Difference between revisions of "The Johns Hopkins Medical Journal 9 (1898)"

From Embryology
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COIsTTIEIsrTS.
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==Contents==
  
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* Development of the Human Intestine and its Position in the Adult. By Franklin P. Mall, 197
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* On the Histoaenesis of the Striated Muscle Fibre, and the Growth of the Human Sartorius Muscle. By John Bkuce MacCallu 208
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* Further Observations on the Chemical Nature of the Active Principle of the Suprarenal Capsule. By John J. Abrl, M.D. 215
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* The Lobule of the Spleen. By Franklin P. Mall,  218
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* The Development of the Bile-Capillaries as Revealed by Golgi's Method. By William F. Hendrickson, 220
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* A Study of the Musculature of the Entire Extra-Hepatic Biliary System, including that of the Duodenal Portion of the Common Bile-duct and of the Sphincter. By William F. HENDRICKiSON, 221
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* Development of the Internal Mammary and Deep Epigastric Arteries in Man. By Franklin P. Mall,  232
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* Two Instances in which the Musculus Sternalis Existed. — One Associated with other Anomalies. By Henry A. Christian, 235
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* On the Pathological Changes in the Spinal Cord in a Case of Pott's Disease. By Sylvan Rosenheim, 240
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* The Treatment of Otomycosis by the InsufHation of Boracic Acid and Oxide of Zinc. By Samuel Theobald, M. D., - 251
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* Books Received, 252
  
  
Development of the Human Intestine and its Position in the Adult. By Franklin P. Mall, 197
 
  
On the Histoaenesis of the Striated Muscle Fibre, and the Growth of the Human Sartorius Muscle. By John Bkuce MacCallum, - - - - - - 208
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===DEVELOPMENT OF THE HUMAN INTESTINE AND ITS POSITION IN THE ADULT===
  
Further Observations on the Chemical Nature of the Active Principle of the Suprarenal Capsule. By John J. Abrl, M. D., ------ - - 215
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{{Ref-Mall1898a}}
 
 
The Lobule of the Spleen. By Franklin P. Mall, - - - - 218
 
 
 
The Development of the Bile-Capillaries as Revealed by Golgi's
 
 
 
Method. By William F. Hendrickson, ------ 220
 
 
 
A Study of the Musculature of the Entire Extra-Hepatic
 
 
 
 
 
 
 
Biliary System, including that of the Duodenal Portion of the Common Bile-duct and of the Sphincter. By William
 
 
 
F. HENDRICKiSON, __--_--- 221
 
 
 
Development of the Internal Mammary and Deep Epigastric
 
 
 
Arteries in Man. By Franklin P. Mall, ------ 232
 
 
 
Two Instances in which the Musculus Sternalis Existed. — One
 
 
 
Associated with other Anomalies. By Henry A. Christian, 235 On the Pathological Changes in the Spinal Cord in a Case of
 
 
 
Pott's Disease. By Sylvan Rosenheim, ------- 240
 
 
 
The Treatment of Otomycosis by the InsufHation of Boracic
 
 
 
Acid and Oxide of Zinc. By Samuel Theobald, M. D., - 251 Books Received, ----------------- 252
 
 
 
 
 
 
 
DEVELOPMENT OF THE HUMAN INTESTINE AND ITS POSITION IN THE ADULT.
 
  
 
By Franklin P. Mall, Professor of Anatomy, Johns Hopkins University.
 
By Franklin P. Mall, Professor of Anatomy, Johns Hopkins University.
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THE LOBULE OF THE SPLEEN.
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===THE LOBULE OF THE SPLEEN===
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{{Ref-Mall1898b}}
  
 
By Franklin P. Mall. (From the Anatomical Laboratory, Johns Hopkins University.)
 
By Franklin P. Mall. (From the Anatomical Laboratory, Johns Hopkins University.)
Line 25,917: Line 25,897:
  
  
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===DEVELOPMENT OF THE INTERNAL MAMMARY AND DEEP EPIGASTRIC ARTERIES IN MAN===
  
DEVELOPMENT OF THE INTERNAL MAMMARY AND DEEP EPIGASTRIC ARTERIES IN MAN.
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{{Ref-Mall1898c}}
  
 
By Franklin P. Mall.
 
By Franklin P. Mall.

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The Johns Hopkins Medical Journal - Volume 9 (1898)

https://archive.org/details/johnshopkinsmedi08john

The Johns Hopkins Medical Journal 9 (1898)

The Johns Hopkins Hospital Bulletin


BULLETIN OF THE JOHNS HOPKINS HOSPITAL. Vol. IX. - No. 82. BALTIMORE, JANUARY, 1898.


Contents

  • On Certain Activities of tiie Epithelial Tissue of the Skin of the Guinea-pig, and Similar Occurrences in Tumors. By Leo Loeb, M. D ,
  • 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.,
  • The Physiological and Pathological Relations between the Nose and the Sexual Apparatus of Man. By John Noland JIacKENZIE, M.D.,
  • 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].
  • Notes on New Books

Books Received


ON CERTAIN ACTIVITIES OF THE EPITHELIAL TISSUE OF THE SKIN OF THE GUINEAFIG, AND SIMILAR OCCURRENCES IN TUMORS

By Leo Loeb, M. D., Baltimore.


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.

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

•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.


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


Arch. f. Entwickelungsmechanik, loc. cit.


2


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 82.


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.


^' , ,/ b ^^^




Fig. 1.


a, epithelial nuclei,

J, holes in protoplasm produced by the traction.

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.

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


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.

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.


i


January, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


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.

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.

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.

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


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.

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.

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


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 82.


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.*


jteS&cDO


imooo


m


a, basal layer.

b, rod-like nuclei of the upper protoplasmic layer.

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.

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


The endothelial cells of a vessel which organize a thrombus 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.

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.


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.



Fig. 4.


«, transplanted black skin.

A, area where transplanted skin has grown.

c, skin that was afterwards removed.


This experiment proves that the white skin in the neighborhood of transplanted black skin becomes true pigmented skin.


January, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


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


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.

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.

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.


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., Resident Medical Officer, The Johns Hopkins Hospital.


Through the kindness of Dr. Bloodgood I am permitted to report the following case from the surgical service of the Johns Hopkins Hospital :

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.

At 10..30 a. m. catheterization yielded 140 cc. of smoky urine


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.

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


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 82.


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.

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.

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.

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.

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


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.

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.

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.

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


January, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


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


8


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 82.


(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


January, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


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


THE JOHNS HOPKINS HOSPITAL BULLETIN.

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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10


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 82.


THE PHYSIOLOGICAL AND PATHOLOGICAL RELATIONS BETWEEN THE NOSE AND THE

SEXUAL APPARATUS OF MAN/^=

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.


" Balnea, vina, Venus corrumpunt corpora nostra, Set vitam faciunt, l)(aluea), v(ina), V(enus)."t

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.

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.

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


Remarks made before the British Medical Association at its Montreal meeting, September, 1897.

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.

X The supposed Greek original. See Antbolog. Palatin. X, 112.

§ Aristot. Opera omnia giaeco-latin. Parisiis, 1834. De animalium generatione, lib. ii, cap. 7.

II Opera omnia. Ed. Kiihn, Lipsiae, 1827, torn, i, p. 562.

H Ordo et methodus generatione dicatarum partium, per anatomen, cognoscendi fabricam. Jenae, 1664, part i, cap. vii, p. 32.

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 :

" O, how this mother swells up towards my heart I Hysterica passio ! down, thou climbing sorrow, Thy element's below.*'

ttOp. cit., De animal, generatione, lib. v, cap. 7.


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.


January, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


11


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.

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.

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.

The earlier physiognomists laid great stress upon the size and form of the nose as an indication of corresponding pecu


Contribution a I'etude du tissu erectile des fosses nasales. These de Lyon, aoiit, 1887.

t Progres Medical, Sept. 10 et 17, 1887. Du tissu erectile des fosses nasales.

t Revue mensuelle de laryngologie, d'otologie et de rhinologie, fevr. et mars, 1888. De I'epistaxis gt'-nitale.

gUeber nervijs. Schnupfen u. Speicheliluss u. den iitiologischen Zusammenhang derselben mit Erkrankungen desSexualapparates. M'inchener Med. Wochenschrift, Jahrgang 1889, No. 4.

jUeber die bisherigen Beobachtungen von pliysiologischen u. pathologisehen Beziehungen der Oberen Luftwege zu den Sexualorganen. Inaug. Diss. Wiirzburg, 1892.

T^Die Beziehungen zwischen Nase u. weiblichen Geschlechtsorganen. Berlin, 1897.

Siisrutas Ayurvedas: id est Medicinae Systema, a venerabili D'hanvintare demonstratum a suo disoipulo compositum. Translated from the Sanscrit into Latin by Franciscus Hessler, Erlangen, tom. iii, cap. xxiv, p. 44, 1850.


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

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."

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.

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."

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.

In astrology Venus was supposed to govern the nose.


See especially Ludwig Septalius : De Naevis tractatus, sect. 26, p. 18, in Bonel's Labarynthi medic, extricati, etc. Genevae,

I'JS.

f Vide Aelius Lampridius in vita Antonii Heliogabilis, in Hist. August, etc. Beponti.

JGuidonis PanciroUi rerum memorabilium sive deperditarum pars prior, etc. Francofurti, 1646, lib. 2, tit. 10, p. m. 176.

gibid.p. 177.

llObservat. medico-physiog. Cent, i, obs. xcvii, p. m. 141 ; Lipsiae, 1706.

IF Vasatus, post-classical.

Virgil, Aeneid, vi, 497. 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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According to all the astrologers, the gentry who

"... feel the pulses of the stars, To find out agues, coughs, catarrhs,"

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.

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.

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.

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


L'Art de Connoistre les Hoinmes. Amsterdam, cliez Jacques le Jeune, 1660. De la metoposcopie, p. 259.

t Life and Times of William Lilly, written by himself. London, 1829.

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.

§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.


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.

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 :

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.

(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.

(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.

{(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.

{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.

(/) 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.

{(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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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.

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.

II. — The presence of vicarious nasal menstruation.

(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.


Nat. His. lib. vii, cap. 7.


(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.

(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.

(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.

III. — The well-known sympalhy between Ihe erectile portions of the generative tract and other erectile structures of the body.

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.

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.

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.

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,**


0p. omn. EJ. Ktilin. Lipsiae, 1827, toui. ii, p. 174. De morbis lib. i, and Aph. sect. 5, art. 33.

t De medicina. Rotterodami, 1750, lib. ii, cap. S.

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.

§Sepulchretuni. L. I, s. xx.

II Historiarum anatomic, et meilic. rariorum, cent, v et vi, ed. Hafniae, 1761, v, p. 184.

H Gynaecologia historico-medica, etc. Dresden and Leipsic, 1730, p. 429.

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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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.

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.

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.

Cases have also been reported in which the act of coitus was accompanied by hemorrhage from the nose (Isch-Wall, Joal).

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


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.

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.

t Ephemerid. nat. cur. Dec. ii, An. viii, obs. 152.

§Ibid., Dec. iii. An. ii, obs. 32.

II Act. nat. cur., vol. viii, obs. 108.

TEphem. nat. cur. Dec. iii, An. v, vi, obs. 183. See also Rahn, op. cit., p. 34.

0p. cit., cent, iv, cap. xlviii. tt Archiv fur Psych., Bd. viii, Heft 2.


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.

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.

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:

" 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."

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.

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.

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


See Elsberg, Archives of Laryngology, Oct., 1883. f See especially a work by Leopold Bernard, Les odeurs dans lea romans de Zola. Montpellier, 1889.

tOf great interest is the influence which civilization exerts upon the development and impressibility of the olfactory sense. With


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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.

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.

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.

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.

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


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.

•Millingen. The Passions, or Mind and Matter, etc. London, 1848, p. lOli.


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.

Pathological.

The following data, derived from personal clinical observation, may possibly throw some light upon the subject.

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.

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.

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.

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.

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.

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.

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.

The coryza that follows intemperate venery resembles iu character that seen in the disease falsely called "hay fever,"


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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.

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.

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.

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.

AVhether the hemorrhages in these cases — which by the way are not confined to the male sex§— come from simple acute


A contribution to the study of coryza vasomotoria periodica, or so-called " hay fever." N. Y. Med. Rec, July 19, 1884.

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.

§See case of Lemarchand de Trigon (girl of 10), quoted by Joal.


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.

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.

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.

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.

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


•1. c.

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 :

"(1) That in the nose there exists a definite, well-defined seusi


January, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


17


I have ou innumerable occasions* shown that phenomena widely different in character and anatomical sphere of opera


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.

(2) That this sensitive area corresponds in all probability with that portion of the nasal mucous membrane which covers the turbinated corpora cavernosa.

(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.

(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.

(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.

(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 ?

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."

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.)

My views upon this subject may be found in the following publications: A contribution to the study of coryza vasomotoria


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.

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.

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.

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.


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


18


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[No. 83.


PROCEEDINGS OF SOCIETIES


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of October 18, 1897.

On the Hiematozoan Infection of Birds.— Dr. W. G. MacCallum.

(See Bulletin, Vol. VIII, p. 235.)

Discussion.

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.

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.

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.

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.


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.

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.

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°.

The Presence in the Blood of Free Grannies derived from Leucocytes, and their Possible Relations to Immunity.— Dr.

W. R. Stokes and Dr. A. Wegefaeth. (See Vol. VIII, p. 246.)

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,


January, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


19


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.

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.

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.

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.

I simply used the term neutrophilic to designate a leucocyte containing fine granules and having a polymorphous nucleus.


NOTES ON NEW BOOKS.

An Epitome of the History of Medicine. By Koswkll Park, M. D.

(Philadelphia : F. A. Davis Co., 1896.)

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.

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


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.

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.

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.

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.

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


20


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 82.


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) :

" When patients come to me I physics, bleeds, and sweats 'em. If after that they choose to die, Why then of course

I. Lettsom."

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.


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.

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


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.

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.

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.

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.


January, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.




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.

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.

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.

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.

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.

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."

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."

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.

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.


The chapters on diseases of the tubes are clear and forcible, especially chapter xxvi, on tubal pregnancy.

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.

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.

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."

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.

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.


22


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 82.


Compatibilities in Prescriptions. By Edsel A. Ruddiman, Ph. M.,

M. D. {New York : John Wiley & Soiis, 1897.)

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.

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.)

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.

Rheumatism and its Treatment by the Use of the Percusso-Punctator. By J. Brindley James. {London : Rebman Publuhiitg Co. Ltd., 1897.)

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


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.

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.

Transactions of the Jlichigan State :Medical Society. 1897. Vol.

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.

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

students for examination purposes," and is not calculated to increase

the reputation of its distinguished authors. It contains nothing

new. It is well printed and profusely illustrated.


BOOKS RECEIVED.


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.

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.


January, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


23


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

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

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

Vena 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

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.


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

Report in Metliclne.

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

Gallstones. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D. On Pyrodin. By H. A. Lafleur, M. D. Cases of Post-febrile Insanity. By William Osler, M. D, Acute Tuberculosis in an Infant of Four 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.

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

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

pages. Price, hound in paper. $a.00. THE PATHOI.OOr OF TOX.M.ItUMIN INTOXICATIONS. Rv Simon Flexner, M. I). 1

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

The Johns Hopkins Press, Baltimore, Md.


24


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 82.


THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.


FACULTY.


Daniel C. Oilman, LL. D., President.

William H. Welch, M. D., LL. D., Dean and Professor of Pathology.

Ira Rehsen, M. D., Ph. D., LL. D., Professor of Chemistry.

William Osler, M. D., LL. D., F. U. C. P., Professor of the Principles and Practice

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.

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.


Georoe P. Dreter, Ph. D., Associate in Physiology.

William W. Russell, M. D., Associate in Gynecology.

Henry J. Berkley, M. D., Associate in Neuro-Pathology.

J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.

