracic lesion was puzzling until his previous history in the dispensary was consulted, when it seemed clear that the aneurismal sac had been slowly filled with clots. Dr. Osier suggested that the case be shown at that time to the medical society as one of healed aneurism, and a description of it is to be found in the proceedings of this society published in the March number of the Bulletin for 1894. Some hesitation was felt in concluding during the life of the patient that his aneurism had really healed. The case, however, came later to autopsy in the pathological laboratory, when it was found that the diagnosis made intra vitani was correct. The aneurism was filled with firm lamellated clots and presented as jjerfect a picture of healed aneurism as one is likely to meet with. The individual died from causes entirely independent of the aortic disease.
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Dr. Flexner. — I recall the case of aneurism of the abdominal aorta which was operated upon by Dr. Halsted. The condition found at autopsy was a very interesting one, and the case as a whole is impressed upon my mind because it served as an example of rapid post-mortem development of the bacillus aerogenes capsulatus, the source of which was easily traced to the intestinal contents.
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The autopsy was made 21 hours post mortem in the last week of April, 1896. Man set. 33, well nourished. The peritoneal cavity contained blood-stained fluid in the dependent parts. On the left side a large swelling existed which proved to be a hffimatoma. It occupied one-half of this side of the peritoneal cavity. The serous covering of the splenic flexure of the colon, the meso-colou and the tissues about the pancreas were all deeply infiltrated with blood and contained numerous gas blebs. The meso-colou of the sigmoid flexure, the meso-rectum and the sjjlenic portion of the transverse colon were enormously thickened by recently clotted blood and measured ou an average 3 to 3.5 cm. in thickness. The mesentery of the descending colon and sigmoid flexure formed a part of the anterior wall of a large aneurismal sac, the lower boundary of which was formed by the infiltrated cul-de-sac between the bladder and the rectum, which had about the same thickness as the meso-colon. The infiltration extended posteriorly to the vertebral column. The posterior boundaries of the sac were formed by the sheaths of the psoas and iliacus muscles, the infiltration with blood having extended below
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Poupart's ligament into tlie thigh along the sheaths of these muscles and the tissues of Hunter's canal. The sac of the false aneurism, which in its extreme dimensions measured 22 cm. in length and 26 cm. in transverse circumference, was filled with dark, fairly recent clots. fSimilar clots gave to the wall of this sac its thickness, upon removing which the anterior portion of the sac was shown to be covered by the peritoneal layer alone. The infiltration with blood passed upwards into the diaphragm aud left peri-renal tissues.
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The oiDening in the aorta which communicated with the large sac was nearly circular and measured 2.5x3 cm. in size. This opening led directly into the true sac of the aneurism, which was situated posteriorly, extending to and eroding the vertebral column, aud reached a pool-ball in size. The communication with the larger sac already described was through this sac, the opening in the latter admitting four fingers.
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The aneurism sprang from the aorta to the right of and about on a line with the creliac axis ; all the vessels leading from the abdominal aorta were preserved intact. The iutima of the aorta generally was smooth, but in the beginning of the ascending arch and in the transverse portion several elevated nodular patches free from calcification existed.
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There can be, I think, uo doubt that at some time, perhaps a week or more jirior to the operation, the rupture of the aneurism took place, permitting a gradual escape of blood into the tissues described. Death followed the rupture of the secondary sac thus formed at the tiiue of the operation.
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The bacteriological examination of the frothy, blood-stained fluid in the peritoneal cavity showed many capsulated bacilli agreeing in morphology with the bacillus aerogenes capsulatus. The liver, pancreas and heart's blood yielded small numbers of similar micro-organisms. Cover-slip preparations made from the large intestine (colon and caecum) showed among many bacteria having the morphology of the bacillus coli communis, not a few of the larger forms agreeing with the gas bacillus ; while films from the small intestine showed the presence of the latter in practically pure culture. The bacillus aerogenes cajjsulatus was isolated in pure culture and shown by inoculation of a pigeon to be pathogenic.
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Diabetes in tlie Negro.— Dr. Pancoast.
 +
 +
Dr. Osier has asked me to report the following case: Henry Roy; colored; aged 50 years; driver. On admission he complained of a severe cough aud of weakness and pain under the sternum. His family history is unimportant. Excepting diphtheria and whooping-cough he has had no severe acute infectious diseases. He had a sore about 25 years ago and apparently no secondary symptoms. The patient has had a slight hacking cough at intervals for years, and says that eight years ago he had night sweats for two weeks. Until five years ago he drank whiskey to some excess. He had noticed no change in frequency of micturition or in amount of urine voided, but as long as he can remember he has risen once or twice at night to pass his water.
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About nine weeks ago he was taken with a severe paroxysmal cough which has increased in severity. His appetite has gradually failed and he has lost in strength and weight. He then weighed 188 pounds aud now weighs 139. For a week
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February, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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41
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before admission his scanty expectoration has at times been blood-tinged, and he has suffered from dull pain beneath the sternum. He has had some shortness of breath ; has vomited once and has been quite thirsty after meals. His skin has been dry.
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 +
Examination shows a rather light-colored negro, much emaciated. In the left axilla we found quite evident dullness on percussion and increased transmission of vocal fremitus and voice sounds. Moist crackles were found at the left apex. He has the Argyle-Eobertson pupil and has lost the patellar reflex. He has congenital phimosis and a large scar on the penis. The sputum is moderate in amount and shows numerous tubercle bacilli and bands of elastic tissue.
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Urine in 34 hours, 2300 cm.; specific gravity 1028; a trace of albumin ; 122 grams of sugar. On the ward diabetic diet, which is not sugar-free, he passed fi'om 20 to 50 grams of sugar in 24 hours. After three days of Van Noorden's standard diet the urine was sugar-fi'ee.
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The patient is shown because diabetes in the negro is rather rare and becaiise he illustrates a common complication (pulmonary tuberculosis). Of particular interest, however, is the fact that his blood and urine give the reactions described by Bremer of St. Louis as diagnostic of diabetes. The slides I exhibit were prepared by Mr. Herrick of the Fourth Year Class and show the difference in staining by Congo red very well indeed. I also exhibit two specimens of urine, the patient's and a control specimen. Mr. Herrick has added eosin and gentian violet to each and the difference in color is very marked. The articles of Dr. Bremer which describe this reaction are in the New York Medical Journal, Vol. 63, page 301 (1896) and Vol. 6.5, page 360 (1897); also in the Medical Kecord, Vol. 52, page 495 (1897).
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Dr. FuTCHER.— Diabetes is a rare disease in the colored race. This is the sixth case we have had in the Hospital. Up to May, 1897, there had been 69 cases of diabetes, five of which were in the colored race, making a percentage of 7.2. Saundby credits Dr. Tyson with saying that he had never met with a case of diabetes in the colored race in America, which shows that it is very rare. Tyson, however, in his Practice of Medicine, 1896, states that the disease is rare in the negro race, but that he has seen several cases.
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The proportion of males and females in the white race who suffer from diabetes is about 3 to 2. In children, however, the ratio is not the same ; girls have it more frequently than boys. In the colored race our experience has been that the cases occur more frequently in women than in men, four of the six cases being in women.
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In regard to Bremer's reaction in the urine he claims that it is also present when the urine is temporarily free from sugar. This case is contrary to that belief. It has been claimed by Lepine and Lyonuet that the blood reaction is due to the variable alkalinity of the blood serum. Bremer believes that it is due to qualitative changes in the corpuscles, and thinks that the test supports Spitzer's view that the glycolytic ferment is contained within the red blood corpuscles. Lepine and Lyonnet have found that the reaction is present in leucffiniic blood, while Bremer claims that if his technique is strictly adhered io leucajmic blood reacts like normal blood.
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He has found it present in cases of experimental phloroglucin
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diabetes.
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Exhibition of Specimen of Round Ulcer of the Stomacli. Erosion of Gastric Artery; Post-mortem Perforation.—
 +
 +
Dr. Flexner.
 +
 +
The specimen which I present this evening came from a negro man about 60 years of age who came to the Hospital for tuberculosis of the elbow joint. The clinical notes state that on October 24th, while in the hospital for the above trouble, he was seized with hasmatmesis. There is no record of a previous attack of this sort. The patient, who was already very weak and much emaciated, died on October 27th. The autopsy was performed six hours post mortem.
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The peritoneal cavity contained about 200 cc. of dark, turbid fluid which was collected in the fossae. The omentum was almost devoid of fat ; no unusual adhesions between the several viscera.
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The stomach itself was moderately dilated and its contents were fluid and dark in color. The mucous membrane was covered with sticky mucus which was streaked with dark lines, the surface presented a coarsely mammillated appearance and there was absence of the normal velvety surface. There existed on the posterior wall, 6 cm. from the pylorus, just at the limits of the lesser curvature, a deep almost circular ulcer 4.5 x 3 cm. in extent, the edges of which were for the most part rounded in form. The ulcer extended to the peritoneal coat, and at one place (perhaps two places) it had penetrated this coat and communicated with the peritoneal cavity. Through this break fluid passed from the interior of the stomach into the abdominal cavity.
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The base of the ulcer, as you can see, is not quite smooth, but it jjresents a somewhat convoluted appearance. This is brought about chiefly by its relation to the branches of the right gastric artery over which it lies. It may be seen that the elevated lines in the under (widest) part of the ulcer correspond to the secondary and tertiary branches of this vessel. Over one such prominent ridge there was a small dark clot; on I'emoving this a slightly elongated erosion was brought to view in a secondary branch of the right gastric artery. A probe can be passed through this opening into the main vessel. All the branches and the main stem of the artery show thickening of the intima.
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 +
Between the ridges described the ulcer, in its lower part, extends to the serous coat ; the upper half has not passed beyond the muscular tunic. The least manipulation brings about breaks in the thin tissue mentioned.
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 +
My object in bringing this specimen before you is as follows : In the first place, ulcer of the stomach is not a common condition with us. As you know, the large statistics collected by Drs. Welch and Brinton would seem to prove that simple ulcerations or cicatrices are found at autopsy in about 5 per cent, of persons dying from all causes. Our experience is quite different, and while I have not collated our autopsies from this point of view, yet I venture to say that our percentage is far below this estimate. The present instance cannot be said to shed any new light on the cause of such round ulcers, but as the sclerosis of the gastric arteries was so
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42
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 8.3.
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much more marked than of the other arteries of the body, it teuds to support the vascular origin of the condition. But I wish to ask your attention especially to the possibility of rapid post-mortem digestion of the stomach, with the production of perforation in places where the walls are already greatly thinned, which is not to be confounded with antemortem perforation. In this case the evidences of perforation were found at once on opening the abdominal cavity ; the dark fluid was evidently derived from the stomach contents ; but the absence of all signs of inflammation is taken to indicate that, although the autopsy was made only sis hours after death, yet the remaining barrier between the cavity of the stomach and that of the peritoneum was in this time digested away.
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===NOTES ON NEW BOOKS===
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A Treatise on Surgery by American Authors. Edited by Roswell Park, A. M., M. D , Professor of Surgery in the Medical Department of the University of Buffalo, etc. Volume II. 804 pp., 451 engravings, 17 plates. (Lea Brothers & Co ., Philadelphia and
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New York, ISg?.)
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The second volume of this interesting work fully sustains the high expectations raised by the appearance of the first, the only disappointment being the smaller extent to which the hand of the editor appears in its contents, and the further extension of that process of condensation which, impossible as it is of dissociation from a work of this encyclopediac range nowadays, interferes with the flow and beauty of the style and diminishts our pleasure in reading it. The illustrations are again remarkable both for their abundance and freshness, although a few of them again show the " defects of the virtues " of the camera.
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Of the twenty chapters, three are by the editor, the one upon Surgical Diseases and Injuries of the Head being especially notable as an eminently concise and practically helpful treatment of an extremely complicated subject. His brief chapter at the close upon Skiagraphy, with its full description of apparatus and methods and its interesting series of radiographs, adds much both to the completeness and to the interest of the volume.
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The names of Bradford, upon Diseases and Injuries of the Spine ; of Dennis, upon the Surgery of the Chest ; Gerster, upon Plastic Surgery ; and Blake, upon the Surgery of the Ear, are sufficient guarantees for the ability and authoritativeness of the treatment of these subjects. And the method of presentation is equally admirable, with the exce|ition of those omissions which are of course absolutely necessary for reasonable brevity in chapters of a general work, and the occasional baldness and disjointedness of style which almost necessarily accompany this.
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The question, however, suggests itself most forcibly whether in this twentieth century age it is any longer necessary to cumber a work of this description with even a nominally complete discussion of such liighly specialized subjects as the diseases of the eye, the ear, and the female reproductive organs. Nearly every practitioner, and certainly every graduate nowadays, is compelled to have in his library at least one work treating upon each of these subjects. Works are written upon these subjects especially intended to meet the needs of the general practitioner, who is beyond the reach of a specialist, and such treatment as can possibly he afforded to them in from thirty to sixty pages of a work upon general surgery can from the very nature of the case and the necessity of naming and classifying all the more important disturbances, hardly have that degree of preliminary detail and logical connection which is absolutely indispensable to a rational
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introduction to the subject, while as a work of reference it would be mainly a source of irritation if not of exasperation.
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Of course we are well aware of the long-standing feud which exists between the general surgeon upon the one hand and the gynecologist proper upon the other, and it is unquestionably fully within the rights of the former to have a chapter upon this subject inserted in his formal text-book, as a sort of assertion of his rights within this domain. But we think that any one who would attempt to perform any of the special operations, particularly inthe region of the eye or ear, without any further knowledge than that which could be obtained from the chapters upon this subject, admirably definite and condensed as they are, would be a man to whose boldness a somewhat less complimentary term might not be improperly applied. As extracts and condensations they are admirable, but life cannot long be maintained upon Liebig.
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The absence of our old friend " the opisthotonos man," of which we complained in the former volume, is more than compensated for by the group of old friends which greet us in the chapter upon the diseases of the eye. But with that exception, as we have before stated, the illustrations are striking for both their freshness and appropriateness.
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One of the most admirable and interesting features of the entire volume is the full treatment accorded to those deformities and disturbances which result from errors and defects in embryonic development. This is particularly noticeable in the editor's own chapter, and also in the excellent chapter by Arthur Bevan upon the Mouth, Teeth and Jaws, in which a brief but admirably clear and vivid description is given of the development of these parts, without which, as the author very happily says, no rational understanding of their deformities can possibly be had. It is one of the most suggestive and promising signs of the times that we are beginning to trace a developmental and morphological basis for such a large and rapidly increasing class, not merely of surgical hut also of medical disturbances. The cysts and bronchial fistulje of the neck, the forms of hare-lip and cleft-palate, the coccygeal sinus, the dermoids of the tongue, and many other conditions are treated here from this point of view, and with a most refreshing gain in point of clearness and interest. We regret, however, that in his otherwise excellent chapter upon the Surgery of the Abdomen, Maurice Richardson has not seen fit to distinctly class the appendix in this group and to treat its etiology and pathology from that point of view. Etiology is dismissed in a single ten-line paragraph which is characterized by the last sentence, namely, []
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that it is obscure. And this we are the more surprised at because from the pen of the editor have come some of the clearest and most convincing statements of the essentially morphologic and ancestial basis of this interesting disturbance. The human appendix is clearly an atrophying vestige of a more voluminous and functional, intestinal pouch, such as is seen in some of tlie herbivora, and is intermediate between these and the small rounded csecum of the carnivora, in which 'the distal two-thirds, or 'appendix," as we term it, has entirely disappeared. Noi only is it degenerate ancestrally, but it rapidly undergoes involution in the individual, from a direct continuation of the crecum in early foetal life up to its occlusion after adult life, which, as Ribbert has shown, is completed in no less than twenty-five per cent, of all persons by the age of forty, so that the diminishing frequency of appendicitis after this age is to be accounted for upon developmental grounds. In short, we tliink that a full recognition of the fact that appendicitis is simply a " short-circuiting " or accelerating of a process of elimination and atrophy which is normally being carried out in the liuman species, to reach its completion somewhere about the fortieth year, will of itself afford an almost complete rational basis for the etiology and jiathology of the disease.
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Dr. Bradford's brief but adequate treatment of the coccygeal dimple and sinus is not only interesting and thoroughly scientific, but of great practical importance, as disease of this structure is fw
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February, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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43
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commoner than is generally supposed. We have seen three or four
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cases which have been mistaken for Jisitilm in ano and determined efforts made to cause the probe to pass through into the rectum.
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The p.itholog,v, as a rule, throughout the volume is admirable, clear, and up to date. We cannot help regretting, however, that at some point in the treatment of cancer the editor's well-known and most interesting views upon its dependence on the ancestral or individual senility of epithelial tissue could not have been developed. This view, it appears to us, throws such a valuable light upon the carcinomata of the uterus and breast, organs which are functionally senile long before the remainder of the body tissues, and which are in consequence the site of nearly seventy per cent, of all cases of carcinoma in the female sex. The atrophying lips of the toothless old man, the remains of the invertebrate grinding stomach at the pylorus, and the vestiges of the crop in the middle third of the oesophagus, seem to display the same fatal tendency.
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In fine, the entire volume displays, with the exception of a few chapters, that combination of scientific thoroughness with concise and eminent practicality in treatment which so favorably impressed us in the former part of the work. And our chief criticism takes the form of regret that in some instances the "boilingdown " process has been carried so far as to result in the precipitation of a rather irritating mass of crystalline facts. Especially is this the case with the chapter upon Injuries of the Face, anywhere in the first five or six pages of which paragra])h8 may be picked out which contain a description of a new condition to every line. The result is that the pages read like quotations from a medical dictionary, and are just about as interesting and satisfactory, while they fall short of it in point of accuracy. For instance, the extraordinary statement is made that 'long-continued proper specific treatment will improve" the opacities of the cornea, malformations of the permanent teeth and fissures at the angles of the mouth due to hereditary syphilis, all of which well-known symptom group is dignified with the extraordinary title of "congenital syphilitic hypertrophy of the face," while the changes due to leprosy are persistently referred to under the title of " elephantiasis."
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The paragraphing of the work and the use of display type have been most skilfully carried out, and with the admirable index, make the tracing down of any particular subject or paragraph a positive pleasure. W. jj.
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A Manual of Clinical Diagnosis by Means of Microscopic and Chemical Methods, for Students, Hospital Physicians and Practitioners. By CiiAKLES E. Simon-, M. D , Baltimore. Second edition, revised and enlarged. Philadelphia and New York, Lea Bros. & Co., 1897. Pp. i to xx and 17 to 563, with 133 illustrations on wood, and 14 colored plates.
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The fact that a second edition of this book has been called for within one year is the best index to the reception given it by the profession. It differs from the majority of text-books on clinical diagnosis in that it limits its sphere almost entirely to the consideration of microscopical and chemical methods as applied to diagnosis and the results yielded by these. The exact ground which it attempts to cover may perhaps be best understood if we say that it deals with those materials (other than excised portions of tissue) which can be obtained from a living patient and can be removed from his bedside for careful examination. It is in fact a manual for the clinical laboratory of the diagnostician.
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The book consists of 13 chapters with the following headings : (I) The Blood; (2) The Secretions of the Mouth ; (3) The Gastric Juice and the Gastric Contents; (4) Fseces; (.5) The Nasal Secretion ; (8) The Sputum ; (7) The Urine ; (S) Transudates and Exuilates; (9) The Examination of Cystic Contents; (10) The Examination of Cerebrospinal Fluid: (11) The Semen; (12) The Vaginal Discharge ; (13) The Secretion of the Mammary Glands.
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Under each of these headings the general characters, chemical constitution and microscopical appearances in health and disease are discussed at considerable length. One has only to consult the list of sub-headings in the table of contents to realize the dimensions which the subject has in recent times assumed.
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The second edition of this book has been revised and extended. It is not, however, entirely free from error. The illustrations of stained malarial parasites, for example, are not In accord with what one actually sees in the preparations, and we have noticed a few other mistakes which we hope will be corrected when another edition appears.
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It is now a matter of general recognition that the successful penetration of research into new fields in almost every department of knowledge is dependent in large measure upon the invention of methods which supplement the activities of our sense organs ; that is to say, methods which extend the domains in which the eye, the ear and the tactile surfaces can be utilized in gaining information concerning the objects to be studied. Whereas, with regard to the urine, for example, the physician of the olden time gathered what information he could from the naked eye appearances, odor, and possibly the taste, the modern clinician helps out his eyes by means of (1) chemical tests yielding color reactions or visible precipitates, and (2) images obtained by the intercalation of microscopic lenses, and the prisms of the spectral apparatus and the polariscope, between his eye and the object. Instead of judging of the condition of the blood solely by a glance at the color of the visible mucous membranes, the latter supplies himself with accurate data concerning the exact holding in haemoglobin, the presence of abnormal hemoglobin compounds, the number of red and white blood corpuscles, the relative proportions of the different varieties of the latter, the presence of protozoa or of bacteria, the existence of chemical abnormalities and of certain specific qualities sometimes possessed by the serum, by using the hfemoglobinometer, the spectroscope, the htemocytometer or the hasmatokrit and the microscope, and by chemical and bacteriological technique. Nowadays rather than rely upon shrewd guesses as to the condition of the cerebrospinal meninges founded upon the symptoms manifested by the patient, the examiner prefers in many instances to study the cerebrospinal fluid directly in order to determine the presence or absence of pus, blood, the tubercle bacillus, the meningococcus or other abnormal element.
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It may be urged by the " ultra-practical man " that these methods are of but little service and that he gets along very well without them. He would relegate such refinements with the sphygmographs, sesthesiometers, phonendoscopes, and perhaps also the stethoscopes, to the limbo in which he mentally confines all physicians who strive for scientific accuracy, or what he would probably choose to designate " liighfalutin poppycock."
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In sciences as new as clinical bacteriology and clinical chemistry, the doors to which may scarcely be said to be fully open, the threshold barely crossed, very many experiments have to be made, and often enormous numbers of new methods tried before one is found which is really of permanent practical value. Undoubtedly in books like those of Simon and von Jaksch, procedures are described which are of no practical significance and which will sooner or later be discarded. On the other hand, a knowledge of the principles which underlie them and the power of intelligently applying the majority of them to the study of clinical cases is just what distinguishes the physician of the " better sort" from the " ordinary " practitioner.
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The scientific physician takes advantage of every possible means to establish his diagnosis on a firm basis; he is analytical; he seeks an explanation for every symptom ; he takes account of all likely complications ; he endeavors to avoid every source of error. He may sometimes, it is true, be led astray. A well marked WIdal reaction may, if he forgets that its presence does not necessarily indicate typhoid ulceration of the intestine, lead him to overlook a local infection of some part in which the typhoid bacillus is the
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44
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 83.
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exciting cause. Or again he may be trapped into making too favorable a prognosis on finding malarial parasites in the blood should he chance to deal with a case in which the malarial invasion is associated with general streptococcus infection, with amoebic abscess of the liver or with typhoid fever. But he learns by his mistakes ; another time he avoids them. If he is magnanimous he acknowledges them and warns his fellow-practitioners of possible pitfalls. The true significance of new tests by this means gradually comes to be understood and medicine is advanced.
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Tlie "ordinary" doctor says he " does very well without these tests," and indeed he does probably better without them than with them. If he attempted to apply many of them, having no knowledge of the principles upon which they rest, he would obtain false results, or, to be more accurate, falsely interpret the results he obtains and deceive not only his patient but also possibly himself. The only methods which he is capable of using satisfactorily are those so reduced to a " rule of thumb" that mistake is practically impossible. When a test has been so thoroughly sifted by trained men that it comes in this category it is said to have undergone the "crucial test of clinical experience." It is then on a par with the examination of measly pork by factory girls, or the making of ordinary agar-agar by the laboratory Biener.
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The newer researches of the clinical laboratory are and must continue to be based upon advances in anatomy, physiology and pathology in the same way that these three sciences are in turn dependent for their progress upon the application of the newer results in chemistry and physics. It is almost trite to say that the better founded the physician is in these fundamental branches the further he can extend his clinical researches. The clinical investigator of fifty years from no-w will be sadly at a loss if he depend upon the anatomy and physiology, the chemistry and physics of to-day. The clinician of ten or twenty years from now must be well versed in these subjects, at least as they are at present understood. But how many students beginning the study of medicine have any adequate knowledge of modern physics and chemistry ? Relatively few of them know enough to read intelligently even the articles of Gruetzner, WUtrich, Hamburger, Kahlenberg and True, Loeb, Heald, Krunig and Paul and Koranyi, to mention some of those who have been writing recently upon the application of physical chemistry to the solution of certain problems in medicine and biology. And what is worse, they do not know enough mathematics to permit them to familiarize themselves with the laws to which the processes of electrolytic dissociation, the velocity of anions and kations, or the passage of substances through semi-permeable membranes conform.
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A student contemplating medicine as a career and capable of looking ahead will shape his course very differently from that generally followed. He will lay a foundation in mathematics which reaches wider than arithmetic, two books of Euclid and simple quadratic equations. It will be all the better for him if do not stop short of Calculus and the Theory of Equations. He will study physics and chemistry until he is not only capable of understanding the forward movements going on in these branches, but until he is capable of taking part in their advance. He will especially thoroughly master the principles of the new physical chemistry, seeing that the human body itself consists of a mass of units bounded apparently (the majority of them at any rate) by semi-permeable membranes, and bathed by fluids in which not only simple but extremely complex substances are present in aqueous solution. The manuals of clinical chemistry and microscopy such as that of Dr. Simon may seem complex to-day ; their contents are, however, only fragments of an alphabet out of which the textbooks of coming generations will be constructed. L. F. B.
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High Altitudes for Consumptives. By A. Edgar Tussey, M. D.
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{Philadelphia: P. Blakialon, Son & Co., 1S96.)
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Although the author seems to have but little belief in the bacillus tuberculosis as a cause of phthisis, yet there is much good
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sense in this volume, and had it been cut down one-half or more we would praise it without hesitation. Its fault lies in an unbounded tendency of the author to moralize. This is all very well in its place, but its place is not properly in what is meant to be a scientific production addressed to the medical profession. There are too many quotations which seem to us out of place and merely an effort to impress the reader ; the author's style is verbose, and the attempt to write "elegant" English is continually thrust before one.
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The object of the author to impress on the general practitioner the use of much greater care than is ordinarily employed in the selection of climates for consumptives is a worthy one, and the end would have been much better attained were the work more condensed. The general practitioner is oftentimes criminally careless in sending phthisical patients away to high climates without a previous careful examination of them. Many a practitioner thinks that a patient with the tubercle bacilli in his sputa should at once be sent off to Colorado. No more serious mistake could be made ; such advice may cause much distress in many ways, or may hasten the death of the patient. If more care was exercised in these cases, the medical profession of this country would to-day have less slurs cast upon it by the middle class (if such a class exist in America) and there would be less heard of quack consumptive cures.
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The work which the author has done in estimating the capacity of the chest is valuable, and spite of its defects we recommend this work to all interested in the proper treatment of consumptives.
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Guy's Hospital Reports, Vol. LI. {London: J. & A. Churchill, 1895.) No volume of reports ever appears from this hospital without containing one or more articles of real value, and this volume has a number of special interest both to the surgeon and physician. The paper by Theodore Fisher on "Hypertrophy of the Heart without Gross Organic Lesion," is one we were very glad to see, for although this condition has been recognized by the leading medical men in all countries within the past few years, it has not yet met with the general recognition which it deserves. The question of alcohol and overwork as productive causes of this lesion is here well discussed. There are other interesting papers on empyema following lobar pneumonia, in which the value of the course of the temperature curve is specially noted; on scarlatinal nephritis and its complications — this paper brings out clearly the difficulty in making a proper classification of the various forms of nephritis which may occur in scarlatina, in spite of the numberless articles on just this topic. There is a long and important paper on the question of amputation in senile gangrene, and another on the extremely rare lesion of bilateral paralysis of the facial and auditory nerves.
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BOOKS RECEIVKO.
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Genilo-urinary Surgery and Venereal Diseases. By J. W. White, M. D., and E. Martin, M. D. 1898. 8vo. 1061 pages. J. B. Lippincott Co., Philadelphia.
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Index-Catalogue of the Library of the Surgeon-General's Office, United States Army. Authors and Subjects. Second Series. Vol. II, B-Bywater. 1897. 4to. 954 pages. Government Printing Office, Washington.
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A Clinical Text-book of Surgical Biagnosis and Treatment. By J. W. Macdonald, M. D. 1898. 8vo. 798 pages. W. B. Saunders, Philadelphia.
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The Physiology and Pathology of the Cerebral Circulation. An Experimental Research. By Leonard Hill, M. B. 1896. 8vo. 208 pages. J. & A. Churchill, London.
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Saint Thomas's Hospital Reports. New Series. Edited by Dr. Hector Mackenzie and ]\Ir. G. H. Makins. Vol. XXV. 1897. 499-1-119 pages. J. & A. Churchill, London.
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The British Quiana Medical Annual. Edited by J. S. Wallbridge and C. W. Daniels. Ninth year of issue. 1897. 8vo. S7-f73 pages. Printed by Baldwin & Co., Georgetown, Demerara.
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Febkuary, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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45
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PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.
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THE JOHNS HOPKINS HOSPITAL REPORTS. Volume I. 423 pages, 99 plates.
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Report in Patliology.
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The Vessels and Walls of the Dog's Stomach; A Study of the Intestinal Contraction;
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Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the
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Vena Portae and its Influence upon the Circulation. By F. P. Mall. M. D. A Contribution to the Pathology of the Gelatinous Type of Cerebellar Sclerosis
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(Atrophy). By Henkt J. BERKiEr, U. D. Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.
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Mall, il. D.
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Report in Dermntolo^y. Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By
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T. C. Gilchrist, M. D., and Emmet Eixford. M. D. A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of
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Protozoa, and the Blastomyces found in the preceding Cases, vdth the so-called
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Parasites found in Various Lesions of the Skin, etc. ; Two Cases of Moliuscum
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Fitjrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By
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T. C. Gilchrist, M. D.
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Report in Pathology. Ad Experimental Study of the Thyroid Gland of Dogs, with especial consideration
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 +
of Hypertrophy of this Gland. By W. S. Halsted, M. D.
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Volume II. 570 pages, with 28 plates and figures.
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Report In Medicine.
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On Fever of Hepatic Origin, particularly the Intermittent Pyrexia associated with
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Gallstones. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D. On Pyrodin. By H. A. Lafleur, M. D. Cases of Post-febrile Insanity. By William Osleb, M. D. Acute Tuberculosis in an Infant of Four Months. By Harry Toulmik, M. D. Rare Forms of Cardiac Thrombi. By William Osler, M. D. Notes on Endocarditis in Phthisis. By WiLLiAit Osler, M. D.
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Report in Aledleine.
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Tubercular Peritonitis. By William Osler, M. D.
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A Case of Raynaud's Disease. By H. M. Thomas, M. D.
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Acute Nephritis in Typhoid Fever. By William Osler, M. D.
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Report in Gynecology.
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The Gynecological Operating Room. By Howard A. Kellt, M. D.
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The Laparotomies performed from October 16, 1689, to March 3, 1890. By Howard
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A. Kelly, M. D., and Hitnter Robs, M. D. The Report of the Autopsies in Two Cases Dying in the Gynecological Wards without Operation; Composite Temperature and Pulse Cliarts of Forty Cases of
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Abdominal Section. By Howard A. Kelly. M. D. The Management of the Drainage Tube in Abdominal Section. By Hunter Robb,
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 +
M. D. The Gonococcus in Pyosalpinx; Tuberculosis of the Fallopian Tubes and Peritoneum;
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Ovarian Tumor; General Gynecological Operations from October 15, 1889, to
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March 4, 1S90. By Howard A. Kelly, M. D. Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howabd
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 +
A. Kelly, M. D., and Albert A. Ghriskey, M. D. Ligature of the Trunks of the Uterine and Ovarian .\rteries as a Means of Checking
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 +
Hemorrliage from the Uterus, etc. By Howard A. Kelly, M. D. Carcinoma of the Cervix Uteri in the Negress. By J. W. Williams, M. D. Elephantiasis of the Clitoris. By Howard A. Kelly, M. D. Myxo-Sarcoma of the Clitoris. By Hunter Robb, M. D. Kolpo-Ureterotomy. Incision of the Ureter through the Vagina, for the treatment
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of Ureteral Stricture; Record of Deaths following Gynecological Operations. By
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 +
Howard A. Kelly, M. V.
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Report in Surgery, I.
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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.
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Report in Neurology, I.
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A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Haematomyelia. By Auodst Hoch, M. D.
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A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By Hehby M. Thomas, M. D.
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 +
Report in Pathology, I.
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 +
Amosbic Dysentery. By William T. Councilman, M. D., and Henri A. Lajleub, M. D.
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Volume III. 766 pages, with 69 plates and figures.
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 +
Report in Pathology.
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Papillomatous Tumors of the Ovary. By J. Whitridge Williams, M. D. Tuberculoaia of the Female Generative Organs. By J. Whitridge Williams, M. D.
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Report in Pathology.
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Multiple Lympho-Sarcomata, with a report of Two Cases. By Simon Flexnee, M. D.
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The Cerebellar Cortex of the Dog. By Henry J. Berkley, M. D.
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A Case of Chronic Nephritis in a Cow. By W. T. Councilman, M. D.
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Bacteria in their Relation to Vegetable Tissue. By H. L. Russell, Ph. D.
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Heart Hypertrophy. By Wm. T. Howard, Jr., M. D.
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Report in Gynecology.
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The Gynecological Operating Room; An External Direct Method of Measuring the Gonjugata Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Alajus; Deviations of the Rectum and Sigmoid Flexure associated with Constipation a Source of Error in Gynecological Diagnosis; Operation for the Suspension of the Retroflexed Uterus. By Howard A. Kelly, JI. D.
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Potassium Permanganate and Oxalic Acid as Germicides against the Pyogenic Cocci. By Mary Sherwood, M. D.
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 +
Intestinal Worms as a Complication in Abdominal Surgery. By A. L. Stavely, M. D.
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Oj-necological Operations not involving Cosliotomy. By Howard A. Kelly, M. D.
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Tabulated by A. L. Stavely, M. D. The Employment of an Artificial Retroposition of the Uterus in covering Extensive
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Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdo minal Pelvic Operations. By Howard A. Kelly, M. D. Photography applied to Surgery. By A. S. JIurray. Traumatic Atresia of the Vagina with Ha:matokoIpos and Hsmatometra. By Howard
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A. Kelly, M. D. Urinalysis in Gynecology. By W. W. Russell, M. D.
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 +
The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D. Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D. One Hundred Cases of Ovariotomy performed on Women over Seventy Tears of Age
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 +
By Howard A. Kelly, M. D., and Mary Sherwood, M. D. Abdominal Operations performed in the Gynecological Department, from March 5.
 +
 +
1890, to December 17, 1892. By Howard A. Kelly, M. D. Record of Deaths occurring in the Gynecological Department from June 6, 1890, to
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May 4, 1892.
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Volume IV. 504 pages, 33 charts and illustrations.
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Report on Typhoid Fever.
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By William Osler, M. D., with additional papers by W. S. Thayer, 51. D , and J Hewetson, M. D.
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 +
Report in Neurology.
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Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of Mw musrulus; The Intrinsic Nerves of the ThvToid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley,
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Report in Surgery.
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The Results of Operations for the Cure of Cancer of the Breast, from June, 1889. to January, 1894. By W. S. Halsted, M. D.
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Report in Gynecology.
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Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic PeritonitisTuberculosis of the Endometrium. By T. S. Ccllen, M. B.
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Report In Pathology.
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Deciduoma Malignum. By J. Whitridge Williams, M. D.
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Volume V. 480 pages, vnih 32 charts and illustrations.
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==CONTENTS==
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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.
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Studies in Typhoid Fever. By William Osier, M. D., with additional papers by G. Bluuer, M. D., Simon Flexnek, M. D., Walter Reed, M. D., and H. C. Parsons, M. D.
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Volume VI. 414 pages, Avith 79 plates and figures.
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Report in Neurology.
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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.
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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 11.— Serum Poisoning.— Experimental Lesions induced by the Action of the Dog's Serum on the Cortical Nerve Cell; Part III.— Ricin Poisoning.— Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Ciironic Ricin Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the Cortical Nerve Cell produced by the Toxinc of Experimental Rabies; Part V.— Patliological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of Alcohol and Ricin Intoxication; Ner\-e Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M.D.
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Report in Pathology.
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Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S.