T. Caspar Gilchrist, M. R. C S., Associate in Dermatology.

Robert L. Randolph, M. D., Associate in Ophthalmology and Otology.

Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.

Thomas B. Futcher, M. B., Associate in Medicine.

Joseph C. Bloodgood, M. D., Associate in Surgery.

Thomas S. Cullen, M. B., Associate in Gynecology.

Ross G. Harrison, Ph. D., Associate in Anatomy.

Frank R. Smith, M. D,, Instructor in Medicine.

George W. Dobbin, M. D., Assistant in Obstetrics.

Walter Jones, Ph. D., Assistant in Physiological Chemistry.

Adolph G. Hoen, M. D., Instructor in Photo-Micrography.

Sydney M. Cone, M. D., Assistant in Surgical Pathology,

Louis E. Livingood, M. D., Assistant in Pathology.

Henry Barton Jacobs, M. D., Instructor in Medicine.

Charles R. Bardeen, M. D., Assistant in Anatomy.

Stewart Paton, M. D., Assistant in Nervous Diseases.

Norman McL. Harris, M. B., Assistant in Pathology,

Harvey W. Cushing, M. D., Assistant in Surgery.

J. M. Lazeab, M. D., Assistant in Clinical Microscopy,

J. L. Walz, Ph. G., Assistant in Pharmacy.


GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 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.

The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.

Men and women are admitted upon the same terms.

In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital. While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. 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.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school receives :

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.

3. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (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.

The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in each subject.

3. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientific school, and the knowledge of French, German, Latin, iihysics, chemistry, and biology above indicated.

Applicants for admission will receive blanks to be filled out relating t p their previous courses of study.

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.

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.

Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.

ADMISSION TO ADVANCED STANDING. ; ,

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.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

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.

The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the

KEGISTR.\R OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.


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.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. IX.- No. 83.]


BALTIMORE. FEBRUARY, 1898.




co:N"TEisrTS


Inflated Rubber Cylinders for Circular Suture of the Intestine. By W. S. Halsted, M. D., - - - 25

Cerebro-Spinal Meningitis. By W. T. Councilman, M. D., - 27 The Diaphragm Phenomenon— The So-called Litten's Sign.


By NoEMAN B. GwYN, M.B.,


35


PAGE.

Proceedings of Societies :

Hospital Medical Society, - - - ZS

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].

Notes on New Books, 42

Books Received, ---------- 44


INFLATED RUBBER CYLINDERS FOR CIRCULAR SUTURE OF THE INTESTINE.*


By W. S. Halsted, M. D., Professor of Surgery in the Johns Hopkins University.


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


Remarks before the Johns Hopkins Hospital Medical Society, December 13, 1897.

t Halsted: Circular Suture of the Intestine. An Experimental Stuily. Am. Jour. Jled. Sciences, October, 18S7.

X Madelung : Arch. f. klin. Chirurgie, Bd. xxvii, p. 321.

§Reichel: DeutscheZeitschr.f. Chirurgie, Bd. xiv, pp. 268 and 270.


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


Schimmelbusch: Anleitung zur aseptischen Wundbehandlung Berlin, 1892, p. 104.


20


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[No. 83.


it are twisted together like heuiiieu cords." The muscular pipe referred to is, of course, the tube of the submucosa, the sausage-skiu, etc.

The following suggestions, emphasized among others, in my article on intestinal anastomosis,* are equally relevant to circular suture of the intestine :

"1. It is bad surgery to employ stitches which enter the lumen of the intestine.

" 2. It is impossible to suture the serosa alone.

"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.

"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.

" 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."

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.

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.

The results obtained by adhering strictly to the foregoing rules have been so perfectf that we have employed no other methods in our practice.

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.


Halsted : I otestinal Anastomosis. Demonstration at a meeting of the Johns Hopkins Hospital Meiiical Society, December 1, 1890. Johns Hopkins Hospital Bulletin, January, 1891.

fAmer. Journ. Med. Sciences, October. 1887.

t W. Edmunds and Charles A. Ballance: Observations and Experiments on Intestinal and Gastro-intestinal Anastomosis. Medico-Chirurg. Trans,, Vol. 78. London, 1S9G.


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.

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.

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.

Experts in intestinal surgery, almost without exception, prefer to jserform circular suture of the intestine without the use of mechanical devices.

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.

The disadvantages of my original method aud of all similar methods (methods without mechanical aids) were as follows:

1. They required about twenty minutes to perform the operation.

2. One or two assistants at the wound were indispensable.

3. Clamps or the fingers of an additional assistant were necessary to prevent the escape of intestinal contents.

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.

5. If the j)ieces of intestine to be united were not of the same size their adjustment might be very difficult.

6. The rolling out of the cut edges of the intestine prevented in places recognition of the precise edges, and hence


A few weeks ago Dr. ^Mitchell discovered in the Medical and 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.


Presection-siitches —Left.


Prese^tioQ-stikhes — Right.



Presection-siitches.



The Johns Hopkins Hospital Billetix No. 83. See page



FIG. 3



FIG.



FIG. 5



FIG. 6.



FIG. 7.



The Johns Hoprivs Hn


February, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


27


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.

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.

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.

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.

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.

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.

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.

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.

Fig. 7. The bag is still distended, and all of the mattress stitches have been placed. From seven to nine of these


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.

Fig. 8. Two mattress stitches drawn aside on a hook ; the temporary stitch has been removed and the collapsed bag is being withdrawn.

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.

Advantages of the Inflated Eubbeu Cylinder in Circular Suture of the Intestine.

1. The vermicular action of the bowel is arrested over the bag, and the stitches can, consequently, be placed at regular and proper intervals.

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.

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.*

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.

5. The cylinder takes the place of at least two assistants. The operation could readily be performed without an assistant.

6. It prevents escape of intestinal contents and hence dispenses with the injurious clamps or the fingers of assistants.

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.

The results should, I believe, be better than by any method hitherto devised.


CEREBRO-SPINAL MENINGlTIS.t

By W. T. Councilman, M. D., Harvard University.


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


February, 33 in March, 39 in April, 21 in May, 14 in June,


I have recently had occasion to unite a distended paper-thin 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.

t Presented to the Johns Hopkins Medical Society, November 15, 1897.


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[No. 83.


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.

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.

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.

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.

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


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.

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.

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.

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.

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.

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


February, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


29


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.

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.

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.

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.

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.


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.

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.

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.

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.

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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[No. 83.


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.

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.

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.

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.

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.

The duration of the disease in the cases in which diplococcus pneumonia was found was: iu 2 cases, 3 days; in 2


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.

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.

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.

The intestinal canal was found normal iu every case.

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.

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.

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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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.

Discussion.

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.

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.

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


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.

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.

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.

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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on the one hand and to the meningococcns intracellularis on the other hand.*

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.

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.

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.

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.


Lubarsch-Oestertag. Ergebnisse der allg. Pathologie u. path. Anat., 3ter Jahrg. I, p. 169.


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.*

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.

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.

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.

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

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


Ab8tracted from report in American Jourual Jledical Sciences, 1S94.


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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.

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


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.

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.

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.

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.

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.

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.

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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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.

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.

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.

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


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.

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).

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."

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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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.

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.

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


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.

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.


THE DIAPHRAGM PHENOMENON-THE SO-CALLED LITTEN'S SIGN.

By Norman B. Gwyn, M. B., Assistant Resident Physician.


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.

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.

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


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."

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.

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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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.

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."

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.

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.

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.

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.


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.

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.

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.

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.

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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costal margin (an occurrence which is never normally the case) one must consider the existence of emphysema.

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.

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.

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.

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.

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.

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.


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.

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.

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.

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.

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.

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.

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.

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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deep iuspiratiou is always necessary. The following are the results in 100 cases examined :

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.

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.

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.


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.

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.

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.

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.

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.


PROCEEDINGS OF SOCIETIES,


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of November 1, 1897.

Dr. Baekee in the Chair.

Cases of Aneurism.— Dr. Hunnee.

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.


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.

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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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.

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.

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.

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.

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.

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.

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


jjain in the left side beneath the ribs, and returned to the Hospital in March, 1897.

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.

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.

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.

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.

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.

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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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.

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.

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


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.

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.

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.

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.

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.

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.

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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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.

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.

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.

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).

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.

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.

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.


He has found it present in cases of experimental phloroglucin

diabetes.


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.

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.

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.

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.

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.

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


42


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 8.3.


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.


NOTES ON NEW BOOKS

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

New York, ISg?.)

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.

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.

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.

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


introduction to the subject, while as a work of reference it would be mainly a source of irritation if not of exasperation.

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.

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.

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, []

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.

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


February, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


43


commoner than is generally supposed. We have seen three or four

cases which have been mistaken for Jisitilm in ano and determined efforts made to cause the probe to pass through into the rectum.

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.

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."

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.

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.

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.

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.


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.

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.

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.

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."

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.

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


44


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 83.


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.

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.

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.

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.

High Altitudes for Consumptives. By A. Edgar Tussey, M. D.

{Philadelphia: P. Blakialon, Son & Co., 1S96.)

Although the author seems to have but little belief in the bacillus tuberculosis as a cause of phthisis, yet there is much good


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.

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.

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.

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.

BOOKS RECEIVKO.

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.

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.

A Clinical Text-book of Surgical Biagnosis and Treatment. By J. W. Macdonald, M. D. 1898. 8vo. 798 pages. W. B. Saunders, Philadelphia.

The Physiology and Pathology of the Cerebral Circulation. An Experimental Research. By Leonard Hill, M. B. 1896. 8vo. 208 pages. J. & A. Churchill, London.

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.

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.


Febkuary, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


45


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Report in Patliology.

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

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

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

(Atrophy). By Henkt J. BERKiEr, U. D. Reticulated Tissue and its Relation to the Connective Tissue Fibrils. By F. P.

Mall, il. D.

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

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

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

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

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

T. C. Gilchrist, M. D.

Report in Pathology. Ad Experimental Study of the Thyroid Gland of Dogs, with especial consideration

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


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

Report In Medicine.

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

Gallstones. By William Osler, M. D. Some Remarks on Anomalies of the Uvula. By John N. Mackenzie, M. D. On Pyrodin. By H. A. Lafleur, M. D. Cases of Post-febrile Insanity. By William 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.

Report in Aledleine.

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. Kellt, M. D.

The Laparotomies performed from October 16, 1689, to March 3, 1890. By Howard

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

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

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

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

March 4, 1S90. By Howard A. Kelly, M. D. Report of the Urinary Examination of Ninety-one Gynecological Cases. By Howabd

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

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

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

Howard A. Kelly, M. V.

Report in Surgery, I.

The Treatment of Wounds with Especial Reference to the Value of the Blood Clot in the Management of Dead Spaces. By W. S. Halsted, M. D.

Report in Neurology, I.

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.

A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By Hehby M. Thomas, M. D.

Report in Pathology, I.

Amosbic Dysentery. By William T. Councilman, M. D., and Henri A. Lajleub, M. D.


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

Report in Pathology.

Papillomatous Tumors of the Ovary. By J. Whitridge Williams, M. D. Tuberculoaia of the Female Generative Organs. By J. Whitridge Williams, M. D.

Report in Pathology.

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

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

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

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

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

Report in Gynecology.

The Gynecological Operating Room; An External Direct Method of Measuring the 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.

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

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


Oj-necological Operations not involving Cosliotomy. By Howard A. Kelly, M. D.

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

Denuded Areas about the Pelvic Floor; Some Sources of Hemorrhage in Abdo minal Pelvic Operations. By Howard A. Kelly, M. D. Photography applied to Surgery. By A. S. JIurray. Traumatic Atresia of the Vagina with Ha:matokoIpos and Hsmatometra. By Howard

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

The Importance of employing Anesthesia in the Diagnosis of Intra-Pelvic Gynecological Conditions. By Hunter Robb, M. D. Resuscitation in Chloroform Asphyxia. By Howard A. Kelly, M. D. One Hundred Cases of Ovariotomy performed on Women over Seventy Tears of Age

By Howard A. Kelly, M. D., and Mary Sherwood, M. D. Abdominal Operations performed in the Gynecological Department, from March 5.

1890, to December 17, 1892. By Howard A. Kelly, M. D. Record of Deaths occurring in the Gynecological Department from June 6, 1890, to

May 4, 1892.


Volume IV. 504 pages, 33 charts and illustrations.

Report on Typhoid Fever.

By William Osler, M. D., with additional papers by W. S. Thayer, 51. D , and J Hewetson, M. D.

Report in Neurology.

Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Gland of Mw musrulus; The Intrinsic Nerves of the ThvToid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley,

Report in Surgery.

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

Report in Gynecology.

Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic PeritonitisTuberculosis of the Endometrium. By T. S. Ccllen, M. B.

Report In Pathology.

Deciduoma Malignum. By J. Whitridge Williams, M. D.


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

CONTENTS

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

Studies in Typhoid Fever. By William 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.


Volume VI. 414 pages, Avith 79 plates and figures.

Report in Neurology.

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

Introductory.— Recent Literature on the Pathology of Diseases of the Brain by the Chromate of Silver Methods; Part I.— Alcohol Poisoning.— Experimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. 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.

Report in Pathology.

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

Cullen, M. B. Pregnancy in a Rudimentary Uterine Horn. Rupture, Death. Probable Migration of

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

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

$30.00. Vols. I, II and III are not sold separntelii. The nrice of

Tola, ir, r and Tl is $3.00 each. -^ ± i


Monographs.

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,

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, St. D., and J.

Hewetson, M. D. And A STUDY OF SOME FATAL CASES OF MALARIA.

By Lewellys F. Barker, M. B. 1 volume of 280 pages. Price, in paper, ?2.75. STUDIES IN TYPHOID FEVER. By William Osler. JI. D., and others. Extracted

from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481

pages. Price, bound in paper, $3.00. THE P.VTIIOLOGV OF rnXALBUMIN ISTOXICATIflNS. liv Pimon Flexner, M. D. I

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

The Johns Hopkins Press, Baltimore, Md.


46


JOHNS HOPKINS HOSPITAL BULLETIN.


[Xo. 83.


THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.


FACULTY.


Daniel C. Gilman, LL. D., President.

William H. Welch, M. D., LL. D., Dean and Professor of Pathology.

Ira Uemsen, M. D., Ph. D., LL. D., Professor of Chemistry.

William Osler, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice

of Medicine. 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.

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.


George P. Dbeyer, Ph. D., Associate in Physiology.

William W. Russell, M. D., Associate in Gynecology,

Henry J. Berkley, M. D., Associate in Neuro-Pathology.

J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.

T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.

Robert L, Randolph, M. D., Associate in Ophthalmology and Otology.

Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.

Thomas B. Futcher, M. B., Associate in Medicine.

Joseph C. Bloodgood, M. D., Associate in Surgery.

Thomas S. Cullen, M. B., Associate in Gynecology.

Ross G. Harrison, Ph. D., Associate in Anatomy,

Frank R. Smith, M. D., Instructor in Medicine.

Georgia W. Dobbin, M. D., Assistant in Obstetrics.

Walter Jones, Ph. D,, Assistant in Physiological Chemistry.

Adolph G. Hoen, M. D., Instructor in Photo-Micrography.

Sydney M. Cone, M. D., Assistant in Surgical Pathology.

Louis E. Livingood, M. D., Assistant in Pathology.

Henry Barton Jacobs, M. D., Instructor in Medicine.

Charles R. Bardeen, M. D., Assistant in Anatomy.

Stewart Paton, M. D., Assistant in Nervous Diseases.

Norman McL. Harris, M. B., Assistant in Pathology.

Harvey W. Cubhing, M. D., Assistant in Surgerj'.

J. M. Lazeab, M. D., Assistant in Clinical Microscopy.

J. L. Walz, Ph. G., Assistant in Pharmacy.


GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 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.

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.

Men and women are admitted upon the same terms.

In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital. While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. 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.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school receives:

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.

2. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.

The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in each subject.

3. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above indicated.