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Cullen, M. B. Pregnancy in a Rudimentary Uterine Horn. Rupture, Death. Probable Migration of
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Oram and Spermatozoa. By Thomas S. Cullen, M. B., and G. L. Wilkins, M. D. Adeno-Myoma Uteri Diffusum Benignum. By Thomas S. Cullen, M. B. A Bacteriological and Anatomical Study of the Summer Diarrhoeas of Infants. Bv
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William D. Booker, M. D. The Pathology of Toxalbumin Intoxications. By Simon Fleinbr, M. D. Thf price of n .ii-l hoiitid in cloth {Vols. I-VI] of tin- Uospitnl Jtejiorts i.i
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$30.00. Vols. I, II and III are not sold separntelii. The nrice of
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Tola, ir, r and Tl is $3.00 each. -^ ± i
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Monographs.
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The following papers are reprinted from Vols. I, IV, V and VI of the Hcports, for those who desire to purchase in this form: STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rixford,
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M. D. 1 volume of 164 pages and 41 full-page plates. Price, bound in paper,
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$3.00. THE MALARIAL FEVERS OF BALTIMORE. By W. S. Thayer, St. D., and J.
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Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.
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By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, ?2.75. STUDIES IN TYPHOID FEVER. By William Osler. JI. D., and others. Extracted
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from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481
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pages. Price, bound in paper, $3.00. THE P.VTIIOLOGV OF rnXALBUMIN ISTOXICATIflNS. liv Pimon Flexner, M. D. I
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volume of Inii puLre.a with 1 fuli-pace lltliosraplis. 1 rice, bound in paper, $i.O(i. Subscriptions for the above publications may be sent to
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The Johns Hopkins Press, Baltimore, Md.
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46
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[Xo. 83.
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THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.
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FACULTY.
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Daniel C. Gilman, LL. D., President.
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William H. Welch, M. D., LL. D., Dean and Professor of Pathology.
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Ira Uemsen, M. D., Ph. D., LL. D., Professor of Chemistry.
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William Osler, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice
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of Medicine. Henrv M. Hurd, M. D., LL. D., Professor of Psychiatry. William S. H.\lsted, M. D., Professor of Surgery. Howard A. Kelly, M. D., Professor of Gynecology and Obstetrics. Franklin P. Mall, M. D., Professor of Anatomy. John J. Abel. M. D., Professor of Pharmacology. William H. Howell, Ph. D., M. D., Professor of Physiology.
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William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology. John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine. Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoolog}-. Robert Fletcher, M. D., M. R. C. S., Lecturer on Forensic Medicine. William D. Cooker, M. D., Clinical Professor of Diseases of Children. John N. Mackenzie, M. D., Clinical Professor of Larj'ngology and Rhinology. Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology. Henry M. 1'homas, M. D., Clinical Professor of Diseases of the Nervous System. Simon Flexneb, M. D., Associate Professor of Pathology. J. Whitridoe Williams, M. D., Associate Professor of Obstetrics. Lewkllys F. Barker. M. B., Associate Professor of Anatomy. Wiluam S. Thayer, M. D., Associate Professor of Medicine. JoH.v M. T. Finney, M. D., Associate Professor of Surgery.
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George P. Dbeyer, Ph. D., Associate in Physiology.
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William W. Russell, M. D., Associate in Gynecology,
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Henry J. Berkley, M. D., Associate in Neuro-Pathology.
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J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.
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T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.
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Robert L, Randolph, M. D., Associate in Ophthalmology and Otology.
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Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.
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Thomas B. Futcher, M. B., Associate in Medicine.
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Joseph C. Bloodgood, M. D., Associate in Surgery.
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Thomas S. Cullen, M. B., Associate in Gynecology.
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Ross G. Harrison, Ph. D., Associate in Anatomy,
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Frank R. Smith, M. D., Instructor in Medicine.
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Georgia W. Dobbin, M. D., Assistant in Obstetrics.
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Walter Jones, Ph. D,, Assistant in Physiological Chemistry.
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Adolph G. Hoen, M. D., Instructor in Photo-Micrography.
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Sydney M. Cone, M. D., Assistant in Surgical Pathology.
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Louis E. Livingood, M. D., Assistant in Pathology.
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Henry Barton Jacobs, M. D., Instructor in Medicine.
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Charles R. Bardeen, M. D., Assistant in Anatomy.
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Stewart Paton, M. D., Assistant in Nervous Diseases.
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Norman McL. Harris, M. B., Assistant in Pathology.
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Harvey W. Cubhing, M. D., Assistant in Surgerj'.
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J. M. Lazeab, M. D., Assistant in Clinical Microscopy.
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J. L. Walz, Ph. G., Assistant in Pharmacy.
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GENERAL STATEMENT.
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The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1803. This School of Medicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from its close affiliation with the Johns Hopkins Hospital.
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The required period of study for the degree of Doctor of Medicine is four years. The academic year hegins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.
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Men and women are admitted upon the same terms.
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In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital. While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. The first two years of the course are devoted mainly to practical work, combined with demonstrations, recitations and, when deemed necessary, lectures, in the Laboratories of Anatomy, Physiology, Physiological Chemistry, Pharmacology and Toxicology, Pathology and Bacteriology. During the last two years the student is given abundant opportunity for the personal study of cases of disease, his time being spent largely in the Hospital Wards and Dispensary and in the Clinical Laboratories. Especially advantageous for thorough clinical training are the arrangements by which the students, divided into groups, engage in practical work in the Dispensary, and throughout the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.
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REQUIREMENTS FOR ADMISSION.
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As candidates for the degree of Doctor of Medicine the school receives:
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1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.
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2. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.
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The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in each subject.
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3. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above indicated.
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Applicants for admission will receive blanks to be filled out relating to their previous courses of study.
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They are required to furnish certificates from officers of the colleges or scientific schools where they have studied, as to the courses pursued in physics, chemistry, and biology. If such certificates are satisfactory, no examination in these subjects will be required from those who possess a degree in arts or science from an approved college or scientific school.
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Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass, at the beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (2) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that only in very rare instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.
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Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.
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ADMISSION TO ADVANCED STANDING.
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Applicants for admission to advanced standiug must furnish evidence (1) that the foregoing terms of admission as regards prelirniu.iry training have beeu rulfllled, (2) ibat courses equivaleut lu liiud and amount to those given here, preceding that year of the course for admission to which appiicatiou is made, have been satisfactoriiy completed, and (3i must pass examinations at tlie beginning of ttie session in October In all the suljjects thai have beeu already pursued by the class to wlilch admission is sought. Certiflcales of standing elsewhere cannot be accepted in i)lace of these examinations.
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SPECIAL COURSES FOR GRADUATES IN MEDICINE. \
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Since the opening of the Johns Hopkins Hospital in lS8!t, courses of iustruction have been offered to graduates in medicine. The attendance upon these courses has steadily increased with each succeeding year and indicates gratifying appreciation of the special advantages here afforded. With the completed oi-ganization of the Medical School, it was found necessaiy to give the courses intended especially for physicians at a later period of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the majority of those desiring to take the courses than the former one. The special courses of instruction for graduates in medicine are now given aunually during the months of May and June. During April there is a preliminary course in Normal Histology. These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended to meet the requirements of practitioners of medicine, and is almost wholly of a practical character. It includes laboratory courses, demonstrations, beside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the several instructors that they are prepared to profit by the opportunities here offered. The number of students who can be accommodated in some of the practical courses is necessarily limited. For these the places are assigned according to the date of application. I
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The Annual Announcement and Catalogue will be sent upon appiicatiou. Inquiries should be addressed to the J
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REGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE. ^
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The Johns Hopkins Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copitt may be procured from Messrs. CUSHINO £ CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.00 o year, may be iddrr.'ified to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; single copies will be sent by mail for fifteen cents each.
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BULLETIN
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OF
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THE JOHNS HOPKINS HOSPITAL.
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Vol. IX.- No. 84.]
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BALTIMORE, MARCH, 1898.
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OOlSTTlBISrTS.
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Leprosy in the United States, with the Report of a Case. By Wm. OSLEK, M. D.,
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Secondary Melano-Sarcoma of the Liver following Sarcoma of the Eye. By Louis Philip Hambukqer, M. D., . - On Infection with a Para-Colon Bacillus in a Case with all the Clinical Features of Typhoid Fever. By Norman B. Gwyn, M.B.,
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The Management of Solid Tumors of the Ovaries complicating Pregnancy, with Report of a Successful Case. By William E. Swan, M. D., - - -
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The Catheterization of the Ureters in the Male through an Open Cystoscope with the Bladder distended with Air by Posture.
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By H. A. Kelly, M.D., - 62
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Proceedings of Societies :
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Hospital Medical Society, 62
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On Super-Arterial Pericardial Fibroid Nodules [Mr. Knox] ; —Discussion of Dr. Hunner's Cases of Aneurism [Dr. Oslek] ; — Discussion of Dr. Pancoast's Diabetes in the Negro [Dr. Osler].
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Notes on New Books, ----64
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Books Received, - ---65
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LEPROSY IN THE UNITED STATES, WITH THE REPORT OF A CASE.
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By William Osler, M. D., Professor of Medicine in the Johns Hophins University. [Clinical Lecture delieered at Ike Johns Hopkins Hospital, Wednesday, Feb. 2, 1S98.]
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To no disease perhaps has attention been more actively called of late years than to leprosy, one of the oldest and most dreaded scourges of the race. In great part this has been due to the activity in England of a Leprosy Commission, and to the establishment of a National Leprosy Fund. Through the energy of Dr. Lassar a Leprosy Conference has recently been held in Berlin, two volumes of the proceedings of which I pass about for your inspection. They contain an immense amount of valuable information with reference to the present status of the disease throughout the world, and the best means for its prevention.
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I take this opportunity of again showing to you the case which has been in Ward I for some mouths, and of speaking upon the present condition of the disease in the United States and the prospects of its spreading. First let me refresh your memories about the patient before you. Her history is as follows : She is now 30 years old. She was born in Baltimore, of French-German parents; her father was a native Frenchman who came here when young; he served in the army, was a very healthy man and had no skin eruption. He died at the age of 50. Her mother, who died at the age of 40, appears to
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have been a healthy woman. When 16 years old the patient visited an uncle in Demerara, remaining only a few months. This uncle, a native American, is at present in Baltimore, and neither he nor any member of his family has ever had a serious skin disease. On returning to this country she lived in Baltimore, one year in Norfolk, and for the last five years in Alleghany City, Pa. She returned to this city in April, and was admitted to the hospital as a case of obstinate lues.
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Her personal history is as follows. She was healthy as a young girl ; she married when 20 years old, had one child at 23, which died shortly after birth ; she has had one miscarriage since. Her present illness began six years ago. Here is a photograph taken two years prior to the onset of the trouble, from which you can judge of the terrible changes the disease has wrought. She noticed first two brown spots over the elbow, and then several spots on the wrist. She was pregnant at the time, and had with their appearance a little fever and slight indisposition. These spots remained stationary until after her confinement, when they increased in size and became nodular. The disease spread rapidly, the feet being attacked next, beginning on the ankles nearly five years ago. Ever
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48
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 84.
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since there has been a steady appearance of lumps and nodules on the skin of the face, legs and arms. Only during the past year have they appeared above the elbows. Two years ago she lost the eyebrows and lashes ; the hair of the head is not falling out. The voice began to get hoarse a few months ago, and eight months since she noticed the formation of scabs in the nose.
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Her condition at present is very characteristic of tubercular leprosy. She looks a great deal older than her age ; the swollen appearance of the eyebrows and cheeks, the rounded outlines of the nose and of the ears, the absence of eyelashes, and the brownish pigmented discoloration, give a picture that is perfectly characteristic. The neck is only slightly involved, showing only a few pigmented areas. The hands, feet and legs are very much involved, the hands showing scars of erosion and ulceration ; the finger-nails are not attacked, but in the left hand are fresh punched-out ulcers. On the arms are scars of several very deep nlcers. On the upper arm the earlier stages are shown, the brownish discoloration, and the skin looks raised and infiltrated, and on palpation one can feel that beneath the skin there is a nodular infiltration. The forehead shows a uniform infiltration. She has little or no disturbance of sensation; she feels touch everywhere and feels pain.
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She has been under our care since April last, and has improved in very many ways. The general nutrition is much better. The open ulcers and sores which were present on admission have, as you see, almost entirely healed. During the months of June, July and August she had a great deal of fever, but now for some time the temperature has been normal. She has gained in weight, and is in every way very much more comfortable. She is a very tidy, neat woman, and now is able to look after her own room. I may add that it has been to both physicians and nurses of our staff a great pleasure to be able to care for her and make her comfortable.
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Where did this patient contract leprosy ? You noticed in the history that she had resided in Demerara in the West Indies, a colony much alBicted with the disease. True, it is now fifteen years since she left there, and it was eight years before the first appearance of the disease. It is well known that the period of incubation may be very much longer, even as long as twenty or thirty years. It may be said that without exception all cases of leprosy met with in the Eastern States are persons who have lived for a shorter or a longer time in countries where the disease prevails. The experience in Great Britain is very instructive in this respect. Abraham estimates that within the past ten years the number of cases has been about one hundred, and so far as is known there has been but one instance in which the disease has been transmitted. This was the well known case reported by Benson, of an Irish soldier who returned from India with leprosy. His brother slept in the same bed with him for at least a year and a half, and after his death he wore the leper's clothes. Three years later the brother became leprous.
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You will find in these volumes of the Transactions of the Leprosy Conference — of which by the way there is a very good abstract in Nos. 2 and 4 of the Philadelphia Medical Journal by Dr. Nuttall — a very full discussion of all the problems
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relating to the disease. Of these by far the most important relates to the method of infection, whether by inoculation, contagion, or hereditary transmission.
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The possibility of successful inoculation must be recognized, though Hansen, the leading living expert on leprosy, declares that as yet all attempts at reproducing the disease by direct inoculation have been unsuccessful. He does not regard Aruing's experiment on the Honolulu convict as satisfactory, since this man had leprous relatives. A number of observers, including some of the best students of the disease, have inoculated themselves with negative results. The direct hereditary transmission must be excessively rare, more so indeed than in tuberculosis. As lepers have, as a rule, very few children, heredity can only play a very small part in the spread of the disease. Alverez stated at the recent Congress that he had never seen a new-born leper child; the youngest patient he had met with was three and a half years old.
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The highly contagious character of leprosy has been a fixed belief for centuries, and much of the popular dread is based upon the highly colored views as to the extreme risk of contact with the disease. For a full discussion of the question I must refer you to the Proceedings of the recent Congress. The opinion was universally in favor of its contagious nature, though the greatest difference of opinion existed as to the methods by which the disease is conveyed, and on this question we really need much more information. An important point was brought out at the Congress as to the much more widespread distribution of the lepra bacilli, particularly in the secretions. In modern times one of the strongest points in favor of the contagious nature of the disease is the manner in which it has spread in the Sandwich Islands. Europeans residing in leprous regions occasionally contract the disease, and with scarcely an exception, as in the patient I have jbst shown you, cases occurring in leprosy-free regions have a history of a residence for a longer or shorter time in localities in which the disease prevails. On the other hand there are a great many facts which would indicate that it is very difficult to catch the disease. It is true that Father Damien at the leper settlement at Molokai, and Father Boglioli (whose portrait I here show you) in Kew Orleans, contracted the disease in the discharge of their ministerial duties, but it has been the almost universal experience in the leper settlement* | and lazarettos that the nurses, physicians and attendants are n not attacked. At the Tracadie settlement, which I visited a few years ago, the head Sister told me that during the forty years no Sister or servant had contracted the disease, though the accommodations are rather contracted. Not one of the Sisters who have nursed in the Trinidad Asylum, for now nearly thirty years, has contracted the disease.
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A very important question is whether there is any possi- I bility that leprosy will again spread in the more civilized dis- I tricts of the earth. A good deal of uneasiness has beeu fostered by sensational newspaper reports. The practical question for us here is, is leprosy spreading in the United States? I have here letters from most of the infected districts, the contents of which I will briefly summarize. Including the two districts in the Dominion of Canada, there may be said to be five foci in which the disease at present prevails.
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March, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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49
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lu the northeru part of New Brunswick leprosy lias existed iu a couple of counties since tlie early j)art of the century. The cases as recognized are segregated in thelazarette at Tracadie. Dr. Smith, the physician in charge, writes under date of January 17, 1898: "The number at present in the hospital is twenty-four, eighteen males and six females. ... Of the above number three are Icelanders whom I brought from Manitoba. Leprosy in Cape Breton has almost died out. With us iu New Brunswick segregation is stamping out the disease. The cases have dwindled from about forty in the early history of the disease to about half that number. One of our inmates is a negro I brought recently from St. John, N. B. He had strayed from Bermuda. Leprosy is not on the increase iu Canada." In British Columbia the disease has been introduced by the Chinese, but I have recently heard from Dr. Hanniugton, of Victoria, that there are only eight cases at present iu the settlement on Darcy Island. Dr. Hanningtou does not think that the disease is spreading. Among the Icelandic immigrants in Manitoba there are a few cases, but the strong probability is that it will gradually die out.
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In the United States there are three important centres. To "New Scandinavia," as parts of Minnesota and Wisconsin have been called, the disease was introduced by the immigrant Swedes and Norwegians. Altogether more than 150 cases were known. The disease has not spread, and Dr. Bracken, the Secretary of the State Board of Health, wrote January 19, 1898, that there are in Minnesota, so far as is known, only twenty-seven cases, and some of these have probably died since the last return. All of them contracted the disease before coming to America. A very encouraging fact is that no instance of leprosy has been known to be contracted from any of these Norwegian settlers. In California leprosy has been introduced by the Chinese, and in a few instances by native Americans returning with the disease from the Sandwich Islands. The total number of cases, however, is not large, certainly not more than a dozen, and the likelihood of the disease progressing in the native American population is very slight.
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By far the most extensive focus of leprosy is in Louisiana. Dr. Isadore Dyer, who was the delegate from Louisiana to the Leprosy Conference in Berlin, has reported fully on the history of the disease iu that State, where it has been known since 1785. Dr. Dyer writes under date of January 12, 1898: "My paper on endemic leprosy in Louisiana, read before the Lepra Conference in Berlin, has not yet been published. It is to appear iu the third or fourth volume of the Transactions of this meeting. Full tables are given of all recorded leprosy in Ijouisiana since 1785, the existing acknowledged cases being separately tabulated. This last table contains 118 cases, in addition to which I have seen six within the past four months, making a total of 124 positive living cases to-day." Dr. Dyer thinks that this does not represent by any means all the cases, bnt says he believes it is quite justifiable to calculate the number of lepers in this State as not less than 300.