Applicants for admission will receive blanks to be filled out relating to their previous courses of study.

They are required to furnish certificates from officers of the colleges or scientific schools where they have studied, as to the courses pursued in physics, chemistry, and biology. If such certificates are satisfactory, no examination in these subjects will be required from those who possess a degree in arts or science from an approved college or scientific school.

Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass, at the beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (2) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that only in very rare instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.

Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.

ADMISSION TO ADVANCED STANDING.

Applicants for admission to advanced 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.

SPECIAL COURSES FOR GRADUATES IN MEDICINE. \

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

The Annual Announcement and Catalogue will be sent upon appiicatiou. Inquiries should be addressed to the J

REGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE. ^


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.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. IX.- No. 84.]


BALTIMORE, MARCH, 1898.




OOlSTTlBISrTS.


Leprosy in the United States, with the Report of a Case. By Wm. OSLEK, M. D.,

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.,

The Management of Solid Tumors of the Ovaries complicating Pregnancy, with Report of a Successful Case. By William E. Swan, M. D., - - -


The Catheterization of the Ureters in the Male through an Open Cystoscope with the Bladder distended with Air by Posture.

By H. A. Kelly, M.D., - 62

Proceedings of Societies :

Hospital Medical Society, 62

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].

Notes on New Books, ----64

Books Received, - ---65


LEPROSY IN THE UNITED STATES, WITH THE REPORT OF A CASE.

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.]


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.

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


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.

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


48


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 84.


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.

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.

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.

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.

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


relating to the disease. Of these by far the most important relates to the method of infection, whether by inoculation, contagion, or hereditary transmission.

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.

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.

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.


March, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


49


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.

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.

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.

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.


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.

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.

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.

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.


NOTICE.

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.

Letters of inquiry can be sent, which will receive prompt answer, or personal interviews may be held.

Under the directions of the founder of the Hospital the free beds are reserved for the sick poor of Baltimore and its suburbs and for accident cases from Baltimore and the State of Maryland. To other indigent patients a uniform rate of $.5.00 per week has been established. The Superintendent has authority to modify these terms to meet the necessity of urgent cases.

The Hospital is designed for cases of acute disease. Cases of chronic disease are not admitted except temporarily. Private patients can be received irrespective of residence. The rates in the private wards are 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.

One week's board is payable when a patient is admitted.


50


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 84.


SECONDARY MELANO-SARCOMA OF THE LIVER FOLLOWING SARCOMA OF THE EYE.


Br Louis Philip Hamburgjpr, M. D., Resident Medical Officer, The Johns Hopkins Hospitcd.


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."

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.

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.

Case I. C. B., male, white, age 42; admitted August 21, 1896, complaining of pain in right side.

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.

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.

There is anorexia ; no Vomiting ; bowels irregular ; he has lost 35 pounds in weight since onset.

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.

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


pable ; no general glandular enlargement. Rectal examination negative. Urine, light amber, acid ; specific gravity 1(20-26; no albumin or sugar ; diazo-reaction present.

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.

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.

The second case we were able to study more thoroughly.

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.

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.

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.

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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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.

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.

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.

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.

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.

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.

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.

. 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.

In each of the above histories one's attention is attracted


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.

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.

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.

Sections prepared from the abdominal lymph glands showed microscopically a pigmented large cell sarcoma.

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.

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


'Boas. Deut. med. Wochenschr., No. 44, Oct. 1897.


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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.

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.

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.

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.

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


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.

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.

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.

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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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.

BiBLIOGKAPHY.

Abel and Davis: The Journal of Experimental Medicine, Vol. I, No. 3, 1890.

Berdez and Nencki : Archiv f. experiment. Path., Bd. 20, S. 346, 1886.

Dressier : Prager Vierteljahrschrif t, 1869.

Eichorst: Handbnch d. spec. Path. u. Therap., Bd. 2, S. 491, S. 575.

Eiselt: Prager Vierteljahrschrift f. prakt. Heilk., 1858, III, S. 190; 1863.

Finkler: Centralblatt f. klin. Med., Bd. I, 1880-81.

Fuchs: Text-book of Ophthalmology.

Ganghofer and Pribram : Prag. Vierteljahrschrift f. prakt. Heilk., 1876, CXXX.

Graefe and Saemisch : Haudb. d. Augenheilk., Bd. 4.

Hutchinson: Brit. Med. Jour., Vol. I, 1893, p. 291.

Lawford and Collins: Eoyal Loud. Ophth. IIosp. Keports, Dec. 1891.

Litteu: Ueber einen Fall von Melanosarcoma der Leber, Deut. med. Wochenschr., 15, S. 41, 1889.

Michel: Lehrb. d. Augenheilk., 1890.

Morner: Zeitschr. f. iihysiolog. Chemie, XI, 1887; XII, 1888.

Nepveu : Gaz. med. de Paris, 1872, 335, 385.

PoUak: Wiener med. Wochenschr., 1889, 39, 40, 41.

Pribram : Prager Vierteljahrschr., 1865, LXXXVIII, 16-23.

llaab: Beitrilge z. path. Anat. d. Augen, Klin. Monatsbliitter, Juli, 1875.


Sieber: Ueber die Pigmente der Choroidea n. der Haare. Arch. f. experiment. Path., XX, 1886.

Stevenson : Note on a Case of Melannria (? L. P. H.), Guy's Hosp. Keports, XIII.

Sutton : Tumors, 1893.

Virchow: Die krankh. Geschwiilste, Bd. 2.

von Jaksch: Zeitschr. f. physiol. Chemie, XIII, 385.

Discussiosr.

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.

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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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.

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


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.


ON INFECTION WITH A PARA-COLON BACILLUS IN A CASE WITH ALL THE CLINICAL

FEATURES OF TYPHOID FEVER.


By Norman B. Gwyn, M. B., Assistant Resident Physician, Johns Hopkins Hospital


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.

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.

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


' Semaine Medical, Aug. 4, 1897


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.

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.

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.

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.

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.

To confirm this result various other orsfauisms were com


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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.

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.

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.

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.

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.

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


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.

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.

The same serum was without action on the bacillus typhosus in any dilution above 1-1 or 1-5.

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.

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.

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.

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.

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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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


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.


THE MANACtEMENT OF SOLID TUMORS OF THE OVARIES COMPLICATING PREGNANCY, WHH

REPORT OF A SUCCESSFUL CASE.

By William E. Swan, M. 1)., Assistant Resident Gyncecologist in the Johns Hopkins Hospital.


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.

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.

Family History. Paternal grandmother died of a new growth in lower abdomen. Maternal grandfather had a cancerous growth on arm; family history otherwise negative.

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.

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.

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.

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


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.

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.

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.

Diagnosis. Pregnancy, associated with solid tumor of the left ovary.

Abdominal section by Dr. Kelly, June 21, 1893.

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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worm gut and silk; gauze dressing, edges rendered adherent with collodion ; iodoform and boric acid powder dusted over same; cotton; Scultetus' bandage.

Time of operation 46 minutes.

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."

July 10, 1893 (20th day}, " Patient sat up in bed ; did not fee] weak nor tired afterwards."

July 2i, 1893 (4 weeks after operation), " Patient discharged; has had no setbacks ; wound nicely healed; patient feels well ; abdomen increased in size."

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.

Frozen sections reveal fibrous tissue with fine points of fatty degeneration.

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.

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)'.

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.

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 :


Total num- Cysts, in- Number

ber of cases eluding of solid Fibro- Sarco- Carcino Name of operator, operated on. dermoids, tumors, mata. mata. mata.

1. Billroth 86 78 8 .. 3 5

2. Schroeder .... 102 97 5 . . 5

3. Thornton 338 328 10 3 .. 7

4.Hildebrandt.. 37 27 10

5. Weber 123 72 51

6. Krassowoski.. 128 128

7. K. VonBrann. 81 71 10 1 2 5

8. Thos. Keith . . 200 183 17

9. Olshausen 193 267 26 6 9 5

Totals 1388 1251 137 10 19 22

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.

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 "

Carcinomata " " " " " " 1.58 "

All others " " " " " " .057 "

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.

Solid tumors of the ovaries may be classified as follows :

Fibromata,

Sarcomata,

Desmoid { Mysomata,

Endotheliomata, Solid -j Enchondromata.

Carcinomata, illomata.


Epithelial I *^^'"" I- ^ I Papil


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').

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").

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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mothers became pregnant at least twice during the existence and probable growth of the same tumor.

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.

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.'

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.

Case I. Breit". In this case an ovarian tumor of stony hardness and adherent to the rectum was removed ; no details given.

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.

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.

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.

Diagnosis. Peritonitis after Caesarean section ; ossified fibroma of the right ovary.

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.

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.

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.

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.


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.

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 :

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.

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.

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.

Case XIll. 3. Murphy. " Abdominal section during pregnancy (reported in 1895).

"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."

Case XIV. P. Ruge."' Woman aged 36; six months pregnant. !Myxo sarcomata of both ovaries ; no details.


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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.

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.

Influence of Pregnancy on the Growth of Ovarian Tumors.

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)."

Wernicke suggested that benign tumors are apt to become malignant during pregnancy. There are no observations which tend to support this view (Olshausen).

Luhlein" in 189.5 published a comprehensive article dealing with ovarian tumors complicating pregnancy. His views may be summarized as follows:

(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.

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.

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)."'

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


possibility of the existence of such a condition in making our examinations.

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."

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.

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

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.

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)."^"

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)."

Complications of pregnancy may arise owing to the presence of solid ovarian tumors.

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)."

2. Infection of the peritoneum is more likely to occur.

3. The tumor by direct pressure on the intestines may


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cause intestinal obstruction, or indirectly twists of the gut or hemorrhoids (Barsouy)."

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)."

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.

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.

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.

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) "

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."

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.

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)."

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


as many apparently innocent cysts (papillary cystomata) may at any time become highly malignant, and if not removed sufficiently early, may prove rapidly fatal.

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.

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.

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.

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 :

(a) Attempts may be made to replace the tumor in the abdominal cavity under anesthesia.

(b) As a last resort, celiotomy.

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.

In summarizing the results of a thorough search of the literature dealing with the subject the following deductions would appear to be justifiable:

I. Solid neoplasms of the ovary complicating pregnancy are exceedingly rare.

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.

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.

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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of course, ou the malignant or benignant nature of the new growth.

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.

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.

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.

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.

Bibliography.

1. Dsirne, J.: Arch, fiir Gyniik., 1893, V0I..XLIII.

2. Olshausen : Billroth's Handbuch.

3. Jetter : Billroth's Handbuch.

4. Olshausen : Die Krankheiten der Ovarien. Stuttgart, 1886.

5. Montgomery: Med. Times, Phila., 1886-7; XVII, 693, 698.

6. Eemy, S. : Quoted by Miiller in his Handbuch der Geburtshiilfe, p. 819.

7. Rokitansky : Winckel's " Diseases of Women," p. 577.

8. Breit, F. : Dissertation, Tubingen, 1861. Case from Lachapelle (Puchelt, S. 173).

9. Spiegelberg: Monatsschriftf. Gebiirtsh. (1866), XXVIII, p. 73.

10. Spiegelberg : Monatsschrift f. Gebiirtsh. (1867), XXX, p. 380.

11. Kleinwiichter: Arch, fiir Gyniik., Berlin (1873), IV, p. 171.

12. Spencer Wells : (Reported by Cayla), see 15.

13. Hempel : Arch, fiir Gyniik., VII, p. 556, 1875.


14. Schroeder: (Quoted by Cayla), see 15.

15. Spencer Wells: Contribution a I'etude de I'ovariotomie pratiquee pendant la grossesse. Paris, 1882.

16. Spencer Wells : See 15.

17. Casati, L. : Raccoglitore Med. Forli., 1883-4, XIX, 277, 292.

18. Carstens, J. H. : Tr. Am. Assn. Obst. and Gynfficol., Phila., 1889, Vol. II, pp. 151, 167.

19. Miinchmeyer: Centralb. f. Gyniik. (1890), XIV, p. 186.

20. Murphy, J. : Lancet (1895), I, p. 148.

21. Ruge, P. : Reported by Olshausen in " Die Krankheiten der Ovarien," 1886.

22. Dsirne: Hegar and Kaltenbach, Op. Gyniik., 1886, p. 248.

23. Olshausen, R. : Die Krankheiten der Ovarien. Stuttgart, 1886.

24. See 23.

25. Napier : Tokyo Med. Jour., Feb., 1888, p. 23.

252. Fenger: American .Journal of Obstetrics, New York, 1891, XXIV, pp. 1097, 1107.

26. Heiberg: Quoted by Olshausen in "Die Krankheiten der Ovarien," 1886.

27. Dsirne: Hegar and Kaltenbach, Operativ Gyniik., 1886, p. 248.

28. Montgomery : Med. Times, 1886-7, XVIII, p. 693.

29. Hohl: Arch. f. Gyniik., Berlin, 1896, LIII, 410, 427.

30. Greigg : Quoted by Montgomery ; see 28.

31. Miiller: Handbuch der Geburtshiilfe, p. 819.

32. Dsirne : See 27.

33. Barsony: Centralbl. fur Gyniik., Leipzig, 1897, XI, 139, 144.

34. Montgomery: See 28.

35. Litzmauu: Quoted by Montgomery; see 28.

36. Breit: See 8.

37. Munde, P. F.: New York Med. Journal (1887), p. 11.

38. Kreutzmann, H. : Am. Journal of Obstetrics, XXVI, p. 204.

39. Cohn : Winckel's " Diseases of Women," p. 541.

40. Montgomei-y : See 28.

41. Kelly: Lectures, Johns Hopkins Univ., 1896-7.

42. Olshausen : Winckel's " Diseases of Women," p. 542.

43. Dsirne: Arch, fiir Gyniik., Berlin (1892), XLII, 415, 456.

44. Hohl : Archiv fiir Gyniik. (1896), Berlin, LII, pp. 410, 437.

45. Lohlein, H.: Gyniik. Tagesfr., Wiesb., 1895, Hft. IV, 1, 31.


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[Xo. 84.


THE CATHETERIZATION OF THE URETERS IN THE MALE THROUGH AN OPEN CYSTOSCOPE WITH THE BLADDER DISTENDED WITH AIR BY POSTURE.

By H. A. Kelly, M. D., Gi/necolor/ist-in-Chief to The Johns Hop/cins Hospital.


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.

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.

Among the visitors present were Drs. Eobt. F. Weir, Willy Meyer, Clement Cleveland, Kobt. A.Murray, Faiquhar B.Curtis, F. Tilden Brown, and others.

I was greatly indebted to the house staff of the hospital for their warm, intelligent interest and assistance throughout.

Dr. Otto G. Kamsay accompanied me from the Johns Hopkins Hospital and aided me skilfully at every step of the investigation.

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.

The source of illumination was a small electric headlight, deriving its current from the house supply, reduced by a Vetter controller.

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


average size, shortened on the cystoscope to a length of about 5 cm.

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.

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.

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.

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.

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.

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.

A preliminary note has been published in the Annah of Surgery (Jan. 1897), where a fuller account will shortly appear.


PROCEEDINGS OF SOCIETIES.


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of December 20, 1897.

Dr. Barker in the Chair.

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,


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.

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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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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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


nodule under discussion were present in the remaining layers nor in the surrounding tissue.

The change described was not seen in arteries not surmounted by the fibrous patch.

These findings would suggest at least some association between the nodules on the surface and the weakening in the arterial wall beneath.

The affection, as far as can be ascertained, was discovered incidentally in every case, and produced no symptoms as far as can be known.

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.

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.

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.

Discussion of Dr. Huiiner's Cases of Aneurism [continued). See February Bulletin, p. 38.

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.

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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[No. 84.


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.

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.

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.

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.

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.

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.

Discussion of Dr. Paiicoast's Diabetes in the 'Se^ro {continved). See February Bulletin, p. 40.

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.


NOTES ON NEW BOOKS.

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.)