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A few cases of leprosy are met with in Florida, South Carolina and in others of the Southern States. Now and again cases occur in the eastern cities, invariably imported, as in the patient at present in the hospital. So far as we know.
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with the exception of the single case recorded by Dr. I. B. Atkinson of this city, there has not been an instance in which the disease has been transmitted from one of these imported cases to a natire American.
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I believe the danger of the disease spreading and becoming in any way a serious menace to the country is entirely fanciful. In the question of the annexation of Hawaii the danger of leprosy has also come up. This really would not be a serious objection. I have seen a letter from Dr. Day, from Honolulu, iu which he claims that the disease is progressively diminishing, and that the statement made by Dr. Prince A. Morrow, 'of New York, that every one in ten individuals in the Sandwich Islands is leprous is entirely unwarranted. He quotes figures to show that the number of cases segregated in Molokai has progressively diminished in the past few years. In a recent letter to the San Francisco Chronicle the President of the Board of Health states that barely one per cent of the population of the Sandwich Islands has leprosy.
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The means for combating the existing cases of the disease are perfectly plain and well understood. The Norwegian method of segregation should be enforced in Louisiana and in the State of California. Remarkable results have followed this plan in Norway. In 1856 there were nearly 3000 lepers in Norway ; now there are not more than 700, and most of them are iu asylums. The segregation should be compulsory iu all instances except when the friends can show that they have ample provision in their own home for the comjilete separation and proper care of the patient.
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In the case of the patient you have just seen, as her husband is not in a position to look after her, it is the duty of the city to care for her in a proper way. She should be removed to Bay View, where a room should be provided with a separate arrangement for washing the clothes and disinfecting the body linen. From a humanitarian standpoint we have been very glad to care for her and to do what we could to check the disease in its active and progressive state. Now that she has improved so much I feel that we are no longer bound to keep her, and as she is a free agent, I shall take an early opportunity to discharge her from my care.
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NOTICE.
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All inquiries coucerning the admission of free, part pay, or private patients to the Johns Hopkins Hospital should be addressed to Dr. Henry M. Hurd, the Superintendent, at the Hospital.
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Letters of inquiry can be sent, which will receive prompt answer, or personal interviews may be held.
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Under the directions of the founder of the Hospital the free beds are reserved for the sick poor of Baltimore and its suburbs and for accident cases from Baltimore and the State of Maryland. To other indigent patients a uniform rate of $.5.00 per week has been established. The Superintendent has authority to modify these terms to meet the necessity of urgent cases.
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The Hospital is designed for cases of acute disease. Cases of chronic disease are not admitted except temporarily. Private patients can be received irrespective of residence. The rates in the private wards are u-overned by the locality of rooms and range from $30.00 to $35.00 per week. The extras are laundry expenses, massage, the services of an exclusive nurse, the services of a throat, eye, ear and skin or nervous specialist, and surgical fees. Wherever room exists in the private wards and the condition of the patient does not forbid it, companions can be accommodated at the rate of $15.00 per week.
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One week's board is payable when a patient is admitted.
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50
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 84.
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SECONDARY MELANO-SARCOMA OF THE LIVER FOLLOWING SARCOMA OF THE EYE.
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Br Louis Philip Hamburgjpr, M. D., Resident Medical Officer, The Johns Hopkins Hospitcd.
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lu au article written in 1889 Litten called attention to the inadequacy of the accounts of melano-sarcoma of the liver following a primary growtli in the eye. With the exception of Virchow's classical work on tumors, the condition had not been presented in the text-books of medicine or of pathological anatomy in a manner befitting its importance, and Litten writes, " Even the best special works on diseases of the liver, in German, French, and English, scarcely mention it."
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Litten's case was that of a man aged 34 years, whom he saw in November, 1884, with a tumor of the liver. He did notsee him again until March, 1888. The man was then cachectic, the tumor had increased iu size, and in some places showed fluctuation. The possibility of echinococcus cysts was discussed and one of the fluctuating points was aspirated. A black fluid was withdrawn containing polymorphonuclear cells filled with pigment and many pigmented polygonal cells — the pigment being dark brown and even black in some cells — and finally, a few red blood corpuscles. The patient wore a glass eye, and upon referring to the ophthalmological records it was discovered that the right eye had been removed in January, 1884, for a melanotic sarcoma of the choroid. Thereupon the urine was carefully examined and melannria was demonstrated. The history of a choroidal tumor, au enlarged and nodular liver and melanuria rendered the diagnosis clear; it was subsequently confirmed at the autopsy.
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Since the publication of the above-mentioned paper many cases of liver metastasis following primary melanotic tumor of the eye have been reported, but even now the clinical picture has not received the attention which it deserves. Within a year two patients have presented themselves at the Johns Hopkins Hospital with this condition.
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Case I. C. B., male, white, age 42; admitted August 21, 1896, complaining of pain in right side.
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Family liistory unimportant. Patient has never had any serious illness. Five years ago, upon the day he sailed from England to this country, his right eye witliout apparent cause became inflamed. He received no medical attention and at tlie end of the voyage the eye was quite blind.
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His present illness began six weeks ago with a sAabbing pain in right side. He then for the first time noted a small lump over the lower ribs on the right side, wliich was so painful upon any exer. tion that he gave up work.
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There is anorexia ; no Vomiting ; bowels irregular ; he has lost 35 pounds in weight since onset.
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Physical Examination. Patient is sparely nourished and rather pale. Right eye atrophied ; on seventh rib just outside the right maramillary line there is a hard fusiform enlargement 6>^x4 cm. and a'. out 1 cm. in depth. It is firm and seems attached to the rib; the overlying skin is not discolored. Examination of heart and lungs negative.
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Abdomen. With the exception of a slight bulging in the right hypochondrium, the abdomen looks natural. Liver flatness begins at the sixth rib in right mammillary line ; its edge is palpable 10 cm. below the costal margin ; it is less distinctly felt as one reaches tlie median line. Surface is smooth and firm ; edge a little irregular. In the epigastrium are four small flattened prominences which feel like subcutnneus flbro-cartilaginous nodules. Spleen not pal
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pable ; no general glandular enlargement. Rectal examination negative. Urine, light amber, acid ; specific gravity 1(20-26; no albumin or sugar ; diazo-reaction present.
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September 4th, Dr. Mills removed the atrophied glebe, and at ita posterior portion a small melano-sarcoma, evidently arising from the choroid, was discovered. The patient remained in the hospital a month. Subsequently, on October 8, 1896, he was readmitted, looking paler and more emaciated, and com plaining of pain in right and left sides, epigastrium, right shoulder.
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The lower right chest is bulging; abdomen is markedly distended, especially in right hypochondrium. On palpation the edge of the liver is felt about 14 cm. below costal margin in riglit mammillary line ; in right and left hypochondrium the edge feels sharp and normal, but below and to the right it is very hard and nodular. Surface is slightly irregular. The patient remained under observation two weeks, and at his own request was discharged ; his subsequent history is not known. During these weeks theliver rapidly increased in size; a small swelling similar to the one on the seventh rib, but about one-third its size, appeared on the fifth rib, riglit side, at junction of its osseous and cartilaginous portions ; lymphatic glands became palpable in right inguinal and left prsterior cervical regions.
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The second case we were able to study more thoroughly.
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Case II. P. W., male, white, age 38 years, admitted July 26, 1S97, complaining of pain in the lateral regions of abdomen and in the back on right side. Family history unimportant. Patient has bad smallpox and rheumatism, otherwise always healthy. About December, 1890, he was struck in the right eye by the branch of a tree. At the time he paid little attention to the incident, but in the course of the winter the eye began to give him pain and his head ached a great deal. During 1891 his vision began to fail, and in January, 1892, a physician whom he consulted enucleated the eyeball.
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Present Illness. Began between two and three years ago, that is, about three years after the enucleation, with pain in the abdomen. For the past year has not been able to do much work, for the pain, which extends all over the abdomen and is of a ' burning " character, is rendered more severe by any exertion. During last six months little nodules have appeared over the chest. Does not think complexion is darker than formerly ; no jaundice ; appetite variable ; vomited once last week ; three years ago weighed 185 poundp, now 117 pounds ; has grown weak. At present he has a great deal of frontal headache. He has had cough for three or four days; slight whitish expectoration.
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Physical Examination. Patient is an emaciated man ; swarthy complexion ; lips and mucous membranes of fair color. He wears a glass eye in the right orbit, and when it is removed a moist glistening brown mass is visible in the posterior portion of orbital cavity. Scattered over arms, thorax, abdomen and back are noilules varying in size from one-half to three and a half cm. in diameter, bluish-green in color, and not adherent to the skin or deep tissues. Percussion note over front of chest resonant. In the supra-clavicular fossiB expiration is prolonged, elsewhere of normal relative length. Percussion note over right half of back below middle of scapula lacks resonance ; in this area many medium-sized r;iles are heard ; a few over base of left lung. Elsewhere the lung isclearon percussion and auscultation. Heart sounds feeble but free from murmurs.
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Abdomen. Full; costal grooves obliterated. Right costal margin considerably more prominent than left; right half of abdomen is more distended than left ; veins are prominent over its suiface.
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March, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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51
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Respiratory movements slight. On deep inspiration a large mass descends in the right half of abdomen. Hepatic flatness begins at the sixthribin the right mammillary line and extends 5;i cm. below costal margin and 13}i cm. below ensiform cartilage in the median line. On palpation a large firm mass occupies an area the limits of which correspond to those obtained on percussion. The mass (evidently the enlarged liver) is extremely firm and distinctly nodular; its edge is rounded. There is general tenderness over abdomen. Spleen not palpable. No general glandular enlargement. Rectal examination negative ; urine showed reactions of melanuria. One of the subcutaneous tumors was removed and proved to be a spindle-cell sarcoma with brown pigment within the cells as well as about them ; there was some alveolar arrangement.
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Blood. Red blood corpuscles 4,480,000 ; white blood corpuscles 10,300 ; hfemoglobin 40 per cent. Differential count : Polymorphonuclears 71.6 per cent.; small mononuclear8^17.4 per cent.; large mononuclears 9 per cent.; eosinophiles 2.8 per cent.
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After admission the patient had attacks of vomiting and diarrhoea, occasional elevations of temperature, now and then paroxysms of coughing during which he expectorated frothy bloodstained sputa. The abdominal tumor and the growth in the orbit rapidly increased in size, new subcutaneous nodules appeared here and there, he suffered great pain in the abdomen, especially on defecation, became progressively weaker and more emaciated, and finally died on October 13, 1897.
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Autopsy. The autopsy, performed by Dr. Flexner, showed the most extensive metastases involving the liver, kidneys, lungs, pancreas, thyroid gland, stomach, intestine, gall-bladder, the abdominal, mediastinal and thoracic lymph glands. The right optic nerve showed a grey degeneration and was atrophied ; the meninges were cedematous.
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The first case is evidently one of primary sarcoma of the choroid with liver metastases; the second, one of general dissemination following what was presttmably a melano-sarcoma of the nveal tract, although an account of the condition of the eye at the time of enucleation could not be obtained.
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In each case the loss of an eye, the subcutaneous tumors and enlarged liver contributed to form the characteristic picture of melano-sarcoma; indeed, in the second patient the loss of an eye, the pigmented nodules and the colossal nodular liver descending visibly with each inspiration, enabled one to make the diagnosis de visu. In addition to emphasizing the clinical aspect of this condition, the cases serve to illustrate many features of pigmented sarcoma of the eye and its sequelffi.
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Following the classification of Virchow, pigmented sarcomata of the eye are divided into three classes: 1. Primary external melauo-sarcomata which arise at the scleral border. 2. An orbital variety, springing most probably from the adipose tissue of the orbit. 3. Primary internal melanosarcomata. It is to this division that the first and probably the second of the present series belong. These are the sarcomata arising from the uveal tract; the great majority have their point of origin in the choroid, and as in our case most frequently from its posterior portion. They are composed of spindle cells, or they may contain besides spindle, round and stellate cells.
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. The disease is not a common one. With the exception of early childhood, it occurs at all ages. Most of the patients are between forty and sixty years of age; a case has been observed as late as the 8ith year.
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In each of the above histories one's attention is attracted
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to certain incidents preceding the development of the tumor. It will be recalled that in the one case there is an account of a trauma one year preceding removal of the globe, and in the other, of an inflammatory trouble coming on five years before the new growth was detected, which had caused meanwhile an atrophy of the eyeball. Now, the association of simple inflammatory conditions, with or without antecedent trauma, and the development of melanotic sarcoma of the eye, has often been commented upon and is frequently so striking that it cannot be dismissed as a chance coincidence. Virchow quotes a number of examples. Thus, Rosas reports the case of a woman who lost her sight through an injury received four years previously while splitting wood. Cooper narrates the case of a woman whose cornea had been cloudy two years as the result of an inflammation. Bowman and Mackenzie each gives an example of the growth developing in an eye in which there was present a condition quite similar to that found in our first patient, namely, atrophia lulbi. Particularly instructive is a ease reported by Raab, inasmuch as imbedded in the tumor could still be demonstrated a portion of the splinter of wood which a year previously had caused the trauma. In 103 cases LaAvford and Collins obtained the history of injury in 6.79 per cent.
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Perhaps no other astiological factors in the domain of new growths have been more discussed than those we have just been considering; the details of this discussion need not be rehearsed. It is particularly interesting, however, in this connection to note the recent endeavor to associate the development of malignant growths of the alimentary tract with trauma.* Once the ocular sarcoma becomes established a metastasis sooner or later occurs. All the organs may contain tumor masses, but certain of them are more prone to involvement than others. When there is a widespread dissemination, the distribution is much the same as that presented by our autopsy.
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Almost all of the organs as above stated were involved. The spleen, bones, bladder, prostate and testicles were free from metastases. The pleurae were extensively involved, but in the parenchyma of the lungs there were only two or three nodules about the size of a walnut and a few smaller masses just beneath the pleura. The tumor masses varied in color from a mottled grey to a deep black ; the former usually firm, the more deeply pigmented portions almost diffluent.
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Sections prepared from the abdominal lymph glands showed microscopically a pigmented large cell sarcoma.
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The liver seems to offer a most favorable soil for the development of secondary growths, and it may be the only organ affected. Some of the largest livers on record belong to this group.
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The liver of Litten's patient weighed about 10 kilo (27 pounds). In our second case the organ weighed 8.3 kilo (22 pounds). The capsule was tense and congested. Pigmented nodules projected from its surface, pushing the capsule out. At about the level of the umbilicus there was a fresh deposit of fibrin as well as old adhesions between the liver and the abdominal walls. There were similar deposits on the superior
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'Boas. Deut. med. Wochenschr., No. 44, Oct. 1897.
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52
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 84.
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surface of the right lobe and adhesions to the CBSophagus. Projecting from the inferior surface of the right lobe near its lower margin was a pedunculated tumor 5x4x6 cm.; soft, lobulated and grey on section. Many nodules of various sizes were scattered through the substance of the liver ; the largest about the size of an orange, black, and almost diffluent • the smaller variety usually greyish or slate color. Microscopically the pigmented tumor cells had an alveolar arrangement with scanty stroma intervening.
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Assuming as we do that dissemination takes place through the blood, what determines the localization of metastases in certain organs and the escape of others is not at all clear. The same difficulty is met with in some cases of multiple lympho-sarcomata, and here it has been suggested that the process is really not to be regarded so much as a metastasis in the nsual sense, but rather as an infectious disease, the result of the diffusion of a virus through the body (Schulz, Flexner). Efforts have been made to detect the materies morbi in the blood, but the results have r,ot been encouraging. Pigment granules and pigmented leucocytes have been found, but actual tumor cells, as far as I know, have not been discovered.
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The urine in cases such as we have been discussing often presents the condition known as melanuria. The urine of the second of our patients may be taken as an illustration of these phenomena.
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On an average 1100 cc. were voided daily, of a brandybrown color, with a specific gravity varying from 1008-1027; reaction, acid ; neither albumin nor sugar present. At times polymorphonnclear cells and calcium oxalate were present in the flocculent sediment. Allowed to stand exposed to the air the iirine became much darker, and the same change immediately ensued on the addition of an oxidizing agent (nitric acid, potassium bichromate). A solution of ferric chloride added to a specimen also caused it to turn black; diazoreaction present.
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The fact that the urine in melanosis is occasionally black has been long known, but it was not until 1858 that Eiselt accurately described the condition of melanuria in the case of a man suffering with " carcinoma " of the liver and eye. The urine darkened on standing, and the same change was produced by addition of nitric acid. The observation was veritied, and from the character of the ui'ine the opinion was ventured that the neoplasm was of a melanotic variety, an opinion which was later confirmed at the autopsy. To the hypothetical pigment the name melanin was given. The subject at once engaged the attention of the Prague school and many publications followed Eiselt's. In 1865 Dressier obtained an iron containing pigment from a melanotic growth of the liver, and about the same time Pribram separated by precipitation with neutral lead acetate a similar pigment from a melanuric urine. He concluded that the two pigments were probably identical. But later, in a brown pigment isolated from the urine of a patient with a melanotic growth in the orbit, Hoppe-Seyler could not demonstrate iron. In 1889 V. Jaksch added another reaction for melanuria, showing that ferric chloride even in dilute solution colored the urine black. He, like Pribram, found iron and also sulphur in the lead acetate precipitate. Almost simultaneously and inde
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pendently of V. Jaksch, PoUak recommended a solution of ferric chloride as a delicate test for melanin. His analysis of tiie precipitated pigment showed besides sulphur and nitrogen, iron.
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While melanuria was being investigated, attentidn had also been directed to the pigments of the sarcomata themselves. The results are not entirely in accord. The presence or absence of iron in the pigment is considered to have an important bearing on the question as to whether they take their origin from the blood. Whereas Berdez and Nencki report the pigment of sarcoma of liver and spleen as free from iron (phymatorhusin), Morner reports an appreciable quantity. In this connection it is of interest to note that in their recent work on the pigment of negro's skin and hair, Abel and Davis jioint out that the difference of opinion regarding the iron content of melanin may be due to the fact that the distinction between the pigmentary granule and the pigment itself has not always been made. The granule contains iron, the pigment a steadily diminishing amount as it is more and more purified, so that finally only the faintest trace remains; from which they conclude that iron is not a constituent part of the melanin derived from the negro's skin. A priori, knowing that the choroid is so often the primary seat of melanotic sarcoma, one might expect a correspondence between the composition of " phymatorhusin " and the melanin of the choroid. But the fact is that while the former is rich in sulphur, in the pigment of the choroid there is neither sulphur nor iron.
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Whoever has approached the subject of the melanins must have been impressed with the jiresent unsatisfactory state of our chemical knowledge regarding them. In composition they approximate the proteids, and like them they present similar difficulties in separation and purification. The point of clinical importance, however, is that in melano-sarcomatosis the urine, as in Finkler's case, is sometimes black. More often, as in our case, it is clear when voided and becomes dark on exposure to air or on the addition of oxidizing agents. lu the first class a melanin is excreted ; in the latter group it is assumed that the melanin or phymatorhusin of the neoplasm is absorbed into the blood, is converted in the tissues into a colorless body melanogen, which is then excreted only to be reconverted into a melanin by oxidation. At what period in the course of the disease melanuria appears is not certain, but it is usually stated that a previous metastasis is necessary. We must look to the ophthalmologists for further information. Its diagnostic value, which might be considerable in an obscure case, is somewhat lessened by the fact that reactions similar to that of melanin-containing urine have been observed in some cases of peritonitis, of simple carcinoma of the stomach and liver, and following administration of tannic acid.
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Finally, the question of the prognosis of melano-sarcoma of the uveal tract demands consideration. Left untreated, a metastasis sooner or later occurs. It is difficult to estimate the duration of the disease, for the ocular tumor is characterized at first only by ophthalmoscopic changes and its presence is not evident. Usually, after a period of one or two years, during which there have been more or less pain and functional disturbance of the eye, the tumor ruptures externally
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March, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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53
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and a metastasis occurs. The secondary deposits often grow with frightful rapidity and death soon ensues. Litten's case, in which the patient with a metastasis survived four years, is probably unique. The average duration of life is about three vears. Widespread dissemination may have taken place before the neoplasm of the eye is suspected, and tumor masses in the liver, as in Litten's case and in Case I, may for the first time lead to a careful examination of the bulb. Early enucleation of the diseased globe has a certain prognostic import. In a study of 79 cases of sarcoma of the uveal tract whose after history could be followed, Lawford and Collins regarding patients apparently free from the disease more than three years after operation as well, report 25 per cent, of recoveries. Unfortunately, as they point out, no such limit can be fixed. Thus in Case II, although there was some evidence (abdominal pain) that metastasis may have taken place three years aftei' the enucleation, yet it was not until nearly five years had elapsed that the patient presented himself with a local recurrence and an enlarged and nodular liver. Jonathan Hutchinson, Jr., cites a case in which the first evidence of metastasis appeared eleven years after the diseased globe had been removed. Such cases illustrate the gloomy outlook in melano-sarcoma of the eye, even when early enucleation is carried out; they make it impossible to say when an individual having had a primary ocular sarcoma can be considered safe from future trouble. It is comforting, however, to know that patients have been followed as long as sixteen and eighteen years after early removal without presenting signs of the disease.
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BiBLIOGKAPHY.
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Abel and Davis: The Journal of Experimental Medicine, Vol. I, No. 3, 1890.
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Berdez and Nencki : Archiv f. experiment. Path., Bd. 20, S. 346, 1886.
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Dressier : Prager Vierteljahrschrif t, 1869.
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Eichorst: Handbnch d. spec. Path. u. Therap., Bd. 2, S. 491, S. 575.
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Eiselt: Prager Vierteljahrschrift f. prakt. Heilk., 1858, III, S. 190; 1863.
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Finkler: Centralblatt f. klin. Med., Bd. I, 1880-81.
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Fuchs: Text-book of Ophthalmology.
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Ganghofer and Pribram : Prag. Vierteljahrschrift f. prakt. Heilk., 1876, CXXX.
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Graefe and Saemisch : Haudb. d. Augenheilk., Bd. 4.
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Hutchinson: Brit. Med. Jour., Vol. I, 1893, p. 291.
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Lawford and Collins: Eoyal Loud. Ophth. IIosp. Keports, Dec. 1891.
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Litteu: Ueber einen Fall von Melanosarcoma der Leber, Deut. med. Wochenschr., 15, S. 41, 1889.
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Michel: Lehrb. d. Augenheilk., 1890.
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Morner: Zeitschr. f. iihysiolog. Chemie, XI, 1887; XII, 1888.
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Nepveu : Gaz. med. de Paris, 1872, 335, 385.
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PoUak: Wiener med. Wochenschr., 1889, 39, 40, 41.
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Pribram : Prager Vierteljahrschr., 1865, LXXXVIII, 16-23.
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llaab: Beitrilge z. path. Anat. d. Augen, Klin. Monatsbliitter, Juli, 1875.
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Sieber: Ueber die Pigmente der Choroidea n. der Haare. Arch. f. experiment. Path., XX, 1886.
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Stevenson : Note on a Case of Melannria (? L. P. H.), Guy's Hosp. Keports, XIII.
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Sutton : Tumors, 1893.
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Virchow: Die krankh. Geschwiilste, Bd. 2.
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von Jaksch: Zeitschr. f. physiol. Chemie, XIII, 385.
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Discussiosr.
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Dr. Abel. — The melanin, or black pigment, making up so large a part of the tumors in the case presented by Dr. Hamburger, is a substance of no little chemical interest. I wish merely to bring out two points relative to this pigment. First, the term melanin should be applied only to the black or brown pigments of the melano-sarcomata of the retinal and choroid coats of the eye, of the hair and skin, of the secretion of the cuttle-fish, etc.; in short, to a large class of substances which have been isolated by chemists, which are known to be stable and highly resistant compounds, possessing certain definite characteristics. The term should not be applied, as it sometimes is by histologists, to every brown or black particle which may be seen as a more or less temporary stage in the breaking down of red corpuscles in pathological conditions. A true melanin has not yet been isolated from an area where there has been an extensive disintegration of red corpuscles. AVe have no proof that the dark particles in such an area contain a genuine black ])igment like the melanins.
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My second point concerns itself with the origin of the melanins. Are they derivatives of hfemoglobin or of some other substance? Histologists have laid great stress on the iron content of a melanotic pigment, holding that the presence of iron lends great probability to the view that the pigment in question is derived from haemoglobin. Now a micro-chemical iron reaction merely shows that iron is present in or on the little particle examined; it does not prove that iron is present in the molecule of the pigmentary substance to which the color of the particle examined is due. Iron may be present in the molecule of a pigment and yet micro-chemical methods may not be able to detect it, as in hsematin, for example. Again, the pigmentary granule as deposited in cells is a very different thing from the pigment considered as a chemical individual; the former is a complex anatomical unit, containing many other substances in addition to the pigment. Confusion has resulted because this point has not been borne in mind. Davis and I showed that the pigmentary granules in the negro's skin and hair contained much iron, while the isolated and purified pigment contains none, and we have every reason for believing that this holds for every particle of melanotic pigment in the body. The fact is that much more than the presence of iron must be established before we can say that a pigment is derived from haemoglobin. Some of the colored derivatives of haemoglobin, as haamatoidin, hfematoporphyrin and biliribin, contain no iron, while the well-known hsematin contains this element. Now all of these natural derivatives of haBmoglobm differ so widely in both their physical and chemical characteristics from the melanins, as thus far isolated, that no chemist can suggest a plausible theory for the derivation of these latter from the color-yielding complex of atoms in the hemoglobin
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54
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[No. 84.
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molecule. To point out only one great obstacle, the melanins, with few exceptions, contain sulphur, the amount varying from 2 to 12 per cent., while the colored derivatives of hjemoglobiu, like those already referred to, contain no suljihur. A theory of the origin of melanins must account for this difference and also for the difference in the carbon, hydrogen and nitrogen content, not to speak of physical differences as shown by the spectroscope. My own observations have led me to think of the sulphur-containing melanins, such as the sarcomelanin of this case, as highly altered proteids, as compounds that must still be classed in a broad way with the proteids. If, therefore, hfemoglobin is to be made the precursor of these pigments, it is the proteid part, or globin of the blood pigment, from which they are derived. Bnt we can as easily suppose some proteid of the parenchymatous juices to be decomposed as that the proteid moiety of hEemoglobin should serve this purpose. We could assert with equal force that all the keratin in the body is derived from hemoglobin.
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Schmiedeberg has recently published the results of an elaborate research on the nature and origin of the melanins which bear out this view. I cannot go into the chemical details of
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the question, but can only give you bis conclusions, to which I subscribe most heartily. The immediate precursor of the melanin is a product derived from a genuine proteid, say serum albumin, by a fermentative process ; it is a highly resistant, modified proteid of the character, we will say, of an antipeptone which has lost carbon-containing groups, perhaps also leucin and tyrosin. This substance would therefore be richer iu sulphur than the original proteid. It is further modified by having ammonia and water split off from it, its hydrogen content being further diminished by oxidation. These deductions are based on a careful comparison of the elementary formula3 of many proteids and of all of the melanins hitherto isolated and analyzed, and they harmonize entirely with the chemical processes known to occur in the body. No other rational theory of the origin of the sulphur-containing melanins, like those found in these tumors, in the hair and skin, etc., can be offered at present. I may remark in closing that the formation of the dark pigments seen in decaying vegetable matter, and which are called humus substances, presents many points of analogy.
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ON INFECTION WITH A PARA-COLON BACILLUS IN A CASE WITH ALL THE CLINICAL
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FEATURES OF TYPHOID FEVER.
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By Norman B. Gwyn, M. B., Assistant Resident Physician, Johns Hopkins Hospital
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Baeberial infection, or the intoxication caused by bacteria, gives to the blood the property of paralyzing and clumping the specific organisms. This is the principle of the Widal reaction, now so well known iu connection with typhoid fever, and the same applies to other well-known organisms, such as the pyocyaneus and the bacillus of hog cholera. From this we may infer that a serum test is a valuable or certain proof of an organism's specificity. No better suggestion of this can be found than that shown by the colon family, in which Durham has shown that the serum of an immunized animal agglutinated decidedly only the organism used for the immunization, other colon organisms being but feebly affected. Widal infers from this that, especially in an infection caused by one of a group like the colon, the serum reaction is only of value as affecting that particular colon organism which has produced the infection.
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For the production of this serum reaction in the blood of an individual, something more than the mere presence of the organism in the body is required. There must be a definite infection or intoxication produced before the blood will acquire its specific property. The presence of the colon bacillus in the normal intestine does not make it presumable that the blood of all persons will agglutinate the colon bacilli.
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Based on the theory of specificity of the serum reaction, Widal* reports a case which he thinks (from the behavior of the patient's serum towards the organism isolated from his
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' Semaine Medical, Aug. 4, 1897
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body) must be considered as an instance of infection by a || para-colon bacillus, and the case he considers as one of para- ^ colon infection.
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The name para-colon is given to the organism as showing its resemblance to the colon family, but Widal gives it a place I more properly between the bacillus typhosus and the colon I bacillus, as its properties are closely allied to both.
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I'he history of his cas3 of so-called para-colon infection is as follows: A phthisical patient developed, after three weeks 9 in the wards, an abscess in the neck about the oesophagus, I showing at the same time some slight constitutional symptoms. From the pus at operation an organism was obtained in pure culture, actively motile, decolorizing by Gram ; it did not liquefy gelatine, clouded bouillon without making a film, and formed a few gas bubbles in glucose agar ; grew on potato as a yellowish green film.
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The two most essential points distinguishing it from the colon family were that it produced no iudol and did not ferment lactose, while the fermentation of glucose distinguishes it from the typhoid bacillus. Further reactions confirmed the fermentation of glucose and mannite, and the absence of the same in lactose and saccharose.
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The main feature of the organism, however, was its serum reaction, and on this its claim of specificity rests. The serum of the patient had a marked agglutinative action on the organism in as high dilutions as 1-1000, the reaction diminishing steadily with convalescence.
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To confirm this result various other orsfauisms were com
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March, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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pared. The different cultures of colon bacillus were affected by the patient's serum no more than by normal sera. Another para-colou bacillns isolated from the mouth agglutinated at 1-150; the bacillus psittacosis responded at 1-50. The serum of a guinea-pig inoculated with the particular para-colon organism gave no result with two colon bacilli, a typhoid bacillus and the other para-colou organism mentioned above. Conversely various normal sera and sera from patients with various affections. Sera of animals inoculated with different organisms had little or no effect upon Widal's para-colon bacillus, with the exception of typhoid sera of very high agglutinative power obtained by experimental inoculation. The sera of animals inoculated with colon bacilli, with the psittacosis organism and the other para-colou, gave little or no reaction on the organism.
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Widal concludes from these serum reactions that the bacillus isolated was the cause of the patient's infection. The other para-colon bacillus referred to, isolated from a person's mouth, differed from that isolated from the abscess in fermenting saccharose in addition to glucose and mannite.
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These two so-called para-colon bacilli, the psittacosis organism, a bacillus called the bacillus of calf septicemia of Thomasson, Widal considers to form a family or group, in much the same way as the colon organisms are classified as a family. The individuality of the members is shown suggestively, though not absolutely, in the serum reactions mentioned above, and by differences in fermentation of the various sugars.
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Kecently we have isolated an organism which from its cultural properties seems to belong to this so-called para-colon group, and is possibly identical with one of Widal's para-colon organisms. It was found, moreover, that the patient's serum had a specific agglutinative power on the organism, and the conclusion was reached that the organism isolated had caused the infection. The case is of further interest as one of typical typhoid fever, and the question arises whether or not the organism found had produced a secondary infection during the disease.
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Louis S., admitted Oct. 11th, 1897, had been ill since Sept. 17th with headache, fever and weakness, and later with vomiting, diarrhoea and pain in abdomen. On Oct. 14th noisy delirium set in ; on Oct. 16th the patient had three hemorrhages from the bowel ; he slowly rallied and went out in five weeks.
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Kose spots were present; the spleen was palpable; the urine showed the diazo reaction ; there was no diarrhcea. The temperature was that of a severe typhoid fever. There was never any Widal reaction found. Blood cultures on Oct. 12th gave a small, actively motile bacillus suggesting the bacillus typhosus. It decolorized fairly well by Gram, grew on agar as a grey blue moist raised film, clouded bouillon, giving no scum on surface and no precipitate. Milk was only faintly acidified, resuming original tint in course of ten or twelve days. Potato showed a brown yellow moist layer of growth. There was no liquefaction of gelatin, slight stab and surface growth. Plates of gelatin and of gelatin diluted with bouillon gave same circumscribed blue grey colonies, about i mm. in diameter; by microscope light brown regularly outlined
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granular colonies with no nucleus. The fermentation reactions showed fermentation of glucose, slight in saccharose, Ifevulose and mannite, but none in lactose. Sugar-free bouillon, to which in tubes 3 per cent, of various sugars was added, was used. There was no production of indol. By Van Ermengeu's flagellar stain, from two to four flagellae could be made out. No peritrichal arrangement as in the bacillus typhosus was seen.
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The serum reactions were as follows : The patient's serum at different dates during his illness gave a rapid, complete agglutination in low dilutions, and showed reaction in dilutions up to 1-150 to 1-200, the highest being at date of discharge. On Dec. 18th, two mouths after date of culture, there still remains a slight reaction.
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The same serum was without action on the bacillus typhosus in any dilution above 1-1 or 1-5.
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Two varieties of colon were agglutinated by patient's serum as high as 1-50 and 1-60, but two normal sera agglutinated the same organisms in dilutions running from 1-60 to 1-100.
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Typhoid sera of agglutinative strength ranging from 1-300 to 1-1100 were without effect on the bacillus in dilutions over 1-1 and 1-5. One typhoid serum, strength 1-900, with bacillus typhosus, gave an incomplete reaction as high as 1-30. Several of these sera had little or no effect even in dilution 1-1. One normal serum affected the bacillus rapidly at 1-1, failing at 1-5. A typhoid bacillus was affected similarly ; a colon was agglutinated as high as 1-120 ; another normal serum had little or no effect at 1-1, while rapidly aad completely agglutinating the colon organisms.
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One other test mentioned by Widal for the distinction of the para-colou organism, is that called the scraped tube reaction, which consists in scraping off the surface growth of an organism from an agar slant and reinoculatiug with other or the same organisms. A fresh transplant of the same organism will not grow on the scraped surface ; other different organisms will. Both colon and typhoid grow on the supposed paracolon tubes, and the para-colon grow on scraped tubes of them. Widal considers this an absolute distinction, stating that by it the different colon members can be distinguished.
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The approach of the organism on the one hand to the typhoid bacillus and on the other to the colon family is well shown by the cultural properties. The effect on milk and the non-production of indol are like the typhoid bacilli; in the fermeutation of glucose it resembles the colon family, from which again the non-fermentation of lactose and the negative indol test clearly exclude it. Its place really seems to lie between these two important organisms.
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By comparing the cultural properties of our bacillus with those previously described, it can be seen that with the exception of the fermentation of saccharose the organism is precisely similar to Widal's para-colon isolated from the abscess; the resemblance to the one isolated from the mouth is more exact, as the latter had some effect upon saccharose. In the colon family, however, the fermentation of saccharose is a variable characteristic and may not occur with every member, so that this slight difference in fermentative quality may perhaps be a feature in the para-colou family as well. From these reactions and characteristics we think that the organism
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56
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[No. 84.
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here described may be considered a para-colon bacillus and may be identified with Widal's organism. Our infection unfortunately cannot be so clearly defined as his, occurring as it did in the course of typhoid, but if a serum reaction is a specific test, such an infection must have undoubtedly occurred. Of great interest, we think, is the fact that at no
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time, even up to the present, Dec. 18th, 1897, has the patient's serum given a Widal reaction, he being the only typical typhoid of 48 cases to fail therein, while his serum still shows after two months the result of the infection by the supposed para-colon organism.
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THE MANACtEMENT OF SOLID TUMORS OF THE OVARIES COMPLICATING PREGNANCY, WHH
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REPORT OF A SUCCESSFUL CASE.
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By William E. Swan, M. 1)., Assistant Resident Gyncecologist in the Johns Hopkins Hospital.
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A careful examination of the literature shows that although solid tumors of the ovaries are not uncommon, their occurrence as a complication of pregnancy is sufficiently rare to justify a detailed report of every additional instance. Inasmuch, also, as the proj^er treatment of this condition is of the utmost importance, the following case offers certain points of interest.