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.

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.

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.

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


March, 1893.]


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65


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.

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?

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.

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.

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.


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.

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.

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.

S. F.


BOOKS RECEIVED.


Twentieth Century Practice. An International Encyclopedia of Modern Medical Science, by Leading Authorities of Europe and

America. Edited by Thomas L. Stedman, M. D. Vol. XIII.

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

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

American Physicians, 1896. On the Disappearance of Endocardial Murmurs of Organic Origin. By

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.,

M. D. Second Edition. Thoroughly Revised. 1897. 8vo. 728

pages. W. B. Saunders, Philadelphia. Elements of Latin. For Students of Medicine and Pharmacy. By

George D. Crothers, A.M., M. D., and Hiram H. Bice, A.M.

1898. 12mo. 242 pages. The F. A. Davis Co., Philadelphia.


ERRATA-JANUARY BULLETIN.

In footnote, page 12, read 1629 instead of 1829.

In footnotes on page 13, the references to Vanderwiel and Schurig should be reversed.

On page 16, line 12, the word nasal should be inserted before reflex neuroses.


m


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[No. 84.


THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1898.


FACULTY.


Daniel C. Oilman, LL. D., President.

William H. Welch, M. D., LL. D., Dean and Professor of Pathology.

Ira Kemses, M. D., Ph. D., LL. D., Professor of Chemistry.

William Osler, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice

of Medicine. Henry M. Hurd, M. D., LL. D., Professor of Psychiatry. William S. 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.

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.


r.EonoE P. Dreyer, Ph. D., Associate in Physiology.

William W. Russell, M. D., Associate in Gynecology.

Hesuv J. Berkley, M. D., Associate in Neuropathology.

J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.

T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.

Robert L. Randolph, M. D., Associate in Ophthalmology and Otology.

Thomas B. .\ldrich. Ph. D., Associate in Physiological Chemistry.

Thomas B. Futcher, M. B., Associate in Medicine.

Joseph C. Bloodoood, M. D., Associate in Surgery.

Thomas S. Cullex, M. B., Associate in Gynecology.

Ross G. Harrison, Ph. D., Associate in Anatomy.

I'RANK R. Smith, M. D., Instructor in Medicine.

Georoe W. Dobbin, M. D., Assistant in Obstetrics.

Walter Jo.ves, Ph. D., Assistant in Physiological Chemistry.

Adolph G. Hoen, M. D., Instructor in Photo-Micrography.

Sydney M. Cone, M. D., Assistant in Surgical Pathology.

Locis E. Livincood, M. D., Assistant in Pathology.

Henry Barton Jacobs, M. D., Instructor in Medicine.

Charles R. Bardeen, M, D., Assistant in Anatomy.

Stewart Paton. M. D., Assistant in Nervous Diseases.

Norman McL. Harris, M. B., Assistant in Pathology.

Harvey W. Cushino, M. D., Assistant in Surgery.

J. M. Lazear, M. D., Assistant in Clinical Microscopy.

J. L. Walz, Ph. G., Assistant in Pharmacy.


GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from its close affiliation with the Johns Hopkins Hospital.

The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.

Men and women are admitted upon the same terms.

In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital. While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. 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 .\natomv, 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 .^nd in the Clinical Laboratories. Especially advantageous for thorough clinical training are the arrangements by which the students, divided into groups, engage in practical work in the Dispensary, and throughout the fourth year serve as clinical clerks and surgical dressers in the wards of the Hospital.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school receives :

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.

3. Graduates of approved colleges or scientific schools who can furnish evidence : (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.

The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in each subject.

3. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above indicated.

Applicants for admission will receive blanks to be filled out relating to their previous courses of study.

They are required to furnish certificates from officers of the colleges or scientific schools where they have studied, as to the courses pursued in physics, chemistry, and biology. If such certificates are satisfactory, no e.vamination in these subjects will be required from those who possess a degree in arts or science from an approved college or scientific school.

Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass, at the beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (3) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that only in very rare instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.

Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.

ADMISSION TO ADVANCED STANDING. Applicants tor admission to advanced standing must furnish evidence 11) that the foregoing terms of admission as regards preliminary training have been fulfilled, (2) that courses equivalent In kind and amount to those given here, preceding that year of the course for admission to which application is made, have been satisfactorily completed, and 13) must pass examinations at the beginning of the ses.slon in October in all the subjects that have been already pursued by the class to which admission is sought. Certificates of standing elsewhere cannot be accepted in place of these examinations.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

Since the opening of the Johns Hopkins Hospital in 1883, courses of instruction have been olTered 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 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 Jnne. During April there is a preliminary course in Normal Histology. These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended to meet the requirements of practitioners of medicine, and is almost wholly of a practical character. It includes laboratory courses, demonstrations, beside teaching, and clinical instruction in the wards, dispensary, amphitheatre, and operating rooms of the Hospital. These courses are open to those who have taken a medical degree and who give evidence satisfactory to the several instructors that they are prepared to profit by the opportunities here offered. The number of students who can be accommodated in some of the practical courses is necessarily limited. For these the places are assigned according to the date of application.

The Annual Announcement and Catalogue will be sent upon application. Inquiries shonid be addressed to the

REGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.


The Johns Hopkim Hospital Bulletins are issued monthly. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies may be procured from Messrs. CVSHING & CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.00 a i/ear, may be addressed to the publishers, THE JOHNS HOPKINS PRESS, BALTIMORE; single copies trill be sent by mail for fifteen cents each.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. IX.- No. 85.]


BALTIMORE. APRIL, 1898.




oolsrTiBisrTS.


Miniature Hammers and tlie Suture of tlie Bile Ducts. By W.

S. Halsted, ]\I. D.,

University Education. By Michael Fcster, . - - . The Results of the Intra-trarheal Inoculation of the Bacillus

Diphtheriae in Rabbits. By Simon Flexner, M. D.,and H.

B. Anderson, M.D.,

The Bacti-riology of Pertussis. By Henrv Koplik, M. D.,


Supplementary Report on the Sterilization of Instruments by Formaldehyde. By H. O. Reik, M. D.,

Correspondence : Does Wilhite's Story of the Negro Boy Incident in the Discovery of Ansesthesia lack Probability"? Letters from J. (>. Wilhite, M. D., and Hugh H. Young, M. D.,

Notes on New Books, --------


MINIATURE HAMMERS AND THE SUTURE OF THE BILE DUCTS.*

By W. S. Halsted, Professor of Surgery in the Johns Hopkins University a)id Sm-yeon-in-Chief to the Johns Hopkins Hospital.


The surgery of the common bile duct is still in its infancy. "Suture of the thickened duct is difficult enough, and suture of the normal duct out of the question," says one. " It is not worth while to exercise such great care in sewing up a slit in the common bile duct, for it is almost impossible to prevent leakage, and a little additional leakage can do no harm if one drains," says another. " Wait until the common bile duct dilates and thickens before venturing to open it," say all surgeons.

"Ein normaler Ductus choledochus ist ein ausserordentlich dilunwandiges Gebilde; eiue Liingswunde in demselben exakt zu verniihen, durfte techniscb ausserordentlich schwierig sein, zumal man durch Einstiilpung der Wundrixnder leicht das Lumen des Kanales zu sehr verengen kann. Zum Gliicke erweitert sich der Ductus choledochus bei Eintritt von irgendwie grosseren Steinen alsbald, seine Wandung wird dicker, so dass Incision und Naht ineist leicht gelingen."f

"Beim dritten Act, habe ich die Schwierigkeit des Nahtverschlusses der Incision des Choledochus, welche in 2 Fiillen iiberhaupt uiimoglich war, keiinen gelernt, die Niiizlichkeit der Tumponnade eiugeseheu, sobald die Choledochotomie fiir sich allein ausgefiihrt oder mit der Cystectomie verbunden


♦ Presented at the Johns Ho|ikin8 Hospital Medical Society, December 13, 1897.

tRiedel. Chirur»ische Behandlung der Galiensteinkrankheit, p. 115. Handbuch der Speciellen Therapie innerer Krankheiten, , Bd. iv.


wurde."* "Eine Choledochotomie rechnet er [Kiimmellf] zu den technisch schwierigsten Operatioi en. "J

To close an incision in the normal ductus communis choledochus has been considered so impracticable, not to say impossible, and the result of the suture, so far as the suture itself is concerned, even of the abnormally thickened duct so uncertain, that it is the practice of all surgeons to wait weeks or months or even years for the duct to dilate and thicken rather than interfere promptly in cases of obstruction of the common bile duct by stone.

It is perhaps justifiable to "give nature a chance" to e.xpel the stone, but the operation should never be postponed solely for the sake of giving the duct time to become thicker. I know from operations upon dogs and man that the normal bile ducts can be sutured easily, accurately, almost infallibly, and without danger of leakage or constriction.

We are all more or less acquainted with the more evident dangers of postponing choledochotomy when it is indicated; the deep jaundice, the retarded blood coagulation and the consequent danger from hemorrhage, whether an operation is performed or not; the cirrhotic hypertrophy of the liver and the concomitant hemorrhages into stomach and intestines, the


K-lir. Ein Ruckblick auf 209Gallen8teinlaparotomieen. Arch, fiir Klin. Chirurgie, Bd. liii, Heft 2, p. 375.

fMittheilungen aus den Hamburgischen Staatskrankenanstalten, 1897, Bd. 1, Heft 2.

|Ref Tschmarke, Centralblatt fiir Chirurgie, 1898, No. 5, p. 134.


68




acute or chronic inflammation of the bile passages ; toxaemia, cholaemic or infectious, and the interfei'ence with metabolism, more serious, perhaps, in its remoter consequences than we have estimated. And when at last the operation is resorted to the patient is perhaps so weak that the surgeon might well wish that he had interfered earlier.

The duct lies in a deep hole, at a great distance from the surface, and is covered by the liver, which is usually enlarged in the cases which we are considering, and which, if very large or very small, may embarrass the operator exceedingly. The suggestion of Dr. Fred. Lange to cut through one or two ribs and the diaphragm when the liver is very large we have found invaluable. And not only when the liver is large have we profited by this hint; for once when it was small and high up under the ribs, the duct, carried up with it, was perhaps even less accessible than in the cases complicated with large liver.

Once then because of a small liver, and several times because the livers were large, have I divided ribs and diaphragm, and each time with gratifying results. When operating upon the bile passages of dogs I divide two or three ribs and the underlying diaphragm as a matter of routine. Cutting through a few ribs and the diaphragm on the left side enabled me to remove a large and very adherent tuberculous kidney.

With the little hammers which I am describing, or with a similar contrivance, I have five times sutured the common bile duct in dogs, and twice the common duct and once the cystic duct in the human subject. Two of the dogs referred to were operated upon last spring and observed during the summer and part of the autumn.

Dog 1. June 24, 1897. Long incision in common bile duct sutured over an aluminum rod with six mattress sutures of fine black silk. The wall of the duct was so thin that all of the stitches necessarily penetrated it. The silk itself was thicker than the wall. I intentionally turned in a great deal of the wall, wishing to temporarily occlude the lumen of the duct ; and having withdrawn the rod and tied the sutures, I was impressed with the thread-like appearance of the duct and thought that I had perhaps totally occluded it. The dog was apparently as well as usual in a day or two and was observed all summer. At no time was he jaundiced, nor did he seem to be in the least inconvenienced by the operation.

Oct. 1st. Dog killed with ether. Autopsy. Except for the few silk threads in the tissues there was little to evidence the operation.

Dog 3. June 34, 1897. Through an incision into the ductus communis choledochus a small shot not quite large enough to occlude the lumen of the duct was introduced. The duct was sutured with mattress sutures over an aluminum rod as in the preceding case.

The aluminum rods, of several sizes, were flexible and were bent to suit the case just before using. I was very much pleased with the rods, because they made not only possible but very easy what hitherto had been considered too ditticult to attempt. The rods suggested to me the rubber bags for intestinal suture which I have already described.*


Philadelphia Med. Journ., Jan. 8, 1898, and The Johns Hopkins Hospital Bulletin, Feb., 1898.


The little hammers which I now use answer the purpose better than the rods. Within the past three weeks I have twice used the hammers on the human subject. If properly employed they convert one of the most difficult operations in surgery into quite a simple one. The hammers are of sizes (vid. Figs. 4 and .5) to meet all cases, from the normal duct in a dog to a much dilated human duct.

To Use the Hammer in Suture of the Common Bile Duct.

It is not necessary to dissect the duct from its bed, but the wall of the duct should be clearly exposed at the site selected for the incision. I usually incise the common bile duct near its duodenal end because the diverticulum of Vater can be more thoroughly explored through an incision at this end of the duct, and because it is easier to suture this end than the other or cystic end of the common bile duct.

Before incising the duct, two presectiou stitches, to serve as retractors, should be taken. These stitches, which are subsequently removed, should enter the lumen of the duct. They are placed close together and the incision into the lumen of the duct is carried between them (vid. Fig. 1).

The stone having been removed and the gall passages thoroughly searched with probe and fingers, the retractor threads are drawn apart and a hammer of the proper size introduced (vid. Fig. 3).

The duct is then gently raised from its bed and drawn towards the operator (vid. Fig. 3) by the hammer, the head of which is of course longer than the incision.

Mattress stitches are then applied as shown in Fig. 3 ; one over the heel behind the handle of the hammer, and the others in front of the very delicate handle. This beautiful drawing was made from the subject and depicts accurately the parts concerned in this stage of the operation.

Although the finest possible needles and silk are used the stitches necessarily perforate the wall of the normal duct. No harm results from this perforation, however, for the normal duct practically always and the thickened duct usually is sterile, and the stitches very soon cut their way out of the lumen and out of the wall of the duct and lie free in the adventitious tissues.

The silk which we use is very much finer than the artist supposed when he made the drawings, and the needles, made for us by Wiilfing-Luer, of Paris, have a split eye and are almost as fine as the silk itself. One should have a needleholder especially made and reserved for these needles. If such a needle-holder is used for coarser work it will soon be ruined.

I have been asked why the handle is not placed in the middle of the hammer. It is placed as near one end as practicable, to enable the operator to introduce the hanmier through as small an incision as possible, an incision not longer than about half the circumference of the hammer.

The Advantages of the Hammer.

1. The duct to be sutured can be drawn towards the incision in the anterior abdominal wall and within easy reach of the operator ; it can also be manipulated nicely by the hammer.


RETRACTOR THREADS.



SUSPENSORY LIG OF LIVER.


GALL BLADDER


HEPATIC

FLEXURE OF

COLON.



PYLORUS.

Fig.


lloruiss IIosriTKi, IUu.i.ktin No. fir-,. Sec piige CR.


MILLIMETERS.


O O

O

o


actual length. Fig. 4.




April, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


69


2 The duct, whetlier normal or thickened and dilated, is gently expanded by the hammer ; hence the stitches can be taken with great accuracy and without fear of including the opposite wall or of occluding the lumen of the duct.

3. The operation is a very clean one, because the hammer blocks the duct and this prevents the escape of its contents and the contents of the gall bladder.


i. With the hammer, wounds of thin normal ducts can be easily and almost infallibly sutured, and hence the surgeon may, if he chooses, fearlessly operate upon the common duct as soon as the obstruction takes place.

The sewing of the thickened and dilated ducts is also greatly facilitated by the employment of the hammer.


UNIVERSITY EDUCATION.

By Michael Foster, University of Cambridge, England. [Address delivered at the Johns Hopkins University, Baltimore, October 11, 1897.]


[President Gilman introducd Prof. Foster in the following words: "I have the pleasure of presenting to this assembly the distinguished physiologist, Dr. Michael Foster, Professor in the University of Cambridge, England, and one of the secretariesof the Royal Society of London. He comes at the invitation of the Medical Faculty of this University, and it is an auspicious opening of the year that brings him here ; auspicious not only by his presence, but by the beautiful weather that has favored us and by the large number of students now enrolled in the medical department.