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A. R., single, white, domestic servant, aged 22, born in the United States, was admitted to the gynecological wards of the Johns Hopkins Hospital, June 13, 1893. In the February previous (five months before) she had noticed an increase in size of the abdomen, which had gradually increased. Except for this enlargement of the abdomen, and amenorrhcea since January 1st, she had had no cause for complaint.
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Family History. Paternal grandmother died of a new growth in lower abdomen. Maternal grandfather had a cancerous growth on arm; family history otherwise negative.
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Personal History. Does not remember having had any serious sickness before. Menstruation began at fifteen ; was irregular up to the 17th year, since then regular till 5i mouths ago, of the 38-day type and of 5 to 6 days' duration ; flow free; slight dysmenorrhoea.
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Present Illness. Has always been healthy up to January, 1893. Early in February she first noticed a slight increase in the size of the abdomen, and absence of the menses, which have not returned since. The enlargement progressed in a symmetrical manner, and at the present time (June 3) the abdomen presents the appearances belonging to a five months pregnancy. The patient has had no morning sickness and has not noticed anything which could be interjjreted as fcetal movements. There has been no increase in the size of, or pain in the breasts; no swelling of the feet or ankles. Sleeps well ; appetite good ; bowels constipated ; slight giddiness ; some dyspnoea on exertion ; otherwise no inconvenience. No pain anywhere.
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Physical Examination. General condition good. The patient is a well nourished, healthy-looking young woman; eyes clear, tongue slightly coated, mucosas of a good color. Heart and lungs negative.
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Abdomen symmetrically distended. Line of pigmentation from umbilicus to pubes marked. On light palpation a rather yielding, slightly resistant mass is felt extending from two inches above the umbilicus to the symphysis pubis, and from 3 to 4 inches to either side of the median line. (Jn palpat
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ing deeply and quickly ballottement is obtained over this area, showing the presence of a layer of fluid. The abdomen over the same area is dull ou percussion ; on auscultation a placental bruit is heard in the right lower quadrant of the abdomen ; no fcetal heart sounds are heard ; no actual movements made out, but indefinite "lumps" are felt through abdominal wall which "retreat" from the examining hand.
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The measurements of the abdomen were as follows: Girth at umbilicus, 30 inches ; girth midway between umbilicus and symphysis, 31 inches ; from the ensiform cartilage to umbilicus, 74 inches; from the umbilicus to the symphysis, 71 inches ; from anterior spine of ilium on either side to umbilicus, 6 J inches.
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Vaginal Examination. Vaginal mucosa dusky violet in color; outlet considerably relaxed; cervix high up, soft, shortened, patulous. Behind the cervix and occupying a large part of the pelvis is a hard, nodular, fixed mass, about 5x7 cm. in diameter, adherent to sacrum postei'iorly. The breasts contained colostrum.
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Diagnosis. Pregnancy, associated with solid tumor of the left ovary.
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Abdominal section by Dr. Kelly, June 21, 1893.
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Incision 18 cm. long through stretched and thinned abdominal walls. The uterus, which was of the size belonging to a five months pregnancy, was forced out by compression made on the sides of the abdomen by the hands of an assistant, the operator meanwhile making direct traction ou it and throwing it forward so that the body rested ou the pubes. By these means there was brought into view a tumor of the left ovary, lying behind the uterus in the pelvis but not attached to it. It presented a whitish appearance, was hard, irregularly oval, and about the size of two clenched fists placed closely together. Pressure upon it had caused some flattening of the surface adjacent to the sacrum. The tumor, which was attached to the left broad ligament by a narrow pedicle, was raised and tied off together with the left tube by means of four intermediate silk ligatures, a few extra silk ligatures being inserted to stop some slight oozing from the severed pedicle. The uterus, which had all this time been protected by means of a large piece of gauze kept constantly saturated with warm salt solution, was now returned to the abdomen. The peritoneum was united by means of a fine silk suture; the remaining layers of the abdominal coverings with silk
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March, 1898.1
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worm gut and silk; gauze dressing, edges rendered adherent with collodion ; iodoform and boric acid powder dusted over same; cotton; Scultetus' bandage.
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Time of operation 46 minutes.
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The convalescence was rapid and uneventful; the highest temperature reached was on the second day, when it rose to 101° F., after which it soon became normal ; the bowels moved on the fourth day. On July 2, 1893 (13th day), note reads: '•For the first few days after operation a slight bloody vaginal discharge was observed ; patient complained of sharp pains through the abdomen. This symptom soon subsided under a moderate use of morphine. Abdominal dressings removed ; wound united throughout jjer 2^1'imavij general condition excellent."
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July 10, 1893 (20th day}, " Patient sat up in bed ; did not fee] weak nor tired afterwards."
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July 2i, 1893 (4 weeks after operation), " Patient discharged; has had no setbacks ; wound nicely healed; patient feels well ; abdomen increased in size."
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Pathological Report. Mass consists of a large tumor developed from left ovary, with about 4 cm. of normal tube, with clear mesosalpinx; tube patulous. Tumor 13x7 cm., density of cartilage, with clear smooth fibrous capsule, which strips off moderately easily. On outer surface is an umbilication about 3 cm. deep, containing a small mass of similar consistence, with broad flat pedicle. Vessels on surface small but injected. Section of mass reveals a dense fibrous structure, yellowish and translucent, with numerous deeper pinkish areas corresponding to umbilication on surface ; tissue much softened, and upon pressure exudes a clear fluid.
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Frozen sections reveal fibrous tissue with fine points of fatty degeneration.
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Sections hardened in alcohol. The specimen consists of dense fibrous tissue with spindle-shaped nuclei. The tumor is richer in cells in the larger portion. The cajjsule is much thickened. Vascular sujjply scanty, esjjecially around the umbilication. Diagnosis: Fibroma of ovary.
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From the after-history it would seem clear that premature labor was artificially induced after the patient returned home. When she left our care she was certainly well, and had nature been left to herself there was nothing in the patient's condition to prevent the continuance of the pregnancy to term, and there was no indication that in this case delivery would have been accompanied with any more danger than that belonging to a normal labo)'.
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Considerable confusion seems to exist in the minds of authors regarding the classification of tumors of the ovaries associated with pregnancy. In many reports of cases of ovariotomy during pregnancy, only incidental reference or none at all is made to the nature of the growth removed. Thus, J. Dsirue' (Liveland) collected from the literature 135 cases of pregnancy associated with ovarian tumors in which ovariotomy was performed, the diagnosis in 43 of these being tumor ovarii, and in the remainder cystoma. None are distinctly specified as being solid tumors.
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Most tumors of the ovary, including those complicating pregnancy, are cystomata, and of these dermoids form a considerable number, as is shown by the following table :
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Total num- Cysts, in- Number
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ber of cases eluding of solid Fibro- Sarco- Carcino Name of operator, operated on. dermoids, tumors, mata. mata. mata.
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1. Billroth 86 78 8 .. 3 5
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2. Schroeder .... 102 97 5 . . 5
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3. Thornton 338 328 10 3 .. 7
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4.Hildebrandt.. 37 27 10
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5. Weber 123 72 51
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6. Krassowoski.. 128 128
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7. K. VonBrann. 81 71 10 1 2 5
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8. Thos. Keith . . 200 183 17
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9. Olshausen 193 267 26 6 9 5
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Totals 1388 1251 137 10 19 22
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The figures iu the above table give, as we see, 9.9 per cent, solid tumors. But Olshausen" holds that this is too large a proportion. Weber, whose statistics tend materially to raise this percentage of solid neoplasms, has probably counted as solid tumors many which other authorities would class among the cystic variety. With Weber's cases omitted we should have only 6.8 per cent, of solid tumors, which is probably more correct.
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The same table shows the relative frequency of the different varieties of solid tumors to be as follows : Fibromata are present in the proportion of .73 per cent. Sarcomata " " " " " " 1.36 "
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Carcinomata " " " " " " 1.58 "
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All others " " " " " " .057 "
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The investigations of Jetter' have shown that any form of ovarian tumor may complicate pregnancy. Of his collection of 166 cases, 97 were cystomata, 37 dermoids, 11 carcinomata, and 31 uncertain. In this small number of cases the proportion of undoubted solid tumors to all others is only 6.6 per cent.
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Solid tumors of the ovaries may be classified as follows :
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Fibromata,
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Sarcomata,
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Desmoid { Mysomata,
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Endotheliomata, Solid -j Enchondromata.
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Carcinomata, illomata.
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Epithelial I *^^'"" I- ^ I Papil
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The lines between these several varieties of tumors are not always distinctly drawn, and almost any two forms may be found associated. The benign forms of epithelial tumors of the ovary are always cystic in nature (Olshausen').
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Ovarian neojjlasms do not preclude the possibility of conception so long as the ovaries contain healthy ovarian tissue. Indeed, rare instances have shown that the removal of both ovaries is not an absolute safeguard against conception. In such cases there are undoubtedly rudimentary masses of ovarian tissue or supplementary ovaries left behind (Montgomery").
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It is diflScult, if not wholly impossible, to arrive at any accurate conclusions as to the frequency of conception in women who are the subjects of ovarian neoplasms. S. Kemy° finds, however, that in 357 women with tumors, 331 pregnancies occurred, with 366 normal delivei'ies; so that some of the
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[No. 84.
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mothers became pregnant at least twice during the existence and probable growth of the same tumor.
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Montgomery, in commenting on the frequency of ovarian tumors complicating pregnancy, says he is able from a very cursory investigation of the literature to present tables of over 150 cases. It is evident that he refers to cysts of the ovary associated with pregnancy.
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Several authors, as Kleinwiichter, Spencer AVells and Eokitansky, have observed pregnancy in connection with unilateral ovarian fibromata. During labor the tumor may obstruct the biith canal, and thus render Csesarean section necessary, as happened in Kleinwiichter's case; the tumor may be contused and become gangrenous, as has been described by Rokitansky.'
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After a careful examination of the literature we have been able to find but fourteen cases of undoubted solid growths of the ovary in association with pregnancy. These are here presented in chronological order with brief histories.
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Case I. Breit". In this case an ovarian tumor of stony hardness and adherent to the rectum was removed ; no details given.
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Case II. Sp'.egelberg' (reported by Bourgonin). Patient was aged 37 and had borne two children. Immediately after the birth of the second child a rapid enlargement of the abdomen was noticed, which pursued a slowly progressive course and ended in death. At autopsy a fibroma of the left ovary weighing 60 pounds was found, with considerable ascites. Size of tumor 51x23 cm.
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Case III. Spiegelberg'" (reported in 1867). The woman died nine days after her second labor, aged 36. Tumors of both ovaries were found at autopsy which microscopic examination showed to be myxosarcomata which had undergone cystic degeneration. One tumor measured 20x12x4 cm.; the other 15x10x4 cm. Death was due to rupture of one of the tumors, apoplexy of both, and peritonitis.
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Case IV. Kleinwiichter" reported in 1872 the following case. Age of patient 31 years ; month of pregnancy not stated, probably full term ; pains began on May 25, and on May 29 were very severe. Patient was brought to the hospital by midwife, who got away before giving any further information. Head presenting. Examination revealed a bony tumor, about the size of a fist, in tlie pelvis. Cfesarean operation performed on May 31, 1868, and a healthy female child weighing 3010 grammes safely delivered. Twentyfive hours afterwards the mother died of general peritonitis.
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Diagnosis. Peritonitis after Caesarean section ; ossified fibroma of the right ovary.
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Case V. Spencer Wells (reported by Cayla). The patient, aged 29, who had had one child, presented herself in March, 1872, with a tumor in right suprapubic region. She was three months pregnant. One month later laparotomy was performed, and a tumor weighing five kilograms was removed. This tumor had been held in place by the epiploon to which it was adherent. The structure of the tumor was that of an ceJematous fibroma. The patient recovered and the child was born at term.
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Case VI. Hem pel" in 1875 reported the case of a patient aged 42 who died four weeks after her 11th labor. At autopsy both ovaries were found enlarged to more than the size of a child's head. The surfaces of the tumor masses were hard and irregular. The tumors proved to be carcinomata, probably secondary to cancer of the stomach.
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Case VII. Schroeder" (reported by Cayla). Woman aged 22, six montlis pregnant ; operation May 25, 1876 ; solid tumor removed from left ovary. Labor at term ; cure.
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Case VIII. Spencer Wells" (reported by Cayla.) Woman aged 41, four months pregnant ; operation October, 1876 ; tumor weighed 7 pounds. Labor at term ; cure. Diagnosis: Round cell sarcoma of left ovary.
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Case IX. Spencer Wells" (Cayla). Woman aged 28, four months pregnant; operation November, 1877. Fibroma of right ovary removed, weighing 10 pounds. Labor at term ; cure.
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Case X. Casati". Large fibro-sarcoma of left ovary. Pregnancy at fourth month. Ovariotomy ; abortion, partial suppurative peritonitis ; cure. Patient was 2!i years old. Menstruated at 18 ; married at 25 ; ten months later had first child. In March, 18SI, had second chilJ ; labor normal. Two months after this noticed tumor in left groin. Four months after labor menses recommenced ; milk stopped at 5th month. On January 4, 1882 (ten months after birth of last child), the patient vras examined and the following diagnosis made :
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Completely solid tumor (probably sarcoma) of left ovary ; partial peritonitis and pleurisy. At operation the woman was found to be four months pregnant. The tumor weighed 1850 grammes, and measured 13x48x36 cm.
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Case XL Dr. .7. H. Carstens,'^ of Detroit, Michigan, in 1889 reported a case almost identical with our own. The patient, aged 26, white, four years married, without having had children or miscarriages, had had frequent micturition and pain for the year previous. She had noticed a hard lump in lower abdomen, which had increased rapidly during ihe last four weeks. The menses, which had formerly been regular, ceased February "4, 1889. General health and family history good. Examination showed the pelvis to be filled with a hard growth which seemed movable. The uterus was found a little to the left of the growth. The os was soft, velvety. Pregnancy suspected. Examination under ether warranted a diagnosis of pregnancy of two months duration and a pelvic tumor, which was thought to be a uterine fibroid with a long pedicle, a sarcoma, or some other hard tumor of the ovary. Operation !May 27, 1889. When the peritoneum was opened a very hard nodular tumor came into view. It was movable, slightly adherent to the bladder, intestines and omentum, but not adherent to the uterus. The long narrow pedicle was tied off together with the right Fallopian tube, which was also removed. The left ovarj- was found to be healthy and was left untouched. Patient made a good recovery. The pregnancy continued and was of seven months duration at the time the case was reported. The tumor was very hard and nodular, i.0 cm. long and 12 cm. in diameter; in the middle was a constriction in which the uterus had rested. A microscopical examination by Dr. George Duffield showed only pure fibrous structure. The ovary had entirely disappeared in the growth.
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Case XII. Miinchmeyer" (reported in 1890). Patient aged 30. Thir(J pregnancy. Month of pregnancy not stated, probably full term. Normal but small pelvis. Enormous elastic tumor(spindlecell sarcoma) occupied the pelvis. Head presenting. Shortly before the delivery of foetus the colossal swelling of the tumor was noticeable. The absence of any symptoms pointing to malignancy of the tumor was noted. The child being already dead, the skull was crushed and the fcetus delivered. The tumor remained for four weeks after the delivery, but shrunk to about the size of a goose egg(?). Ovariotomy was then performed ; the patient made a good recoverj', and was discharged three weeks subserjuently.
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Case XIll. 3. Murphy. " Abdominal section during pregnancy (reported in 1895).
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"A lady 32 years old was sent into the Sunderland Nursing Institute, under my care, to have an ovarian tumor removed, she beirg about six months pregnant. The operation was performed at noon, April 20, 1803. The tumor proved to be a solid round-cell sarcoma, weighing two pounds, with somewhat numerous adhesions. The labor pains commenced 24 hours after the operation and became severe at 10 a. m. The patient soon gave birth to a boy, who lived for 12 hours. The convalescence was uneventful. She If ft the Institute in three weeks. Her highest temperature was 99.5° F."
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Case XIV. P. Ruge."' Woman aged 36; six months pregnant. !Myxo sarcomata of both ovaries ; no details.
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March, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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From au examination of the results iu the above fourteen cases we find that eight of the patients were submitted to operation before labor, with the death of one mother and with loss of but two children from miscarriages and one by craniotomy, four children going to full term and one being delivered by Cajsarean section. Three mothers were not operated on ; of these, two died soon after labor as a result of complications due to the tumors, and one lived ; in three cases no details are given.
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The incompleteness of the above collection of cases is painfully apparent. A glance at the various dates of their publication — 1861 to 1895 — would suggest at once that many similar cases must have occurred previous to the former and probably also subsequent to the latter date. Their non-appearance either in the Index Catalogue of the Surgeon-General's Library or the Index Medicus, would lead to the conclusion that such instances were either not reported at all, or that the accounts of them did not possess suflRcient detail and clearness to enable the cases to be recognized as belonging to this category. So called solid dermoids and all other tumors not distinctly specified to be solid have been rejected from our list.
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Influence of Pregnancy on the Growth of Ovarian Tumors.
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In this connection two main theories may be cited: (1) That the increased blood flow increases the growth of the tumor (Spiegelberg and Olshausen). (2) That a decrease in the size of ovarian tumors during pregnancy occurs, owing to lack of space and inactivity of the ovaries (Koeberle). The former of these two views is generally accepted (Dsirne)."
 +
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Wernicke suggested that benign tumors are apt to become malignant during pregnancy. There are no observations which tend to support this view (Olshausen).
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Luhlein" in 189.5 published a comprehensive article dealing with ovarian tumors complicating pregnancy. His views may be summarized as follows:
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(1) He dissents from Wernicke's view and holds that benign tumors of the ovary do not tend to become malignant during pregnancy. (2) He doubts if tumors enlarge much during pregnancy and cites cases to support this position. He quotes many observations to show that the ovaries are in a state of rest during pregnancy.
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The recognition of the co-existence of pregnancy with a solid ovarian tumor or tumors is of the greatest importance, and often presents a difficult problem. The limits of this paper forbid more than a brief discussion of the main characteristics of this condition.
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Solid tumors of the ovaries are often bilateral, though there are many exceptions to this rule ; they are seldom larger than a man's head ; the general form of the ovary is maintained ; adhesions are rare, but ascites is usually present (Olshausen)."'