I can say of him that though his face is not familiar, a very large number of the young men and ladies present feel that they have already taken him by the hand, as his manual of physiology has been in use among us from the beginning of the Johns Hopkins University. You will be glad to be reminded that when biological studies were introduced here it was through the agency of Dr. H. Newell Martin, who had been a pupil of Dr. Foster's, first in London and afterwards in Cambridge. During the past score of years by correspondence we have maintained the most friendly relations, and we rejoice in this favorable opportunity to hear what be may say upon University Education."]

The Johns Hopkins University, which has done me the honor to ask me to say a few words on this occasion, is, although already distinguished, a new and young university. I can remember well its beginning, and as Dr. Gilmau has hinted, I may claim to have taken some small part in its birth. When I moved in 1870 from London to Cambridge, T took with me a bright lad of whose ability and industry I had already taken notice. At Cambridge he became my right hand man, and I had some hopes that I should long have his help; but President Gilman appeared upon the scene, and his influence was so strong that I felt that my own interests were not to be considered, and that I ought to send that favorite across the waters to occupy the first chair of biology in this new university. Although the memories of him whom I need scarcely name, Henry Newell Martin, are tinged with melancholy, still I feel that this university must always look back with pride and affection on the work which he has done in this country, and in this affection and pride I claim a small share for myself.

Your university is a new one. I come from a very old one; one which was founded six hundred years ago, which has lived through all those centuries, and which, though it has some of the charms, has also soine of the evils of antiquity. The traditions of the past weigh heavy upon us. When we attempt to stretch our limbs to meet the new needs of new


times we find some old written law, some well established prejudice, some vested interest preventing our full development. You are a new university; and although I have purposely refrained from refreshing my mind as to the exact status of your regulations and as to how far you may have already entangled yourselves in the toils of enactments, still I will take it for granted that you differ from us in the freedom with which you can move forward towards the needs of the coming times ; and I think perhaps I could not do better at the present moment than to use the opportunity offered me to take my old university as a text and to draw from it and its history some few plain reflections which I hope may be practical and useful with regard to the conduct of universities. Although I understand that I have been especially invited by the medical faculty, I will take leave to treat ouly of general things, since the welfare of the medical faculty is bound up in that of the whole university.

The morphologists tell us we can learn much by studying the embryo, and something perhaps may be learned by looking back at this old University of Cambridge in the days of long ago — in the days when it too was a relatively young university. Things were very different then from what they are now. The dimly

.lighted streets or alleys in which the students lived were an emblem of the whole university. There was little outward show of glory then, there were no beautiful buildings, few books, and each student's duty was, in part, to listen to the lecture, to the reading of something which was written, but whicli he could not see with his own eyes. In spite of all these difficulties there were certain features of the university of that time which I trust I may say have been, with some

, little wavering here and there, maintained since, and which I cannot help thinking have contributed in very large measure to make it what I may venture to call it, a famous and great

_ university. ,;s One of the most striking features of the attitude of both 'students and teachers at that early time was that they recognized in the training of the university a preparation for practical life. There were at that time three main occupations in which learning was of practical use; and in correspondence to those three occupations there were established the three great faculties of the university, the faculty of theology, the faculty of law and the faculty of medicine. And, if one reads what those men of old wrote concerning what they thought ought


70


JOHNS HOPKINS HOSPITAL BULLETIN.


[ No. 85.


to be done in the university, one is very much impressed by the conviction which they had that the teaching should be an earnest preparation for practical life. If it soon became necessary to establish a fourth faculty, the faculty of arts, that was simply as a faculty preparatory to the others, as one supplying the first steps for and leading up towards the knowledge which should be of use in practical life; and it is worth noting that although they called that faculty the faculty of arts, and although the acquisition of the Latin language was one of the chief studies of that faculty, necessarily so because all the instruction which could be given was given in that tongue, among what they called the arts were the beginnings of the kind of knowledge which we now call science.

Another feature of the university life of those early times was the very strong feeling that the work of the university consisted not in the mere acquisition of knowledge, but in the training of the mind. The amount of knowledge which they had for distribution was very limited ; but they used that small stock of knowledge to the very best of their ability, as the means of awakening the minds of the students and training them for thinking and arriving at conclusions. This is seen even in what they called at that time examinations, though the word then had a very different meaning from what it has now; there were then no written examinations, there was not that demand on paper so characteristic of modern times, and that great necessity of modern civilization, the waste-paper basket, was unknown. The examiners went quietly to work to ascertain in the most sure way whether a student had profited by what he had listened to. Instead of having two examiners for some hundreds of students, they appointed nine to each student; and these went in with him and out with him until they satisfied themselves that he knew something and had gathered something from what bad been told him. And then as a final test they put him on the " stool " and made him debate in public, the test being used in such a way as to bring out his stock of knowledge, and especially his power of using it and of showing that his mind had been trained at the same time that he had gathered in a certain number of facts.

There was another feature of the university which we sometimes find it difficult to realize: the spirit of inquiry was rife among them. At that time the ways of thinking were devious ; but still within the limited circle in which they moved, along the only lines then open to them, the thinkers used their minds in the spirit of free inquiry. When one i-eflects upon the circumstances in which they worked, one cannot help realizing that their long-drawn-out discussions were at bottom an expression of the love of inquiry, and that if they had had the advantages which we enjoy now, that which we call their subtlety would have broken out into discovery and invention.

Lastly, it was a feature of the university at that time that it was willing to take into its bosom any one who showed that he had any promise of benefiting by the instruction there given. It was an open home for all who wished for learning.

These are some of the features of the University of Cambridge in the olden times, and may we not, using them as a text, attempt to draw some conclusions as to what are the proper and essential functions of a university and what ought


to be some of its guiding principles ? As I gaid just now, the knowledge which they possessed was extremely limited, the facts with which they had to deal were very few. What can we say of knowledge at the present time? May we not say, if theirs was too little for them, ours threatens to be too great for us; that we are entering upon an age in which the facts which have to be learned and the various kinds of knowledge which have to be acquired are becoming too many for us ? It is or it may be perfectly true that one of the advantages of learning is that it enables the learner to learn more rapidly ; V)ut is not this true, notwithstanding that the increment of knowledge is increasing far more rapidly than the increment of the power to learn ? Is it not a serious matter for consideration that the things that the university has to teach are rapidly becoming far too numerous for the learner to learn? Is it not true that we cannot do now as they did in those old times, teach the student all that was known ? We are compelled to make a choice, we must teach to the student some things and omit to teach him others. That is a necessity which it seems to me is increasing as the years goon. Nevertheless that position is a cruel one ; for it may be truly said that every kind of knowledge has a vah^e of its own ; each kind of knowledge has for the learner a value which can be given by no other kind, and he who fails to gain any one kind of knowledge is thereby a loser. For building up the student into the full and complete man, the best course would be to take in all the knowledge which can be offered by a university; but as I said just now, a choice must he made, and the consideration of the principles which should guide the decision as to what should be chosen and what should be left demands the most serious attention. Here I think we may venture to follow the example of the old university. Admitting that each kind of knowledge is particularly fitting for a particular calling, that for every jiarticular calling in life there is a knowledge, or there are kinds of knowledge which are suited or fitted for that calling and without which that calling can not be pursued with success, in the necessary choice which must be made between this study and that is it not a wise course to take that which best serves the future calling of the student? I cannot but think that in this choice of which I am speaking, the arguments for what are sometimes called technical education are unanswerable; that one of the principles of most importance in determining the choice of the studies to be taken up by the student lies in the fitness of the study for giving him power in the calling which he proposes to adojjt. We must, however, remember that the knowledge which is thus to be imjiarted to him must be not merely a knowledge of facts, but bring with it the power of thiiiking. If technical education is understood in this way, not as a mere accumulation of facts, not as the mere heaping up of knowledge, but as the training of the mind in some particular kind of knowledge, the dangers, I venture to say, which some fear, will prove unreal, and it will be seen to be a true principle of university education.

There is another aspect in which we may look at university duties. May we not say that the tendency of modern civilization is to smooth down individual differences, and that the whole tendency of the environment of man is to make each


April, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


71


man increasingly more like his brother? There was a time when one could tell by the dress where a man came from, but this has become les^ and less easy, and it is not in dress alone, but in his very nature that man all over the world becomes more like his fellows. I myself during the short time I have been in this country have felt it more and more difficult to tell what are the differences between an American and an Englishman, and I trust that these differences are equally difficult to you. This may be a favorable aspect, but there is an unfavorable side to this continual influence of things about us. Mr. Francis Galton has shown that there is a great tendency in things to make men more and more alike in stature, and there seems a corresponding tendency to make men all alike in the stature of theii- minds. We seem tending in many ways to a monotonous mediocrity of intellect. This influence is especially strong among young people. I see for myself in the University of Cambridge that when one young man does one thing they all do it ; they go astray like sheep, and they also go straight like sheep. Surely it ought to be a function of the university to counteract this tendency and so to bring the influences of learning upon the young as to develop individual differences. That I take it is one of the most important functions which a university can exercise, but one which is not always kept in view in university enactments. Here I can speak of my own university, and in doing so can lay the blame for the present condition of things on the traditions of the past. I find in my own university discouragement for the development of individual power. Every lad who comes to the University of Cambridge is compelled to pass through the same examination, to know the same things to the same extent, whatever may be the nature of his mind. He must know a little Latin, a little Greek, a little mathematics, a little history and one or two other subjects. Each one who comes, whatever his previous history, must pass through this one gate; the whole university has been pushed through this one common gate. Now I know that this may be defended; it may be said for instance that it is a bad thing not to know Latin. I quite agree with that. I think it a very bad thing not to know Latin, but I also think it a very bad thing for a lad to be thrown into life, it may be to go through life, without any clear idea whatever of the fundamental laws which govern the phenomena of living things. It may be said that it is a bad thing not to know Greek ; I agree with that. Not to know Greek is to my mind worse than not to know Latin, but I think also that it is a bad thing for a lad to go through life ignorant of the fundamental laws of chemical action. If you go along in that line of argument you end by compelling a lad to know everything before he enters the university. If I had my way and could wipe out the traditions of the past I should vary that entrance examination. I should hold on to the old tradition of the university that it was ready to receive everybody who was likely to profit by its instructions. I should make the examination look, not backward as it does now, but forward, and should only insist that the lad must give such proofs of intelligence and industry as to lead to the hojie that the years of university life would not be spent in vain. When the lad has really entered the university (at times he does not do so until he has spent two or even three years at


the place in preparation, and sometimes goes away from the place without having really been admitted), it seems to me there should be a still wider scope for his studies. He has even now, it is true, an opportunity to take a degree in one or other of several branches of learning, but in each case he must follow out a particular schedule which has been laid down and which compels him to walk along a particular path and no other. If he wishes, for example, to study mathematics with philosophy, he would find that he could not do so, for in the examinations mathematicians have nothing to do with philosophy, and philosophy nothing to do with mathematics ; and so in other things. I venture to think that this is not a satisfactory condition of things, and that throughout the who'e academic course there should be a freedom of the young mind to develop in the line in which it was intended to develop. When I urge this upon my friends they all say, " It is very good, but it is impossible, the examination machinery would become so complicated as to break down." But I would ask the question. Are examinations all in all ? were the examinations made for universities, or were universities made for examinations? I myself have no doubt about the answer. I trust that this new university, which can walk with freedom along new lines, will find some way of so arranging studies and examinations that the two will not conflict, and that anybody coming here will find that the particular gifts that have been given to him and which it was intended should be developed will meet their fullest expansion.

Lastly, there was another feature which the old university possessed and which I may also call an essential feature of a university, that is, the spirit of inquiry. No university can prosper as a university that not only does its best to favor special inquiries when these are started within it, but also in the whole course of its teaching develops, or strives to develop the spirit of inquiry. Now here again I fear that examinations — such at all events is my experience — are antagonistic to inquiry; and I would suggest that in arranging examinations one ought always to look ahead to see how far one can possibly order those examinations so as to favor the teaching which teaches in the real and true way, teaching by regarding each bit of learning as in itself an act of inquiry, and so as to favor in the highest degree actual inquiry when it is taken in hand. This of course is antagonistic to one function of examinations, namely, that of putting young men to compete against each other. You cannot so judge inquiries as to put the inquirers in any class list or in any order; the most you can do is to give an inquiry the stamp of approval of the university, a testimony that the inquiry has been carried out in a satisfactory way. It is true that in this way you lose that which is sometimes thought to be of great value, emulation between the scholars ; but if you take away that kind of emulation you substitute for it another one far more strong and effective, that emulation that comes of striving with nature. I take it that the good which is done to a lad in starting him upon an inquiry is infinitely greater than any which can be gained by competition with his fellow students. Here I am glad to say a good word for my own university ; for we have in a very quiet way, and unobserved, secured the adoption of an enactment which allows a lad to enter the


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university aad obtain his degree and all which follows upon that without entering into a single examination. At the present moment it is possible for one, it is true under exceptional circumstances, to come to the University of Cambridge in England, and if he convinces a competent body of judges that he is a person likely to carry on inquiry in a successful manner he can enter the university as a student, and if he satisfies another body of men after a time that his inquiries have resulted in a real contribution to knowledge he can secure his degree. He can get that without ever having touched a written examination paper, and I am proud that we are able to offer that to the world; for it has happened again and again that a man who had real genius for a par


ticular line of inquiry stumbled over the preliminary studies of which I have spoken, knocked at the door of our university in vain and was sent way. Now such an one would be admitted, and I venture to say that in the long run the university will be the gainer.

These then are some few thoughts concerning universities and their methods. I say I have purposely learned nothing about your enactments, but from what I know of your short jiast I feel confident that this university will in the future be conspicuous for progress. May I hope that it will carry on education along some of the lines which I have indicated to-day, and perhaps some day we in the old country may mend our ways after your pattern.


THE RESULTS OF THE INTRA-TRACHEAL INOCULATION OF THE BACILLUS DIPHTHERm IN

RABBITS.

By Simon Flexner, M. D., Baltimore, and H. B. Anderson, M. D., Toronto. \Proni the Pathological Laboratory of the Johns Hopkins University and Jlospital.]


I.


The interest which was aroused by the discovery of Frosch,' Kolisko and Paltauf," Wright,' and others, that the bacillus diphtherife not uncommonly invades the internal organs in diphtheria, was further stimulated by the publication of the work of Kutscher, which dealt with the relation of the bacillus diphtherias to the pneumonic processes that are associated not infrequently with pharyngeal and laryngeal diphtheria. The studies of the foregoing writers, which will be examined more in detail hereafter, led to the supposition that, contrary to the previously expressed views concerning the aetiology of the pneumonic processes in diphtheria, it was probable that in many cases the diphtheria bacillus might itself be the causative agent. In the winter of 1894 we presented to the Johns Hopkins Hospital Medical Society a preliminary communication on the subject of the effects of the injection of pure cultures of the bacillus dipbtberiae into the tracheae of rabbits. We were then able to say that by this means a definite and wide-spread pneumonic process could be provoked, which led in many instances to the death of the animal. These experiments seemed therefore to be more conclusive than the previous observations upon human beings with reference to the probable action of the diphtheria germ in this respect, for the reason that in the former subsidiary or secondary micro-organisms were definitely excluded from any part in the production of the pathological lesions. Our studies carried us incidentally into a consideration of the fate of the introduced micro-organisms, as it soon appeared that even after considerable numbers of diphtheria bacilli in pure culture had been inserted through the trachea iuto the lung, their recovery from these situations was often attended with much diflBculty and sometimes was impossible.

Although the credit of the demonstration of the invasion of the internal organs by the bacillus diphtheria has usually been given to Frosch, it is an undoubted fact that Loeffler'


had previously encountered these organisms certainly in the lungs and perhaps in the liver, in human beings. In the light of our present knowledge it is interesting to note how LoefHer endeavored to explain away these observations on the supposition that the bacilli had entered these organs post mortem and not during life.

In briefly reviewing the literature we shall confine ourselves to a consideration of those instances in which the organisms have been isolated either alone or together with other bacteria from the lungs, more particularly in association with pneumonic processes.

In the communication in which Frosch' pointed out the common invasion of the internal organs by the specific bacillus in cases of diphtheria he states that the organisms were present in the lungs and elsewhere. AVithout giving any particular details, he adds that as compared with the remaining viscera they were found most often in pneumonic areas, the spleen and the lymphatic glands. Whether they existed there alone or in association with other micro-organisms he does not say. One is led to believe, however, that in a majority of instances at least other micro-organisms were present, inasmuch as he states in conclusion that in almost all of his cases he found a mixed infection with various kinds of bacteria, but generally with streptococci and staphylococci.

Kutscher" investigated the invasion of diphtheria bacilli into the lungs in human beings and their relation to the broncho-pneumonias of diphtheria. For this purpose he studied the lungs of ten children who came to autopsy, and in whom the diagnosis of diphtheria had been made during life. Cultures were made in a part only of the cases ; sections of the organs, however, were studied in all. The cases included examples of pharyngeal and laryngeal diphtheria with extension into the bronchi. The results arrived at by Kutscher indicated that in a small number of instances the


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bacillus diphtherias may be contained alone within the consolidated patches in the lungs, but that there is likely to be an association of bacteria, the chief accompanying forms being the pyogenic streptococci and staphylococci. Diphtheria bacilli were absent from the lung tissue not the seat of hepatization ; not so, however, the streptococci. In some instances the consolidation was entirely microscopic, and in these cases streptococci were found without lesions being pi'esent about them, while, on the other liand, the diphtheria bacilli were discovered only in the broncho-pneumonic foci.

As a result of these studies Kutscher' expressed himself to the effect that the lungs must be considered as the organs most often and most severely implicated in the secondary invasion of the diphtheria organisms. He regards the commonest mode of invasion to be by aspiration, which certainly must be the most usual way, and places next in order of frequency an infection through the lymphatic channels on the ground that bacilli were found in the perivascular lymphatics. Kutscher further pointed out that in not a single instance was he able to demonstrate the presence of these micro-organisms within the blood-vessels themselves. The question whether the bacilli in the internal organs may themselves be the cause of lesions he believes must be answered affirmatively with reference to the lungs. In support of this belief he urges that the bacilli have been found not only in advanced lesions, but often and alone in the earlier ones, and that they occur in bronchi which are little affected, as well as in those filled with a cellular exudate in which the epithelium has been largely destroyed. The probability of the bacilli being secondary invaders after the pulmonary lesions had been brought about in other ways is therefore excluded.

Although in a few cases diptheria bacilli had been demonstrated in the lung by Johnston," Strelitz," Booker" and one of us (Flexner"), the next series of examinations comprising a larger number of cases, and therefore of more conclusive significance, was furnished by Wright, who, in studying fourteen fatal cases of diphtheria, isolated this organism from the lungs in thirteen. For the most part there existed bronchopneumonic areas in which these bacilli were found, although they were associated, as a rule, with the usual pyogenic cocci. In ten of the fourteen autopsies there were distinct lesions of broncho-pneumonia, but the occurrence of the Klebs-Loeffler bacillus in the lung seemed to be independent of the coincidence of these lesions, for, as Wright points out, it was absent in at least one instance of broncho-pneumonia, and present in the tissues in the absence of these lesions. The diphtheria bacillus was associated with the streptococcus in nine cases, in seven of which pneumonia was present.

In a subsequent report by Wright, associated with Stokes, ° an analysis of thirty-one cases of diphtheria is given, in which cultures from the lungs revealed the presence of the KlebsLoeffler bacillus alone or in combination in thirty out of the thirty-one cases examined. Of these thirty-one cases bronchopneumonia was present in nineteen.

Their series of cases also shows that the diphtheria bacillus may be present in the lungs independently of the occurrence of broncho-pneumonia, for in twelve cases in which no pneu


monic condition was demonstrable, cultures from the lungs showed the presence of these micro-organisms.

Belfanti studied a series of 26 cases of broncho-pneumonia associated with diphtheria and found the Klebs-Loeffler bacillus in 21. Of these 21 cases it was present alone in four, and combined with other bacteria seventeen times.

The most recent contribution to this subject has been furnished by Kanthack and Stephens,'- who report that of twentysix fatal cases in which the lungs were examined for their presence, the Klebs-Loeffler bacilli were found in every one with ease and in large numbers. In comparing these results with those obtained from a similar examination of other organs of the body, these authors conclude, and on this point agree with Frosch and with Wright, that the Klebs-Loeffler bacillus escapes most readily into the lungs; indeed they urge that in these organs the bacilli are found not in small numbers, as had been previously considered, but are very numerous. Of the twenty-six cases examined, Kanthack and Stephens describe the lesions of broncho-pneumonia in fifteen, and state that they must take exception to the statement frequently made that the broncho-pneumonia in diphtheria is of pyococcal origin, maintaining that it would rather appear to be a veritable diphtheritic complication. It is worth mentioning that the broncho-pneumonias of diphtheria are according to them most frequently encountered in those cases in which the invasion of the larynx by the membrane had taken place. Of twenty-four laryngeal cases which they describe, bronchopneumonia existed in thirteen.

In interpreting the results of the observations upon the relation of the pyogenic organisms to broncho-pneumonic areas in the lungs with or without the coincidence of the Klebs-Loeffler bacillus, we must take exception to the statement made by Kanthack and Stevens'^ that " staphylococci, pneumococci and streptococci are normal inhabitants of the bronchi, bronchioles and alveoli; and therefore on cultivation must of necessity appear on the agar-agar surfaces." We think a sufficient answer to this statement is found in the frequency with which such cttltures from perfectly normal human lungs at autopsy give negative results. We are far more inclined to regard the pyogenic organisms as not without pathological significance, notwithstanding the fact, as we hope to show, th;it the diphtheria bacillus is quite capable alone of causing definite pneumonic processes.

IL

The results derived from our studies of the intra- tracheal inoculation of fluid cultures and suspensions of the KlebsLoeffler bacillus were unmistakable in their significance. We were able in quite a number of cases to provoke an inflammatory process within the lungs which varied in extent, involving sometimes a small area, even a fragment of the lobe, and at others the gi eater portion of one lung, or considerable parts of both. In the course of these studies attention was directed to some other points, more or less in dispute, and especially to the question of the fate of the introduced micro-organisms and the length of time during which they were demonstrable within the substance of the lungs.

The method pursued in conducting these investigations was


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[No. 85.


quite simple, and after a few preliminary failures uniformly successfnl. It consisted of exj)osing the trachea above the clavicles in half and full-grown rabbits, the precaution having first been taken of carefully removing the hair over the site of operation. The only real difficulty which was encountered was the avoidance of infection of the tissues about the trachea. lu the early experiments this was not always successfully overcome, but later, by introducing the needle through a small pledget of sterilized cotton, placed in contact with the exposed trachea, and withdrawing it through the pad, we were able as a rule to avoid infection of the soft tissues. The wound was sutured and covered with a celloidin dressing.

The amount and the character of the injected material varied with the different cases and are recorded in the individual protocols. The duration of life succeeding inoculation also varied considerably, and the extent of lung involvement seemed to depend more or less upon the j)eriod of incubation. For the study of the pneumonic process in its entirety inoculated animals were allowed to live as long as possible, while for the study of the fate of the introduced micro-organisms, as well as the time required for the development of the jjathological lesions, the animals were killed at intervals varying from one to twelve hours after inoculation.

Our attention was attracted in the early experiments to the frequency with which, in the hepatized lungs, the introduced bacilli were missed in cultures, in cover-slip preparations, and in the tissues, so that it became necessary to search elsewhere for them, or to discover the manner of their destruction in situ.

Exp. 1. Full-grown white rabbit received Feb. 10, 1895, .5 cc. of a bouillon culture of the bacillus diphtheria; reinforced by the addition of five drops of the condensation water of a serum culture two days old. It lived about 65 hours.

Autopsy. Practically no reaction about the local wound ; the lymph glands neither enlarged nor congested. The mucous membrane of the trachea near the larynx showed a few small points of congestion. The trachea and bronchi contained frothy serum. The lungs were voluminous and completely consolidated excepting the edges of the lower lobes, whicli contained air. The pleural surfaces showed points of ecchymosis and had a moist, somewhat glutinous appearance. The consolidated portions presented a peculiar semi-translucent gelatinous appearance, and on section an cedematous fluid in small quantities escaped. The remaining organs showed nothing remarkable.

Bacteriological examination. Trachea ; no diphtheria bacilli found. Pleurfe ; no bacilli found. Lungs; films were examined from various portions, and no distinct bacilli could be found. What may have been pale and perhaps degenerated organisms, two or three in number, were found on one cover-slip. Many pus cells containing amphophilic granules were present.

Cultures on Loeffler's blood serum from the consolidated portion of the lungs, the heart's blood and liver were perfectly negative.

Exp. 2. Full-grown Maltese rabbit received .5 cc. of a 4S-hour old bouillon culture on Feb. 7th. Death in 47 hours. Autopsy immediately after death. Heart still beating slightly, but irregularly. Trachea filled with frothy serum. The lungs, with the exception of the edges of the bases and apices, which contained air, completely consolid.ated. They were voluminous and completely filled the pleural cavities. Beneath the pleura were small h.Tmorrliagic points. Upon section the smooth gelatinous appearance described in the previous animal was observed. The trachea showed slight congestion at tho point of entrance of the needle.


Bacterioscopic examination. In the trachea in the neighborhood of the puncture a few diphtheria bacilli were found, both free and enclosed in epithelial cells. Examination of the pleura was negative. In the lungs what may have been a few extracellular degenerated forms.

Cultures from the lungs and heart's blood negative.

Exp. 3. Half-grown rabbit received .5 cc. of a slightly turbid suspension in condensation water of a blood-serum culture. Died in 27 hours.

Autopsy. The trachea much congested throughout and covered with punctiform luemorrhages, but without visible membrane. The cesophagus also much congested. The local wound somewhat swollen and cedematous. The superior lobes of the right lung were almost completely consolidated, the remaini^er contained air.

Bacterioscopic examination. From the exudate about the trachea a small number of diphtheria bacilli. From the lungs and pleura, negative; from the cesophagus, typical bacilli.

Cultures. Heart's blood and lungs on Loeffler's blood serum negative.

Exp. 4. A white half-grown rabbit received .5 cc. of a bouillon culture reinforced by the addition of five drops of the condensation water of a strum culture two days old. The animal succumbed on the seventh day. There was absolutely no pneumonia ; the lungs appearing somewhat congested, but contained air in all parts.

The cultures were negative. Cause of death not apparent.

Exp. 5. Full-grown rabbit received at 3.15 P. M., June 22nd, .9 cc. of a turbid suspension. Died during the night.

Autopsy. Trachea, no membrane ; somewhat congested.

The lungs much congested ; no definite consolidation.

Bacterioscopic examination. From trachea numerous bacilli, both free and within cells.

Lyings. Upon cover-slips many polymorphonuclear cells, but no bacilli.

The cultures showed Klebs-Loeffler bacilli in the congested portion of the lungs, the bone-marrow (femur) and the heart's blood.

This series of cases shows in the first place that the diphtheria bacillits by itself is capable of provoking a definite and often wide-spread pneumonic process when introduced directly into the lungs of rabbits ; but that in certain cases, notwithstanding the entrance of numerous bacilli into- the lungs, a pneumonic process fails to be provoked. Further, it shows that when the number of bacilli is great the animal may succumb, presumably to the intoxication induced by these organisms, before an outspoken pneumonia has developed, thus illustrating anew the effects of the absorption of the poisonous products from the lung substance. Again, Experiment 5 shows that in addition to the invasion of the body presumably by the toxic products of the diphtheria bacillus, we may have a more or less wide distribution of the organisms themselves, and that they may be found in very distant situations. Finally, this series of experiments proves that after the provocation of the pneumonic process the bacilli may themselves either disappear completely, or be so reduced in numbers as to be iucai)able of demonstration in cover-slips, or that their vitality nuiy be either destroyed or interfered with to such an extent that any attempt at cultivation, even on favorable media, will be followed by negative results.

Exp. 6. A full-grown rabbit received 1.3 cc. of a turbid suspension in bouillon of the bacillus dii)litheria5. The animal was killed by a sharp blow on the back of tlie neck one hour after the inoculation.


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Aulopsi/. The lungs were voluiiiiiious and slightly niottleil. IlMinorrUages were nut discovered beneath the serous membrane.

Bacterioseopie examination. Cover-slips from the lower lobes of the lungs showed, besides a few polymorphonuclear leucocytes containing am])hophilic granules, and some few epithelial cells, bacilli singly as well as in small and in large clumps, chiefly existing free among the cells. Occasionally enclosed within an epithelial cell there was to be found a single bacillus, and more rarely several bacilli. The cells which contained the bacilli stained in the same normal manner as the remaining cells, and the bacilli themselves showed no variation in staining properties as compared with the extracellular forms.

Cultures. From both apices and bases of the lungs a variable number of colonies of the introduced bacilli ; from the pleural membrane a single colony of the same organism. The heart's blood, spleen and bone-marrow gave negative results.

Exp. 7. A black, nearly grown rabbit received 1.3 cc. of a turbid suspension similar to the last ; the animal was chloroformed after the lapse of one hour.

Autopsy. The lower lobes of both lungs were swollen, slightly congested, and the serous membrane covering the lungs showed here and there punctiform ecchymotic spots.

Bacterioseopie examination. The cover-slip preparations from the various parts of the lungs showed essentially the same appearances as those described for the previous experiment, but it seemed as though the cells containing bacilli were perhaps a little more numerous in this case. The polymorphonuclear amphopbiles appearel to be about as numerous as in the preceding experiment, and as in that case the introduced bacilli were never found within these cells. An examination of the bronchial epithelium showed a complete absence of bacilli within the columnar epithelial cells, even when they were quite numerous between them.

Cultures. From the lungs, considerable growth of the introduced bacilli. From the heart's blood, bone-marrow and spleen the cultures remained sterile.

Exp. 8. A nearly full-grown rabbit received on Feb. 2Gth 1 cc. of a turbid suspension of the bacillus dipbtherise. The animal was killed at the end of 3i hours.

Autopsy. Lungs voluminous. In the superior and inferior lobes of both lungs considerable hiemorrhages existed beneath the pleura, which on section could be seen to extend into the lung substance. Admixed with the blood there was much frothy serum ; elsewhere the lung tissue was pale and moderately dry.

Bacterioseopie examination. Fdms prepared from tfie hremorrbagic areas showed large numbers of epithelial cells enclosing diphtheria bacilli. The bacilli were often arranged in the same parallel rows which one observes in the cover-slip preparations from the cultures themselves. The bacilli stained in all respects normally ; rarely there appeal e 1 within the cells specks of chromatin which had the samii staining property as the bacilli and might have been fragments of the latter, but they were hardly more numeious than one occasionally finds in cultures of the same organism. The cells containing these bacilli themselves appeared entirely normal. The bacilli were very rarely found to have invaded the nuclei of the cells. Leucocytes with typically polymorphous nuclei were present in the cover slips, but they were never seen to contain the inoculated bacteria. The free bacilli were seen only exception.ally among the cells ; when found here they were usually single and rarely in clumps.

Cultures. The lungs and spleen gave growths of the bacillus diphtheria!. From the lieart's blood the cultures were sterile.

Exp. 9. Nearly full-grown rabbit received .5 cc. of a faintly turbid suspension of the bacillus diphtheria;. Killed after six hours.

Autopsy. Lungs partly collapsed ; the pleura covered with small hiemorrhages. The lower lobes of the lungs were congested and edematous ; no definite consolidation. Bacterioseopie examination. The films from the superior and mid


dle lubes were negative. From the congested and oedematous li'wer lobes bacilli in small numbers were obtained, occurring singly and in small groups, extracellular and enclosed within epithelial cells. The polymorphonuclear cells, which showed an increase in number as compared with the two previous cases, did not contain the introduced micro-organisms.