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Although the signs and other evidences of pregnancy, in association with solid tumors of the ovaries, are sufficiently characteristic, it is a noteworthy fact that many experienced and able operators have recognized the pregnancy only after the abdomen has been laid open. It is therefore not out of place to emphasize the importance of keeping in mind the
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possibility of the existence of such a condition in making our examinations.
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In this connection it is interesting to note that Napier," after reporting a case of ovarian cyst in which he successfully performed cystectomy at the third month of an unsuspected pregnancy, quotes from Barnes' "Diseases of Women," as follows: "Ovariotomy during pregnancy has been performed several times, the operatornot suspecting theexistence of pregnancy before the operation. What should be done when a pregnant uterus is discovered during some stage of ovariotomy ? Wells says let it {i. e. the uterus) alone. Dr. Atlee performed ovariotomy in the second month of an unsuspected pregnancy. Dr. Marion Sims performed ovariotomy in the third month of pregnancy, not suspecting its existence, with good results to mother and child."
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The prognosis in cases of ovarian tumor complicating pregnancy is by no means favorable. The great danger to the mother will be appreciated from the figures in the following statistics.
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Litzmann has collected 54 cases with 24 maternal deaths ; Jetter, 215 deliveries in 165 mothers with 64 deaths ; Playfair, 57 deliveries with 23 deaths; Braxton Hicks, 6 deliveries with no deaths ; Kogers, 5 deliveries, no deaths ; Spencer Wells, 11 deliveries, one death ; Fritsch, 4 deliveries, one death. In all, 355 deliveries are reported with 114 maternal deaths, or a maternal mortality of about 32 per cent. The mortality to the children from either abortion or premature labor is, according to Engstrom, much greater. In 216 cases he finds it to be about 48 per cent. (Fenger).'"i
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Heiberg'" has collected 271 cases of pregnancy with ovarian tumors and found that over one-fourth of the mothei-s and two-thirds of the children perished ; while Dsirne" says that only 60 per cent, of the pregnancies complicated by ovarian tumors terminated without accident to mother or child.
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The situation and size of the tumors are of marked significance in determining the prognosis. Most solid tumors, especially during their early growth, remain in the true pelvis. When small they may be overlooked, and the hindrance which they offer to delivery may be unsuspected or attributed to pelvic narrowing (Montgomery)." Large tumors rarely hinder the engagement of the fcBtal head, unless a part of them occupy the pelvis; whereas small tumors, especially dermoids, often retard the descent of the head, so that 02ieration is necessary (Hohl)."^"
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Greigg," from his post-mortem researches upon puerperal septicemia, shows that it is possible that some cases of this disease arise from injury, during parturition, to unrecognized ovarian tumors. We must consider not only the mechanical difficulties in the way of delivery, but also the cachexia due to the presence of malignant new grow'ths (Miiller)."
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Complications of pregnancy may arise owing to the presence of solid ovarian tumors.
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1. The stem of the tumor may become twisted and thus give rise to the presence in the abdominal cavity of a necrotic foreign body. This accident occurs in 9.1 per cent, of all cases (Dsirne)."
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2. Infection of the peritoneum is more likely to occur.
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3. The tumor by direct pressure on the intestines may
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[No. 84.
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cause intestinal obstruction, or indirectly twists of the gut or hemorrhoids (Barsouy)."
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The mortality in ovarian tumor cases complicating pregnancy, treated by the expectant plan, is frightful. In 75 cases (cysts included) collected from the literature, 31, or 41 per cent., were fatal to the mothers, while but 32 children, or 29 per cent., are reported as having been saved (Montgomery)."
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Litzmanu" gives the maternal mortality as 43 per cent., and the fffital as 83 per cent.; while Dsirne, as stated above, reports that but 60 per cent, of these cases when left alone terminate without accident to mother or child.
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Such a death rate urgently demands renewed investigation and the adoption of a definite plan of treatment. When we come to the consideration of ovariotomy during pregnancy, we find far better results.
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Of cases of ovariotomy during pregnancy, Dsirue finds that abortion followed in 23 per cent., and death in only 5.09 per cent. Breit'° (1861) reports results of operation on tumors of the ovary in pregnancy during labor, or the puerperium, as follows : In 315 cases, 140 mothers recovered, 64 died ; in 11 the results were unrecorded. Of the children, 81 lived, 53 died, of 61 there was no record ; 21 abortions occurred.
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So far as the chances of maternal recovery from ovariotomy during pregnancy are concerned, they are fully as good as when no pregnancy exists. As regards the continuance of gestation, if the operation is performed in the early months the prospect is usually also favorable (Munde) "
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In this connection Kreutzmann* states the facts clearly when he says : "The bringing about of abortion would be in order (1) if it is proved that ovariotomy during pregnancy is always followed by abortion; and (3) if the statistics show that the results of ovariotomy in pregnant women are much less favorable than in non-pregnant women. The fact that the percentage of abortions following operation is only about 20 per cent, is an answer to the first proposition. As concerns the second, statistics have demonstrated that with most operators the mortality in ovariotomies performed during gestation is less than those in non-pregnant women."
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Since ovariotomy, then, can give such good results, the advisability of operative procedures must be taken into consideration in each individual case. Surgeons of wide experience, as Spencer Wells, Tait, Cauchois, Olshausen, and the late Carl Schroeder, are agreed in commending ovariotomy as the best means of dealing with all cases of ovarian neoplasms associated with pregnancy. Again, in view of tlie fact that Cohn" has proved every sixth ovarian tumor to be probably malignant, the early removal of the diseased structures is of vital importance.
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The most favorable time for operation is at some period during the first half of pregnancy. In the later mouths the increased hyperasmia and engorgement of the broad ligaments increase the danger of untoward results (Montgomery)."
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Kelly has published statistics which go to show that all tumors of the ovary should be extirjiated as soon as recognized, no matter how small or inoffensive they may appear. His experience with cysts of the ovary has clearly demonstrated that it is not safe to allow them to remain, inasmuch
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as many apparently innocent cysts (papillary cystomata) may at any time become highly malignant, and if not removed sufficiently early, may prove rapidly fatal.
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According to Olshausen,'- from 60 to 70 per cent, of all patients with proliferating cystomata (cystoma ovarii proliferans papillare) die within three years from the time of the first symptoms, and a further 10 per cent, die during the fourth year.
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This surgical law which insists upon the early extirpation of all ovarian tumors applies with still more force in cases of solid ovarian neoplasms associated with gravidity.
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Time for Operatmi. The elective time for the operation seems clearly defined, as all agree that the lowest mortality to both mother and child is secured by operating between the second and fourth months of gestation. There is one apparen t exception to this rule. Dsirne" states that in intra-ligameutary tumoi'S, owing to the danger of hemorrhage, it is often better to produce abortion before extirpating the tumor. It may, however, be asserted that the results in these particular cases will be determined largely by the skill and operative dexterity of the surgeon, and that under favorable conditions these cases can also be successfully operated on without previous interference with gestation.
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When the case is not seen before labor, and when the tumor interferes with the engagement of the head in the true pelvis, one or both of the following procedures are indicated :
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(a) Attempts may be made to replace the tumor in the abdominal cavity under anesthesia.
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(b) As a last resort, celiotomy.
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In the puerperium Hohl" says that we should operate not later than the second week. Others hold that if the labor is normal it is better to wait several weeks longer.
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In summarizing the results of a thorough search of the literature dealing with the subject the following deductions would appear to be justifiable:
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I. Solid neoplasms of the ovary complicating pregnancy are exceedingly rare.
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II.- The diagnosis of this rare combination of a physiological and pathological process may be very diflBcult. In certain cases much help can be obtained from recto-abdominal palpation under narcosis, using Kelly's method to gently produce artificial descensus of the uterus. The physical examination with the signs of pregnancy, and those which belong more particularly to solid ovarian growths, will generally enable us to make at least a probable diagnosis and one sufficient to warrant .in exploratory section.
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III. The prognosis in cases of solid growths of the ovary complicating pregnancy is much worse, both for mother and child, than in those of cystic neoplasms of these organs. This is to be explained by the fact that the former are usually smaller and remain in the true pelvis and obstruct the parturient canal, while the latter, owing to their bulk and consistence, rise above the pelvis, and the dystocia, if produced at all, is of a less serious nature.
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Abdominal section and. extirpation of solid tumors during the early months of pregnancy produce equally good results, so far as the life of the fa?tus is concerned, as in the case of cysts ; the ultimate I'esult in the case of the mother depending.
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March, 1898.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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of course, ou the malignant or benignant nature of the new growth.
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IV. In the management of these cases we have seen that if the extirpation is undertaken during the elective period of gestation (second to fourth month) the maternal mortality was but 5 per cent., due to hemorrhage, shock, sepsis, and other causes ; whereas the foetal mortality due to abortion is only 20 to 22 per cent, as compared with 40 per cent, for the former and 80 per cent, for the latter when these cases are left to unaided nature.
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The general rule, then, should be to operate on all cases between the second and fourth months of gravidity. It would be hard to find a stronger argument in favor of the elective operation for e.xtirpation of these ovarian neoplasms than is furnished by a comparison of the statistics of the best authorities.
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V. The compulsory operation (during the latter half of gestation, during labor, or the puerperium) will rarely be required. One then should be guided by the suggestions of Hohl, preference being given to the procedures in the order above mentioned.
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In conclusion I desire to express my deep sense of obligation to Professor Kelly for permission to report this unusual case ; to Dr. Cullen for much encouragement and assistance in obtaining references; and to Dr. Bardeeu for valuable aid in abstracting literature.
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Bibliography.
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1. Dsirne, J.: Arch, fiir Gyniik., 1893, V0I..XLIII.
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2. Olshausen : Billroth's Handbuch.
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3. Jetter : Billroth's Handbuch.
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4. Olshausen : Die Krankheiten der Ovarien. Stuttgart, 1886.
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5. Montgomery: Med. Times, Phila., 1886-7; XVII, 693, 698.
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6. Eemy, S. : Quoted by Miiller in his Handbuch der Geburtshiilfe, p. 819.
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7. Rokitansky : Winckel's " Diseases of Women," p. 577.
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8. Breit, F. : Dissertation, Tubingen, 1861. Case from Lachapelle (Puchelt, S. 173).
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9. Spiegelberg: Monatsschriftf. Gebiirtsh. (1866), XXVIII, p. 73.
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10. Spiegelberg : Monatsschrift f. Gebiirtsh. (1867), XXX, p. 380.
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11. Kleinwiichter: Arch, fiir Gyniik., Berlin (1873), IV, p. 171.
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12. Spencer Wells : (Reported by Cayla), see 15.
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13. Hempel : Arch, fiir Gyniik., VII, p. 556, 1875.
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14. Schroeder: (Quoted by Cayla), see 15.
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15. Spencer Wells: Contribution a I'etude de I'ovariotomie pratiquee pendant la grossesse. Paris, 1882.
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16. Spencer Wells : See 15.
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17. Casati, L. : Raccoglitore Med. Forli., 1883-4, XIX, 277, 292.
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18. Carstens, J. H. : Tr. Am. Assn. Obst. and Gynfficol., Phila., 1889, Vol. II, pp. 151, 167.
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19. Miinchmeyer: Centralb. f. Gyniik. (1890), XIV, p. 186.
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20. Murphy, J. : Lancet (1895), I, p. 148.
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21. Ruge, P. : Reported by Olshausen in " Die Krankheiten der Ovarien," 1886.
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22. Dsirne: Hegar and Kaltenbach, Op. Gyniik., 1886, p. 248.
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23. Olshausen, R. : Die Krankheiten der Ovarien. Stuttgart, 1886.
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24. See 23.
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25. Napier : Tokyo Med. Jour., Feb., 1888, p. 23.
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252. Fenger: American .Journal of Obstetrics, New York, 1891, XXIV, pp. 1097, 1107.
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26. Heiberg: Quoted by Olshausen in "Die Krankheiten der Ovarien," 1886.
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27. Dsirne: Hegar and Kaltenbach, Operativ Gyniik., 1886, p. 248.
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28. Montgomery : Med. Times, 1886-7, XVIII, p. 693.
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29. Hohl: Arch. f. Gyniik., Berlin, 1896, LIII, 410, 427.
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30. Greigg : Quoted by Montgomery ; see 28.
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31. Miiller: Handbuch der Geburtshiilfe, p. 819.
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32. Dsirne : See 27.
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33. Barsony: Centralbl. fur Gyniik., Leipzig, 1897, XI, 139, 144.
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34. Montgomery: See 28.
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35. Litzmauu: Quoted by Montgomery; see 28.
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36. Breit: See 8.
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37. Munde, P. F.: New York Med. Journal (1887), p. 11.
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38. Kreutzmann, H. : Am. Journal of Obstetrics, XXVI, p. 204.
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39. Cohn : Winckel's " Diseases of Women," p. 541.
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40. Montgomei-y : See 28.
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41. Kelly: Lectures, Johns Hopkins Univ., 1896-7.
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42. Olshausen : Winckel's " Diseases of Women," p. 542.
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43. Dsirne: Arch, fiir Gyniik., Berlin (1892), XLII, 415, 456.
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44. Hohl : Archiv fiir Gyniik. (1896), Berlin, LII, pp. 410, 437.
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45. Lohlein, H.: Gyniik. Tagesfr., Wiesb., 1895, Hft. IV, 1, 31.
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62
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[Xo. 84.
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THE CATHETERIZATION OF THE URETERS IN THE MALE THROUGH AN OPEN CYSTOSCOPE WITH THE BLADDER DISTENDED WITH AIR BY POSTURE.
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By H. A. Kelly, M. D., Gi/necolor/ist-in-Chief to The Johns Hop/cins Hospital.
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The difficulties and the dangers of the various devices for electric cystoscopy with the source of illumination introdiiced within the bladder are so great that I feel sure urologists everywhere will welcome and test carefully any new method of examination which bids fair to limit or to supplant these methods by one which is simpler, more direct and more satisfactory in its results.
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I have succeeded in devising such a method and in demonstrating its utility in the presence of an audience of expert urologists and surgeons at St. Luke's Hospital, New York City, Feb. 4th, 1898, through the kind invitation of Dr. L. Bolton Bangs, consulting surgeon, and the courtesy of Dr. Robt. Abbe, visiting surgeon, who oflered me his clinic hour.
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Among the visitors present were Drs. Eobt. F. Weir, Willy Meyer, Clement Cleveland, Kobt. A.Murray, Faiquhar B.Curtis, F. Tilden Brown, and others.
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I was greatly indebted to the house staff of the hospital for their warm, intelligent interest and assistance throughout.
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Dr. Otto G. Kamsay accompanied me from the Johns Hopkins Hospital and aided me skilfully at every step of the investigation.
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The cystoscope used was a straight metal nickel-plated tube 15.5 cm. long, 7 mm. in diameter, the caliber being equal from end to end, except at the conical external orifice, which measured 3.7 cm. at its outer border and was blackened on the inside to prevent the reflection of the light from obscuring the field. A stout handle 10 cm. long was attached to the outer end.
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The source of illumination was a small electric headlight, deriving its current from the house supply, reduced by a Vetter controller.
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The patient, a young man, was put under Schleich's anesthetic, when I introduced the cystoscope armed with its obturator as far as the prostate, and then guided it easily over the prostate and into the bladder by raising and guiding the end with one finger introduced into the rectum. The penis, of
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average size, shortened on the cystoscope to a length of about 5 cm.
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He was then carefully turned over and placed in the kneechest posture and brought to the edge of the table and the obturator withdrawn ; air at once entered the bladder and the investigation was made.
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The light was good and the base of the bladder at once came clearly into view; the posterior wall was seen by elevating the handle a little, then by turning it to the right and to the left the left and right lateral walls were clearly seen. I then withdrew the speculum until the internal urethral orifice began to close over it, and then pushed it in a little, turned it about 30 degrees to the left and dropped the handle, when the right ureteral orifice came clearly into view, as clearly as I have ever seen it in a woman.
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Dr. Willy Meyer looked through the cystoscope and agreed it could not have been seen clearer or more unmistakably if it had been on the surface of the body.
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Dr. Eamsay then handed me one of my renal catheters, 50 cm. long and 2 mm. in diameter, armed with a stylet, and this was guided, after two attempts, up into the ureteral orifice, and easily stripped of the stylet, into the ureter, ascending up to the pelvis of the kidney. Dr. Abbe now looked through the cystoscope and saw the catheter entering the bladder wall.
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The patient was then put to bed with the catheter in position, and before leaving the hospital I had the satisfaction of knowing that half a test-tube full of slightly cloudy urine had been collected.
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By this method of cystoscopy not only is the diagnosis of vesical lesions simplified, but simpler and direct plans of treatment, such as curetting, cauterizing and making applications to localized areas are made possible. Small tumors may also be easily excised or snared.
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A preliminary note has been published in the Annah of Surgery (Jan. 1897), where a fuller account will shortly appear.
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PROCEEDINGS OF SOCIETIES.
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THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.
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Meeting of December 20, 1897.
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Dr. Barker in the Chair.
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On Super-Arterial Pericardial Fibroid Nodules.— Mr. Knox. In 1866 Kussmaul and Maier reported an instance of the development upon many of the smaller visceral arteries, of nodules, to which condition they applied the name of peri-arteritis nodosa. Since this time additional cases of a similar disease have been described by Chvostek and Weichselbaum,
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Meyer, Fletcher and Von Kahlden. This rare condition is characterized by the presence upon the smaller arteries, except those of the brain and spinal cord, of small grayish-white nodules, which microscopically are found to be associated with hypertrophy of the internal and adventitial coats of the affected vessels, and with weakening or even rupture of the middle coat. The origin of this affection is conceived to be either some form of infection or intoxication.
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Some months ago my attention was directed, through the kindness of Dr. Flexner, to a heart which showed upon its surface, over the arteries, opaque elevations suggesting those of
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March, 1898.J
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JOHNS HOPKINS HOSPITAL BULLETIN.
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peri-arteritis nodosa. Later, at the autopsies, several other hearts affected in like manner were fonud, and I was permitted to study the specimens in the Pathological Laboratory.
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The extent of the process varied, from tortuous, more or less uniform elevations over the arteries, to whitish dots, minute in size and few iu number, which almost escape attention.
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The elevations may be separated from each other by wide intervals, may be quite close, resembling beads strung along the vessel, or they may coalesce throughout the entire length of the artery.