Cultures from the lungs and spleen were positive ; from the heart's blood no growth was obtained.

Exp. 10. Full grown rabbit received .75 cc. of suspension of a culture on blood serum two days old. Animal killed at the end of six hours.

Autopsy. The trachea at the seat of inoculation showed some congestion but no false membrane. The bases of the lungs were congested, the pleura covered with minute hiemorrhages.

Bacterioseopie examination, (a) Smears from the mucous membrane of the trachea at the site of inoculation showed diphtheria bacilli in considerable numbers, all extracellular, and among these jiolymorphonuclear cells, (b) From the base of the lungs mononuclear, epithelial and polymorphonuclear cells, the former containing bacilli. Similar micro-organisms, although in smaller number, also existed between the cells.

Cultures. From the lung a large number of colonies. From the s|>leen, bone-marrow, heart's blood and liver, smaller numbers of colonies of the introduced micro-organisms.

Exp. 11. A rabbit received .75 cc. of a turbid suspension of a growth of the bacilli upon blood serum. Killed at the end of twelve hours.

Autopsy. Trachea about the site of inoculation showed much congestion, which extended above and below the point at which the needle had been introduceil, but no false membrane existed. The caudal lobes of the lungs were much congested, and beneath the pleura minute haemorrhages appeared. The spleen appeared enlarged.

Bacterioseopie examination. Smears from the trachea showed numerous polymorphonuclear cells, but no bacilli. From the lungs (bases) bacilli extracellular and polymorphonuclear cells.

Cultures. From the heart's blood, spleen and bone-marrow the introduced bacilli were cultivated. From the tracheal glands and lungs the tubes were negative.

Exp. 12. Was a repetition of the previous experiment and gave similar results, with the exception that the bacilli were cultivated from the congested and oedematous lower lobes of the lungs. It is therefore probable that in the previous case the absence of the bacilli from similar situations is to be regarded as an accidental occurrence.

Exp. 13. Full-grown rabbit received .80 cc. of a suspension of the bacillus diphtberiie. Killed in 18 hours.

Autopsy. The trachea appeared very much congested, but there was an entire absence of false membrane. The caudal lobe of the lung on the right side was dark red in color, but not frankly consolidated, whereas on the left side a definite consolidation in the corresponding lobe had taken place. The spleen was decidedly enlarged and congested.

Bacterioseopie examination. Cover-slips from the trachea show-ed many polymorphonuclear cells, fewer epithelial cells, no bacilli. From the lungs many polymorphonuclear cells and epithelial cells with single nuclei, but no bacilli.

Cultures from the lungs and heart's blood, positive ; from the spleen, liver and bone marrow, negative.

Exp. 14. A large rabbit received 1 cc. of a bouillon culture. Killed after 24 hours by breaking up the medulla.

Autopsy. The middle lobe of the right lung contained a consolidated patch the size of a silver dollar, over which the pleura was congested and contained small hemorrhages. •

Bacterioseopie examination. Films from the consolidated portion of the lung showed many polymorphonuclear leucocytes, some epithelial cells, but no bacilli.


76




Cultures from the lung as well as heart's blood, spleen and bonemarrow were negative.

Exp. 15. Full-grown rabbit received .75 cc. of a turbid suspension derived from a blood-serum culture. Killed in 24 hours.

Autopsy. The caudal lobe of the right lung and the lowerpart of the cephalic lobe on the same side were congested and consolidated as well. In addition the caudal lobe of the left lung contained several smaller areas of consolidation. The spleen was much enlarged. The trachea over the site of inoculation and at a distance from it was much congested. There was an entire absence of false membrane.

Bacterioacopic examination. Smears from the consolidated portions of the lung, trachea, spleen, bone-marrow and heart's blood were all negative.

Cultures from the same sources remained entirely sterile.

The object of this group of experiments was two-fold, namely, to determine, if possible, the manner in which the introduced bacilli so completely disappeared, and in the next place to consider the length of time necessary for the development of the pneumonic processes and the nature of the inflammation provoked.

Animals which had received large numbers of the KlebsLoeffler bacilli showed at the end of one hour changes in the lungs, which, however, were not very marked. They consisted simply of an cedema of the tissues, together with more or less mottled congestion. Of greater significance, however, was the fact that an emigration of leucocytes had already taken place, and that some, although few, of the introduced bacilli were enclosed within cells, these being exclusively the epithelial cells of the alveoli. At the end of 3 J hours the pathological process was much more advanced, the first expression apparently resulting from changes in the blood-vessels, to judge from the definite hasmorrhages, often of considerable extent and very numerous, which were discoverable both in the pleura and in the substance of the lung. By this time, although large numbers of the bacilli had been introduced, comparatively few were now free, the overwhelming majority of them being enclosed either within the protoplasm or the nuclei of cells. In this short time the bacilli might be found to have extended their invasion beyond the thoracic organs; and whereas at the end of one hour they were still limited to the substance of the lungs, at the end of 3 J hours they were found in the spleen as well. It should be mentioned here that owing to the small size of the bronchial lymphatic glands, cultures from these were not very satisfactory, and were therefore not regularly made. At the end of G hours the effects of the inoculation were still more noticeable, and the distribution of the microorganisms more extensive, as they were demonstrated by the culture method at the end of this time in the heart's blood, spleen, bone-marrow and liver. The bacilli were still capable of cultivation from these distant organs as well as from the lungs at the end of twelve and eighteen hours, while after the lapse of twenty-four hours, at which time a frank consolidation of the lung substance had taken place, they could not be cultivated either from the lungs or from the remaining organs mentioned. We should like to emphasize that, although the inclusion of the bacteria by cells takes place so rapidly and extensively, in no instance did we succeed in discovering the bacilli within the substance of the polymorphonuclear leucocytes.


The foregoing experiments serve to confirm the observation upon human beings relating to the existence of a jmrely diphtheritic broncho-pneumonia, and lend support to the view that the laryngeal cases are specially prone to the development of such pathological conditions, as they present the most favorable opportunity for the direct aspiration of the infectious agent. That an actual increase of the introduced microorganisms takes place is proven, we think, by the observations made upon human beings which have been given in detail in an earlier part of this paper; in view of which fact the disappearance of the introduced bacteria in cases of experimental inoculation is all the more perplexing. The interpretation of this phenomenon is indeed not at once apparent. On the other hand it is worth considering whether in those cases of human diphtheria in which the bacilli have not been found in the local pathological processes, it may not be also unjustifiable to conclude that the bacilli never were present there, and were not concerned in their causation.

It is certainly interesting to observe that there may take place from the lungs a rapid distribution of the introduced bacilli throughout the body, so that at the end of from four to six hours they may be found widely distributed throughout the organs. It has appeared to us as if the opportunities for such distribution are greater in cases of intra-tracheal inoculation than in the ordinary modes of subcutaneous inoculation, where, as is well known, the bacilli are not found extensively distributed through the viscera. However, there is at least one difference between the observations in the two sets of cases, for in the course of the ordinary subcutaneous inoculation a longer time as a rule elapses between the inoculation and the death of the animal, which may account for the absence of the bacilli in the internal organs. As an illustration of this point we may mention that in animals which were either killed after the lapse of twenty-four hours or died spontaneously later, we failed to obtain the introduced bacilli from these viscera.

The experiments which we have conducted justify us in considering for a moment the question of the action of the lungs as an infection atrium into the body of pathogenic microorganisms, and they would lead us to agree with Hildebrandt," who showed, contrary to the previous belief of Fliigge," that the alveolar epithelium is not a perfect barrier to the invasion of pathogenic bacteria from the interior of the lungs. At the time that the bacilli are already well distributed through the body the alveolar epithelium still appears entirely normal, although containing many bacilli within its substance. The supposition that bacilli are capable of passing from the bodies of the epithelial cells in some way into the general blood current or into the lymphatics, without leaving behind them obvious evidences of injury to these structures, would therefore appear to be justifiable. As to the mechanism of this procedure one can only deal in conjectures, when it is remembered that in this case we are dealing with non-motile organisms which must be transported from place to place by a force not resident within themselves.* The capacity of the alveolar epi


Ultimately, of course, this is the same problem as that dealing with the mode of passage of inert particles, such as soot, India ink


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theliiiui to luke up liviug foreigu matter it: the manner similar to what is observed in dust inhalation had been previously observed by Muskatbliith"' in his experiments upon the effects of the intra-tracheal inoculation of anthrax spores. He observed that in animals which had been killed on an average sixteen hours after inoculation, the greater majority of the bacilli were contained within epithelial cells corresponding with the so-called "staubzellen." Even when the englobing cells were free in the alveoli they gave every indication of having been derived from the pre-existing epithelium of these parts, and indeed were often found to be still in connection with the latter. As in our observations, he found that the leucocytes, the phagocytes par excellenre, had no part in the inclusion of the bacteria. He was neither able to detect evidence of injury to the cells containing the bacteria, nor that the bacteria within them were undergoing disintegration.

It must not be forgotten that after the introduction into the lungs of such numbers of bacteria as were inoculated into these animals a portion at least of them may have been thrown of through the bronchial secretions. In this way not an inconsiderable number may have been finally disposed of, and this possibility is rather strengthened by the observation of Case 3, in which an inflammation of the oesophagus was noted and the Klebs-Loeffler bacilli were found in considerable numbers in this situation. Muskatbliith regarded the reaction on the part of the lungs, with the pouring out of inflammatory products, as favoring the destruction of the anthrax organisms in situ, a conception which could, with more or less justice, be applied to the cases in which at autopsy in the pneumonic areas we failed to obtain the introduced micro-organisms. It is, however, probable in the light of our present knowledge of the mechanisms employed by the animal body to dispose of pathogenic and other micro-organisms, that no inconsiderable action must be attributed to the spleen, liver and bone-marrow.

It appears to be worth while to direct attention to the fact that in not one of our animals was a pseudo-membranous tracheitis observed, although evidences of inflammation were more or less common. This is probably to be explained by the assumption that the injury to the mucous membrane was too slight to afford a favorable opportunity for the development of the organisms in that situation, rather than that the animals did not live, or were not permitted to live, long enough for the membrane to develop.

III.

In order to study the development of the pathological lesions in the lungs, sections of these organs were studied in


and red blood corpuscles, through the alveoli. Arnold in particular has investigated this question and found that these substances are transported to and deposited within the neighboring lymphatic glands. Baumgarten" regards the transportation of bacteria and spores of fungi to be likewise of a purely mechanical nature. Moreover, he found that pathogenic bacteria were capable of being mechanically taken up in the same manner, in the absence of lesions of the alveolar lining; for the intra-tracheal injection of tubercle bacilli, killed by boiling, was followed by their passage in a few hours through the alveolar walls into the intrapulmonary lymph follicles.


the following manner: Beginning with the lungs of the animals killed one hour after inoculation, the succeeding ones were examined in a consecutive series. Sections were prepared from different parts of the organs; in those in which consolidation was apparent the hepatized portions were always included. The staining agents employed consisted of htemotoxylin and eosin, safranin in aqueous solution, and Weigert's fibrin stain. The last sufficed for staining the bacteria, as well as fibrin, when present or when capable of retaining the dye, which was by no means always the case.

The histological lesions in the animals killed after one hour were very inconsiderable and consisted of dilatation of the alveolar capillaries, extravasation of a few red blood corpuscles, the appearance of polymorphonuclear leucocytes in occasional alveoli and in the bronchial walls, more rarely in the lumiua of the bronchi in small numbers, perhaps an increase in the flat epithelial, nucleated cells within the alveoli, and more or less oedema. At the end of three and a half hours, on the other hand, the jiathological condition was well advanced. Small vessels, apparently arteries, contained fibrinous and leucocytic thrombi ; the congestion of the alveolar capillaries and larger interlobular vessels was a striking feature; the blood within the vessels contained an increased number of white elements, and both red and white blood corpuscles had begun to leave the vessels in relatively large numbers. The alveoli contain many cells of an epithelial habitus, and the fact of desquamation of the alveolar epithelium is made directly apparent. There exists at this time a definite purulent bronchitis. Branches of the bronchial tree which are still lined with columnar ciliated epithelium contain many polymorphonuclear leucocytes, and similar cells may be discovered working their way through the walls of the bronchi to reach the lumiua. The lining epithelium of these structures was never found to have suffered severely; no defects existed in this layer. A few cell fragments were seen amid the increasing cellular accumulations.

The animals which were permitted to live six hours showed much more advanced lesions. Up to this time the pathological changes have been limite'd to the interior of the bronchi and alveoli ; but now the stroma of the lungs begins to show changes. As a whole it is thickened, partly owing to oedema and partly to an increase in the cellular constituents. Many of the new cells are polymorphonuclear leucocytes, but among these are many cells with round, solidly staining nuclei which may have been derived from such leucocytes or have had a different origin. Fragments of cells begin to be more common in this situation and karyokinesis begins to be a]iparent. The capillaries, chiefly those in the alveolar walls, show large, somewhat diffusely staining, nucleated protoplasmic masses resembling giant cells. That these masses are the results of the fusion of intravascular white elements seems highly probable. The endothelium of the capillaries and small veins is swollen, but no actual injury was observed. The number of cells within the alveoli is much increased; they still consist of polymorphonuclear and epithelial elements in about equal proportions. Definite mitotic figures begin to be fairly common within the alveolar epithelium, and an occasionally nonnucleated (necrotic?) cell of this kind makes its appearance.


78




The bronchi contain much exudate, consisting chiefly of leucocytes with iiTegular nuclei, but mononuclear epithelial cells are also present, and a large amount of detritus derived by fragmentation from cell nuclei. Evidence of cell destruction to a slight extent is to be observed in the walls of the bronchi, and it not infrequently extends into and involves the lymph nodes imbedded in their walls. The lining epithelium shows little or uo injury. As regards the origin of the cells composing the exudate within the bronchi it may be said that the bronchial mucous membrane furnishes but few of the elements. They come almost exclusively from below, from the terminal bronchioles in which the lining epithelium is almost or quite fiat, and from the adjacent atria and air-sacs (Miller)." Specimens twelve hours old show still more clearly that the contents of the larger bronchi are excreted from below, inasmuch as the terminal structures give every evidence of a rapid filling up with cells, while the high epithelium of the former is quite perfect and the bronchial walls but little infiltrated with wandering cells. It is not alone the lumina of the bronchioles, the atria and the air-sacs which give evidences of increased cellular invasion; this is also appai-ent in the stroma as well. The much thickened stroma is overloaded with cells, having as a rule irregular and fragmented nuclei, and showing in addition, here and there, karyokinetic figures, some of which certainly would appear to be within the capillaries. Moreover, the air-cells springing from all these structures, terminal bronchioles, atria and air-sacs, are now more or less completely filled with cells, partly emigrated, partly desquamated from the walls. Fibrin is present in the form of fine fibrils, too fine ajij^arently to retain the Weigert stain, but yet evident upon close inspection. The consolidation of the lungs at this early stage is partial only, and more microscopic than macroscopic in form. Edematous foci and small areas of extravasated blood are intermingled. The pleura is still intact. The succeeding stages, that is, after 2-i, 47 and 65 hours, show appearances similar to those described, with such modifications only as involvement of larger areas and more perfect solidification might be expected to introduce. Adjacent to hepatized foci others of compensatory emphysema or insuiHation exist, and the cellular infiltration of the stroma, always a prominent feature after twelve hours, may involve the emphysematous parts. Ha3morrhages are never entirely absent and may become considerable in the cases of longer duration ; fibrin, never a very prominent feature, increases more or less;* multiplication of cells resembling the offspring of epithelial cells may be so rapid as in some places to be the sole elements within certain alveoli ; the pleura becomes the seat of small leucocytic accumulations upon its surface which are derived from the lung substance, the cells of which may be seen wandering through the endothelial layer, which itself remains intact. Fibrin was never


The lungs of the animal which lived 65 hours (Experiment 1) showed the greatest quantity of fibrin observed. The tissue which had been hardened in Flemming's osmic acid solution and stained in safranin was best adapted for the study of this material. The fl!)rin was found in fine threads and convoluted masses within the alveoli and the intralobular lymphatics. It was perhaps most abundant where the cellular accumulations were least marked.


discovered upon its surface. The extent of destruction of nuclei within the bronchial as well as in the alveolar exudates grows until in many places fragmented nuclei alone compose the consolidating material. In this respect the exudate differs from most of those with which we are familiar in the lungs in acute disease. Even where a whole lobe, or indeed a whole lung, apparently is hepatized, the consolidation is not complete ; the effect is brought about by the imperfect approximation of many foci of lobular consolidation.