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The nodules were found exclusively upon the ventricles and the interventricular septa; never within the heart muscle, upon the auricles, nor over the veins. They were never noticed elsewhere in the body.
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Ou microscopical examination there were no constant alterations to be made out in hfematoxyliu and eosin stained specimens in any of the arterial coats, but between the adventitia of the vessel and the surface there was a marked fibrous thickening projecting beyond the level of the pericardium and producing the nodules seen in gross specimens. At the base of the nodule and at the sides lymphocytes and a small number of polymorphonuclear leucocytes were accumulated.
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The appearance in cross-section was as though a compact mass of firm connective tissue, convex on its inner surface, had been placed upon the artery in the loose pericardial tissue.
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The nodule may be only a small oval patch over a portion of the artery, or it may extend a considerable distance upon each side.
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The earliest stages of the process met with showed simply a serous infiltration and an accumulation of small round cells superficial to the artery on its outer side.
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In no case was any tendency to fibrous formation noticed on the inner side of the vessel, next to the heart muscle, nor in the heart muscle itself.
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The constant relationship of the fibrous thickenings to the arteries suggested that the nodules were in some way associated with changes in the arterial walls not brought out by the stain in hematoxylin and eosin, and a representative number of the sections were stained for elastic tissue by the fuchsin method described by Manchot.
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There were of course variations in the sections, but the results were sufficiently uniform to be quite suggestive. In a few sections there were distinct breaks in the inner elastic coat just opposite the nodule, but the most noticeable alteration and the one present in most of the preparations was a diminution in the strength of the order elastic coat between the muscle and the adventitial layers.
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This membrane was well reiiresented on the inner side of the artery often by a heavy dark red band, but as one approached tlie outer half it became thinned, the fibers looser and separated from each other until usually just beneath, at times a little to one side of the fibrous thickening, only a few straggling strands of the elastic fiber remained.
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In no instance was this change accompanied by an increase in the thickness of the inner elastic coat. Occasionally only were defects in either elastic layer seen on the inner side of an artery. Iu these cases no alterations corresponding to the
 +
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nodule under discussion were present in the remaining layers nor in the surrounding tissue.
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The change described was not seen in arteries not surmounted by the fibrous patch.
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These findings would suggest at least some association between the nodules on the surface and the weakening in the arterial wall beneath.
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The affection, as far as can be ascertained, was discovered incidentally in every case, and produced no symptoms as far as can be known.
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From the above description there can be nodoubt that the condition found in the epicardium of these cases is entirely distinct from peri-arteritis nodosa. There was, too, nothing in the histological appearances that was suggestive of a primary bacterial or toxic action upon the tissues leading to the fibrous formation, and the bacteriological studies of the cases at autopsy did not support such an assumption.
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In considering the histological appearances one is tempted to regard the changes in the elastic coat as the primary alteration. Moreover, a number of facts iu the protocols lend support to this idea, for the individuals in whom the condition was found were subject to unusual strains put upon their cardio- vascular system.
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Of four cases in which the nodules were present, three showed heart hypertrophy. In one, lesions of the valves existed ; in another, arterio- sclerosis. Three of the cases suffered from nephritis; in three there was oedema, and in one case aneurism. Three of the four patients gave histories of heavy work, irregular life, and the ingestion of large amounts of alcoholic beverages.
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Discussion of Dr. Huiiner's Cases of Aneurism [continued). See February Bulletin, p. 38.
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Di\ OsLER. — The most interesting thing about this case relates to the diagnosis. This patient was under observation last year, and there were several points of great interest at first which made us doubt whether he really had aneurism of the aorta. We could not grasp a very positive tumor. There were well-marked pulsation and a definite thrill and murmur, but these, in the absence of a tumor, when you have reached a certain grade in your experience, are insufficient. He had aortic regurgitation, but that also made us hesitate, for you know how frequently, particularly in young persons, great dynamic pulsation is present. He was under observation for many months, and several additional features came out which made the diagnosis of aneurism of the aorta reasonably certain. In the first place the characters of the pains, that had kept up in a very persistent way aud required a great deal of morphia to relieve. Then he developed a loud bruit at the back ; but what really clinched the diagnosis was a pulsation at the back which could be both seen and felt. Another suggestive point was the fact that the abdominal pulsation was altogether above the infra-costal line. It did not extend the entire length of the abdominal aorta. You can feel the thrill, but you do not feel a very positive tumor, which is evidently deep-seated, probably in the ciliac axis.
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In the second case the pulsation is more evident and very visible. Here the tumor is much more evident, the thrill is
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64
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 84.
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very intense, and there is a loud systolic and also a diastolic murmur. He has no bruit behind. His pains are not nearly so intense. The situation of the pulsation, its very wide area, the very pronounced character of the tumor, and its expansile pulsation, are features that make the diagnosis certain. One of the most important points in this case is its onset in early life; he is only 27, very early for aneurism.
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The possibility is that lead, in which he worked for so many years, had caused the sclerosis of his arteries. In the first case the aneurism is probably in contact with the lower ribs on the left side. In this case I do not think the aorta has eroded the vertebrae to any great extent. He has not had the boring pains such as are almost always present when the aneurism is eroding the vertebrse.
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We have had five instances of abdominal aneurism in the Hospital, out of a total of 57 aneurisms of the larger vessels. It is very much less common than aneurism of the thoracic aorta.
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Some of you remember the man, Lee Kenny, who had a singularly movable tumor in the upper part of the abdomen, which was aneurismal, which pulsated with considerable force and which you could grasp in the hand. Dr. Halsted did a laparotomy, thinking it was possibly not in the aorta but in one of the branches, but it proved to be in the aorta. He was somewhat improved after the operation, but we lost sight of him.
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In a certain number of aneurisms of the abdominal aorta a cure has been effected. The celebrated case of Murray was the first; the aneurism was seated low, just above the bifurcation, and digital compression for an hour caused cessation of pulsation in the sac, and patient lived for nine or ten years. The autopsy showed a healed aneurismal sac. There have been several other instances where compression either by fingers or the clamp cured the aneurism by filling the-sac and securing consolidation.
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In this first case I think operative procedures would be out of the question. In the second one the possibility of wiring has to be considered. In several cases this has been done successfully. In this man the operation would be justifiable.
 +
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Discussion of Dr. Paiicoast's Diabetes in the 'Se^ro {continved). See February Bulletin, p. 40.
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Dr. OsLER. — This case illustrates a point that was brought to my mind a few weeks ago. A woman with diabetes went to Europe in the middle of June. She had a slight cough at the time which had not attracted the attention of her physicians. In .July the cough became worse, and her doctor in Ireland found extensive disease of one lung. On her return she refused to see her old physicians, as she blamed them for overlooking a serious condition of affairs and permitting her to go abroad. She persisted in this point, though I tried to explain that her trouble had developed very rapidly.
 +
 +
Here is a case in point. This man developed tuberculosis within a period of nine weeks and lost in weight from 180 to 130 pounds. The loss of weight and the rapid downward progress are well recognized features in some cases of diabetic phthisis.
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NOTES ON NEW BOOKS.
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Pathological Technique. A Practical Manual for the Bacteriological Laboratory. By Frank B.\ke Mallory, A. M., M. D., and James Homer Wright, A. M., M. D. [W. B. Saunders, Philadelphia, 1897.)
 +
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The manual wliich bears the above title comes to us from the pathological laboratories connected with the Harvard Medical School, and while it is offered as a practical guide for workers in pathological laboratories, we shall be much mistaken if it does not find a much wider sphere of usefulness. The volume, which is well made and of convenient size, is subdivided into three i)art8; the subject-matter of each, while closely connected with that of the other two, being treated in detail separately.
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Part I, in which the technique of autopsies is outlined, contains a full and satisfactory presentation of the best recognized procedures in making post-mortem examinations. The authors have adhered to no one authority, but have chosen from several sources methods which they regard as the most useful and practical. While, as might naturally have been expected, the Virchow method is mainly followed, the authors have not felt themselves bound to follow it in all its details and do not hesitate to recommend the employment of certain procedures which have emanated from the Austrian school of pathologists. Many of the illustrations in this part of the work are borrowed from the little manual of Nauwerck, and the authors are to be commended for reproducing and making available for the English-speaking student these excellent drawings. In the part devoted to the section of the brain the method of Virchow is justly criticized as causing too much disturbance of the relations in the cortex, while that of Pitre, which is also given in detail, is not commended. In the light of our present knowledge the authors would seem to consider the hardening of the entire organ in formalin as affording the best means for future accurate study of the topography of focal lesions, while at the same time the tissue is preserved so as to be available for the finer histological methods. The demands of modern neurology, the growth of the knowledge of cerebral localization and the importance of following closely the various tracts have rendered it evident that the customary time which can be devoted to an autopsy is every day becoming more and more unsuitable for the examination and description of lesions in this organ.
 +
 +
On page 20 a typographical error has slipped into this part of the work. The statement that "The greenish discoloration seen earliest over the abdomen is due to sulphate of iron," is evidently intended to read, stdphide of iron.
 +
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Part II, which treats of the general methods of bacteriological examinations, is subdivided into (1) Bacteriological apparatus ; (2) Culture media; (3) Bacteriological examinations at autopsies ; (4) The methods of studying bacteria in cultures; (-5) Bacteriological diagnosis ; (6) Clinical bacteriology.
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This section of the work is all that can be desired in a book of the scope of the present one. The directions for the preparations of media and cultures and the isolation of micro-organisms in pure culture and their identification, which is the ultimate purpose of bacteriological study, are clearly and succinctly stated. AVe fail, however, to notice any allusion to the autoclave for the sterilization of culture media. There is, in our opinion, no more valuable piece of apparatus for the bacteriological laboratory. Besides its other advantages it enables the time element in the preparation of such media to be greatly reduced. But, however convenient it may be to obviate the loss of time consumed in fractional sterilization, and whatever the advantages in having the media ready to use at once after their preparation, the chief value of the autoclave lies in the certainty with which, at a single exposure, even the most resistant spores («. g. of the bacillus subtilis) are destroyed. The atmosphere of Boston or its climate may be unfavorable to the prevalence of epidemics of hay-bacillus infection, or perchance the city water
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March, 1893.]
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JOHNS HOPKINS HOSPITAL BULLETIN.
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65
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supply is free from contamination with this organism ; but in the latitude of Baltimore, especially in the fall season, it constitutes a pest to the bacteriologist, against the ravages of which the autoclave alone has been found to furnish a sufficient protection. With the exception of blood serum we do not hesitate to put all culture media, including even gelatine (which is exposed for 6 or 8 minutes), through the autoclave at a uressure of two atmospheres and at a temperature approaching 120° C.
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The routine examination by cultures and films or cover-slips is recommended in post-mortem examinations. We are glad to find this point emphasized. The day is perhaps not far distant when this procedure will be regarded as essential to the proper conduct of an autopsy, so that every examination will be deemed incomplete unless the bacteriological study has been carried out. Not a few problems in the causation of disease and of death have already received their solution through the systematic search for pathogenic bacteria in human post-mortem examinations. No modern physician, and still less a pathologist or bacteriologist, regards bacteria as the only living agents which cause the infectious diseases, and we are therefore bound to exercise due caution and a chariness in drawing conclusions based upon negative results from the bacteriological study in suspicious cases. It is not too much to hope that the near future will make amenable to cultivation and study the group of protozoa, just as the bacteria, by the introduction of solid culture media and the invention of a few simple mechanical processes, have been rendered so easy of observation. And when this feat shall have been accomplished, may not the whole group of exanthematous fevers be " resolved " and fall into their natural nosological places?
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It is quite natural that differences of opinion should arise, especially regarding details, as to the best or most generally useful method to be employed in the systematic bacteriological study of autopsies. The authors of this manual advise as the best medium coagulated blood serum, which by their method of preparation is easily accessible for routine work. Of its suitableness as a culture medium there can be no question, but there remains the objection that where a mixture of bacterial forms or species prevails in the original material, their isolation can be most easily effected before the existing proportions are disturbed, and data of the relative numbers of each species present can be obtained only by an immediate separation. For this purpose the "plate" method, using preferably agar-agar, would seem to be the only one applicable. In the end, special cases will dictate special methods of procedure, and the rarity or frequency of departures from the rule will depend on circumstances, among which should perhaps be placed first the readiness with which the operator appreciates the unusual and his capacity to deal quickly with special problems as they arise. In carrying out a post-mortem examination in what is now regarded a proper manner, so many details have to be considered, that unless the time factor is to be entirely neglected, dexterity in operation and quickness in decision are faculties which are especially to be cultivated and by no means to be despised.
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 +
As regards the " time factor" the improvements in histological technique allow no free latitude. If the pathological histology of the future is to keep pace with its younger brother histology, and is to advance beyond the achievements of the period which ended with the semi-centennial just celebrated by Virchow's Archives, and which marks the era of the influence upon medical science of the cellular doctrine of organized nature, then minutes must replace hours in the time elapsing after death before autopsy in order that the organic tissues may be suitable for histological research.
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The statement that the micro-organism causing actinomycosis has not as yet been proved to belong to the bacteria (fission-fungi) is made with due conservatism, but it seems hardly justifiable to place it provisionally among the cladothrices. If it is a bacterium it belongs, according to our present classification, among the streptotbrices.
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The differentiation of the smegma bacilli from the bacillus of tuberculosis is not quite so simple a matter as one little experienced in this undertaking might conclude from the remarks on pages 92 and 93. As the question is often an important one in diagnosis, it might not have been out of place to mention some of the difficulties and to have supplied other methods of distinction, especially the use of an alcoholic solution of methylene-blue, as recommended by Grethe.
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Part III, which is devoted to the enumeration and description of histological and clinical microscopic methods, gives an excellent account of tlie processes employed in hardening, imbedding, sectioning, staining and mounting microscopic sections of tissues. The examination of sputa, blood, fwces, gastric contents and urine is also ilealt with. Where so much is attempted it is not to be expected that all the headings will be treated of with equal completeness. The chief value of this chapter will be found in the paees devoted to histological methods, and it goes without saying that the special works dealing with clinical microscopy will need to be consulted by those who require more than a brief outline of matters relating to any one subject, for the minute details of which the authors could not spare space.
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Drs. Mallory and Wright have given to the English-speaking student an excellent laboratory guide in the methods of modern pathological, histological and clinical study and research.
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S. F.
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BOOKS RECEIVED.
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Twentieth Century Practice. An International Encyclopedia of Modern Medical Science, by Leading Authorities of Europe and
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America. Edited by Thomas L. Stedman, M. D. Vol. XIII.
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 +
Infectious Diseases. 1898. 8vo. 621 pages. W. Wood & Co. Biennial Rejmrt of the Department of Health of the City of Chicago,
 +
 +
being for the Tears 1S95 and 1896. 1897. 8vo. 397 pages -f 51 + 30.
 +
 +
Press of Cameron, Amberg & Co., Chicago. Case of Carcinoma of Descending Colon; Excision and Anastomosis;
 +
 +
Recovery. By John H. Musser, M. D., and Thomas S. K. Morton,
 +
 +
M. D. Reprinted from the University Medical Magazine, July,
 +
 +
1896. Angina Pectoris : Its Relation to Dilatation of the Heart. By John
 +
 +
H. Musser, M. D. Reprinted from the American Journal of
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 +
the Medical Sciences, September, 1897. A Case of Luccemia. By John H. Musser, M. D., and Joseph Sailer,
 +
 +
M. D. Reprinted from the Transactions of the Association of
 +
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American Physicians, 1896. On the Disappearance of Endocardial Murmurs of Organic Origin. By
 +
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John H. Musser, M. D. Reprinted from the British Medical
 +
 +
Journal, October 16, 1897. A Clinical Study of Widal's Serum Diagnosis of Typhoid Fever. By
 +
 +
John H. Musser, M. D., and John M. Swan, M. D. Reprinted
 +
 +
from the Journal of the American Medical Association, August
 +
 +
14, 1897. A TeH-Bookof the Diseases of Women. By Henry J. Garrigues, A.M.,
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M. D. Second Edition. Thoroughly Revised. 1897. 8vo. 728
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pages. W. B. Saunders, Philadelphia. Elements of Latin. For Students of Medicine and Pharmacy. By
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George D. Crothers, A.M., M. D., and Hiram H. Bice, A.M.
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 +
1898. 12mo. 242 pages. The F. A. Davis Co., Philadelphia.
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ERRATA-JANUARY BULLETIN.
 +
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In footnote, page 12, read 1629 instead of 1829.
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In footnotes on page 13, the references to Vanderwiel and Schurig should be reversed.
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On page 16, line 12, the word nasal should be inserted before reflex neuroses.
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m
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JOHNS HOPKINS HOSPITAL BULLETIN.
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[No. 84.
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THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.
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FACULTY.
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Daniel C. Oilman, LL. D., President.
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William H. Welch, M. D., LL. D., Dean and Professor of Pathology.
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Ira Kemses, M. D., Ph. D., LL. D., Professor of Chemistry.
 +
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William Osler, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice
 +
 +
of Medicine. Henry M. Hurd, M. D., LL. D., Professor of Psychiatry. William S. Halsted, M. D., Professor of Surgery. Howard A. Kelly, M. D., Professor of Gynecjlogy and Obstetrics. Franklin P. Mall, M. D., Professor of Anatomy. John J. Abel, M. D., Professor of Pharmacology. William H. Howell, Ph. D., M. D., Professor of Physiology.
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William K. Brooks, Ph. D,, LL. D., Professor of Comparative Anatomy and Zoology. John S. Billings, 51. D., LL. D., Lecturer on the History and Literature of Medicine! Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoology. Robert Fletcher, M. D., M. R. C. S., Lecturer on Forensic Medicine. William D. Cooker, M. D., Clinical Professor of Diseases of Children. John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology. Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology. Henry M. 1'homas, M. D., Clinical Professor of Diseases of the Nervous System. Simon Flexner, M. D., Associate Professor of Pathology. J. Whitridoe Williams, M. D., Associate Professor of Obstetrics. Lewellys F. Barker, M. B., Associate Professor of Anatomy. William S. Thayer, M. D., Associate Professor of Medicine. JoHM M. T. FiNKET, M. D., Associate Professor of Surgery.
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r.EonoE P. Dreyer, Ph. D., Associate in Physiology.
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William W. Russell, M. D., Associate in Gynecology.
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Hesuv J. Berkley, M. D., Associate in Neuropathology.
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