The exjjerimental pneumonias following the intra-tracheal inoculation of pure cultures of the bacillus diphtheria; in rabbits are lobular or pseudo-lobar in character ; they are cellular pneumonias for the most part, fibrin playing a relatively inconsiderable role in their production ; they are rapidly developed and originate in the bronchioles, atria and air-sacs; the bronchi are but little affected in the early stages, and even later are hardly more involved than in the acute lobar pneumonias of human beings. The bacillus diphtheriae and its toxic products when introduced directly into the lungs exert their action primarily upon the blood-vessels; very soon, however, the alveoli themselves are deleteriously affected, and within the brief period of six hours the entire framework of the lungs feels the injurious influence. The expression of these effects is seen partly in the exudative and partly in the proliferative changes which ensue. Among the latter the appearance of cell division by mitosis after the lapse of only twelve hours seems worthy of special mention.

The relation of the bacilli to the lung structures is a simple one. Sections stained in Weigert's fibrin stain show, in those cases in which the duration of life of the animal did not exceed twelve hours, many of the characteristic bacilli. They were almost never free, but enclosed in cells, which were either distinctly mononuclear in character or large, flat and scale-like, without demonstrable nuclei, and certainly not of the nature of vascular leucocytes^ That they have come from the alveoli is certain, for similar cells crowded with bacilli may at times be found still attached to the walls. The study of the relation subsisting between the micro-organisms and the lungs shows conclusively that the invasion takes place from the bronchioles, and very soon the bacilli are discovered within cells in the stroma. Whether or not they were contained within definite vessels could not be determined with certainty.*

Within the bronchi the bacteria appear amid the cellular exudate sometimes enclosed within the scale-like cells mentioned, and again, but not certainly, within polymorphonuclear leucocytes. If actually englobed by the latter the process is not a very active one. That the polymorphonuclear leucocytes at times take up the bacilli in cases of human diphtheritic pseudo-membranous bronchitis we have already shown in our studies of the broncho-pneumonia of this disease."

After the lapse of 18 hours the bacilli are found only with difficulty in sections, and in instances of still longer duration


In this connection Miller's observation that lymph-vessels are not found in the structures of the lungs beyond the terminal bronchus is significant. The atria and air-sacs have no lymphatics in their walls."


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not ;it all. We did not discover the bacilli in aniuuils which had lived 24, 47 and 65 hours respectively.

BiP.LIOGKAPHY.

1. Frosch : Die Verlireitung des Diphthcriebacilliis im Korper des Menschen. Zeitschrift fiir Hygiene u. Infectionskrankheiten, XIII, 1893, 49.

2. Kolisko and Paltauf : Znm Wesen des Croups nnd der Diphtheric. Wiener klin. Wocheuschrift, No. 8, 1889.

3. Wright: Studies in the Pathology of Diphtheria. Boston Medical and Surgical Journal, October 4 and 11, 1894.

4. Loeffler : Untersuchungen iiber die Bedeutung der MikroOrgauismen f iir die Entsteliung der Diphtheric beim Menschen, bei der Taube und beim Kalbe. Mittheilungen aus dem Kaiserlichen Gesundheitsamte, II, 1884.

5. Kutscher: Der Nachweis der Diphtheriebacillen in den Lungen mehrerer an Diphtheric verstorbener Kinder durch gefilrbte Schnittpriiparate. Zeitschrift fiir Hygiene u. Infectionskrankheiten, XVIII, 1894, 167.

6. Wright and Stokes: A Keport on the Bacteriological Investigations of Autopsies. Boston Medical and Surgical Journal, March 31 and 38 and April 4, 1895.

7. Belfanti : Snlle Broncopolniito Difteriche — studio batteriologico od anatomo-patologico. Lo Spieri men tale, XLIX, Sezione Biologica, 1895, 278.

8. .Johnston : Notes on the Bacteriological Study of Diphtheria. Montreal Medical Journal, Septembei', 1891.


9. Strelitz : Zur Kenntniss der im ^'erlaufe der Diphtlurien auftretendeu Pneumonien. Arcliiv f. Kinderheilknnde, XIII, 1891.

10. Booker: As to the Aetiology of Primary Pseudo-membranous Inflammation of the Larynx and Trachea, with iiemarks on the Distribution of Diphtheria Bacilli in Organs of the Body distant from the seat of local Infection. Archives of Pediatrics, August, 1893.

11. Flexner: Diphtheria with Broncho-Pneumonia. Bulletin of the Johns Hopkins Hospital, IV, 1893, 33.

13. Kanthack and Stephens : The Escape of Diphtheria Bacilli into the Blood and Tissues. The Journal of Pathology and Bacteriology, IV, 1896, 45.

13. Hildebrandt: Baumgarten's Lehrbuch der pathologischen Mykologie, II, 1890, 455.

14. Fliigge : Die Microorganismen, etc. Leipzig, 1886, p. 605.

15. Muskatbliith: Neue Versnche iiber Infection von den Lungen aus. Centralblatt fiir Bacteriologie und Parasitenkunde, I, 1887, 331.

16. Miller: The Structure of the Lung. Journal of Jlorphology, VIII, No. 1.

17. Baumgarten: Lehrbuch der iiathologischeu Jlykologie, I, 406, Anmerkung 114, 1890.

18. Miller: The Lymphatics of the Lung. Preliminary paper. Auatomische Anzeiger, XII, 1896.

Winter, 1896.


THE BACTERIOLOGY OF PERTUSSIS.=^=

By Henry Koplik, M. D., New York.


Pertussis is a disease which has long been suspected or known to be communicable from individual to individual, and it is not surj^rising to And that various authors have approached the subject of its etiology in divers ways. The sputum seems to have been the principal subject of study, and bacteria and protozoa in the sputum have been selected, each in turn, as etiological factors. I need only mention the names of Deichler, Kurloff, on the one hand, Letzerich, Burger, Affauassjew, Bitter, Cohn and Neumann on the other, to recall to the mind a whole series of studies on the sputum, the one dealing witli protozoan-like bodies in the siJutum, the other with bacterial forms. In my own work, which has spread itself at intervals over several years, and lately culminated in the study of a series of cases of pertussis, I have directed my attention to the bacterial forms esj)ecially found iu the sputum. I will not go into details here of my studies in other directions iu this disease, such as bacterial studies of the blood, for they have led to no results. If we look over the literatute mentioned above we may safely divide the communications on bacterial forms into two distinct sets : those which, like the work of Letzerich and Burger, were carried


Read before the Johns Hopkins Hospital Medical Society, February 21 , 1S98.


out without the aid of modern methods, and in which the instruments used were what we would call primitive ; and those which can be judged to day, inasmuch as the methods employed were modern, such as those of Afanassjew, Szemetzchenko, Cohn and Neumann, and Ritter. Of those mentioned I will consider at length only the work of Burger and Afanassjew. Burger,* by means of a Seitz dry lens, 340 diameters, describes a bacillus or'bacterium which he could easily see and which he calls biscuit form. He saw these in rows and chains and small rods twice as long as they were broad. He mentions distinctly that he found these bacteria in the flocculi of the sputum. It seems at this distance that it would be asking too much to decide just what Burger saw iu the sputum of his cases, more especially as it is now known that both diplococci and bacilli of various varieties and size exist in this sputum. We miss unity in Burger's description. He did not isolate any one form, and from his description may have had several forms in his Held when he studietl the sputum, thinking they were all a single form.

Afanassjew's work appeared in the St. Petersburg Med. Wochen., 1887. Czaplewski and Hensel, who do me the great honor to agree with me in my conclusions, admit that


Berlin, klin. Wochen., 1883.


80




they have not had access to the origiaal work of Afanassjew. In view of this fact I will quote from Afanassjew's original article.

Afanassjew describes the sputum of pertussis as a transparent mucus in which are seen grayish white spots of the size of a pin's head. In the mucus of the sputum are seen bacteria and short, small bacilli, single or in pairs, at times in chains of no great length, arranged in the direction of the mucus of the sputum ; at times in small groups. The length of these bacteria is 0.6 to 2.2 micro-millimeters, and are easily overlooked with low powers, and can only be distinctly seen with higher powers. "For this reason," says Afanassjew, " I doubt whether Burger has seen the bacterium described by me in the sputum, inasmuch as he says that he saw them distinctly with 340 diameters. I have made use only of powers magnifying 700 to 1000, with Zeiss ocular 3 and 4, and immersion y^j with the tube drawn out." Afanassjew describes his bacteria as follows : " In gelatin, after two or three days, we find round or oval colonies, light brown with even borders, also oval colonies with a darker centre. The youngest colonies were almost colorless, but slightly granular, and did not fluidify the gelatin."

He also describes colonies of a thicker shorter bacillus, which in passing I may say may have been a contamination of his cultures. The bacillus described by Afanassjew grows at the temperature of the room, slowly, or more rapidly, at 38° C. or 37° C.

"Agar stick culture gives on the second day on the surface around the puncture a cloudy gray flat growth, transparent, glistening like a drop of fluid. In the following days the surface culture becomes more and more opaque and whitish gray."

"Gelatin stick gives a slower growth, thinner, on the surface flatter, grayish white with irregular edges; later on the edges become whiter and form a nail-head which is dry and rarely reaches to the periphery of the tube. The stick itself is not characteristic."

"Blood serum gives a grayish or whitish growth similar to the agar."

"Potato gives rapid ahtmdant yellowish, and after brownish growth.^'

"In bouillon or hanging droj) we find the bacteria are alive, move very rapidly, inasmuch as they perform bobbing circular movements which soon cease."

" In the bouillon the bacteria grovv in small threads."

I think in this article we may fairly leave out of consideration the work of Cohn and Neumann, and also of Eitter, which are chiefly concerned with the consideration of diplococci not clearly identified, and pass on to the recent work of Czaplewski and Hensel. The work of these authors was made known first through a preliminary communication in the Deutsche Med. Wochen., 1897, No. 37, and in the Centralbl. fiir Bacteriol., Dec. 32, 1897. They had worked upon over 44 cases of pertussis (an epidemic), in 18 of which they isolated what they call a polbacterium or bacillus, reminding one very much as to size of the influenza bacillus, if not smaller. The bacterium is, according to their view, not motile in itself. There was a slight motility in fresh bouillon


cultures, which they were inclined to interpret as a Brown's molecular movement, but no independent movement of their own over the whole field of view. Gram stain did not decolorize fresh cultures, though it did the sputum.

The bacterium grew on Loeflier serum, agar, gelatin (nonfluidifying) bouillon, but not as yet on potato.

Loeflier serum gave an uncharacteristic grayish white growth ; agar a delicate gray growth of transparent confluent colonies. On agar involution forms are described.

On gelatin it does not fluidify the medium, stick is not characteristic, and is made up of delicate whitish yellow granules like streptococci.

In bouillon we have cloudiness after a day and a sediment in the bottom, which on shaking resolves itself into thready slimy masses.

There is no mention in the work of Czaplewski and Hensel of the isolation of their bacillus in pure culture by means of plates and colony inoculation.

My own bacterial work on the sputum of pertussis was first read before the British Medical Association, in the latter part of August, 1897, and published subsequently in the British Medical Journal and the Centralblatt fiir Bakteriologie, 1897, Band XXII, Nos. 8-9.

In this communication I described a series of cases examined during the winter and spring of the same year. There were sixteen cases, and since then I may say I have been examining other cases with identical results.

The sputum was collected during a paroxysm of coughing in sterilized Petri dishes and allowed to stand a short while. The sputum separates in these cases into a glairy colorless mucus, in which are distinctly seen small grayish white particles like the scales of dandruff. These particles were fished out with a platinum needle, and without being subjected to further manipulation, such as washing, were sown in the media employed. In uncomplicated cases the above pellets of sputum are easily recognized, but if bronchitis or pneumonia complicates the case the sputum is more purulent and thick and does not separate as described. I also made use of hydrocele fluid, obliquely solidified at 65° C. to 70° C, in a transparent solid medium in test tubes, as my medium for cultivating this bacterium. I found and still think this medium especially fitted for the cultivation and isolation of the bacterium or bacillus described by me. I think this is due to the fact that hydrocele fluid is a poor medium for most bacterial species and favorable to the one interesting us. I made use of all the other media, but found that it was necessary to use the hydrocele fluid first to get the crude culture en masse, and from this to inoculate other media and make plates. I will not detail individual cases, as this has been done elsewhere, but will desci'ibe the bacillus isolated by me.

7'he Spvtum. If a small grayish white pellet of the sputum of the convulsive stage described above is spread between two cover-glasses stained with Loeffier blue or fuchsin and examined, we see as a constant element a small exceedingly minute bacterium, either singly arranged in the direction of the striae of the sputum or in small colonies ; it may be seen in the epithelial cells or on the epithelial cells, or free, or in the meshes of the sputum. This bacterium or bacillus is so thin and



iACirxrs Peutussis in the Sputum. Fuchsin staiu x 580. Zeiss aiiparatus immersion J,,.



Peuti ssis Bacillus. Puke Cultuue. Loeffler serum x 580 diameters. Zeiss apparatus ' immersion.


ruE .loilNS noPK[.\s Hn


^^m.


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small as to be quite easily overlooked even with a -^ immersion, and in zoogloea it looks like a collection of cocci. Close study of the zoogloea reveals the fact of bacillary form. In cases not complicated by bronchitis or pneumonia these minute bacteria or bacilli are the only forms to be seen. As soon, however, as bronchitis or pneumonia sets in, other bacterial forms occur in the sputum and can be seen, and this will partly explain the difficulty of former workers in isolating this bacillus. If a small grayish pellet of the sputum be spread on obliquely solidified hydrocele fluid, or hydrocele fluid f and glucose bouillon i, we obtain after a lapse of 24 to 48 hours in the incubator at 37° C. to 38° C. a mixed bacterial growth of a whitish or transparent gray color. A small part of this is suspended in bouillon according to Loeflier, and then a few platinum loops of the mixture spread on another hydrocele tube. In this way isolated colonies may be obtained, or agar plates may be made in the usual way from the whole growth. In this manner we find that the bacillus grows in pure culture on hydrocele fluid as a delicate grayish white or pearly growth. If sugar bouillon is added to the hydrocele fluid the growth is thicker, not so delicately transparent and more of a creamy color.

On agar we have at first a delicate grayish white growth, which in time becomes thicker and whiter and more opaque. If the agar is white and made with beef extract, the growth is very delicate, grayish and not so white. Colonies in agar are whitish or grayish white by reflected light, of a straw color or deeper olive tint by transmitted light. They are irregularly round or oval.

In gelatin there develops at the room temperature and quite slowly a fine granular stick, whitish, much like that of streptococci. It has a nail-head and does not fluidify the gelatin. Colonies in gelatin have a round or an irregularly round form, whitish yellow by reflected and straw colored or olive colored by transmitted light. They are finely granular. The colonies do not become very large.

In pepton bouillon we have a finely granular appearance after 24 hours and a cloudiness ; after a time we have a sediment in the bottom of the test tube which is made up of small adherent masses. After a week or more the surface of the bouillon becomes covered with a thin sediment membrane which is made up of bacilli.

On Loeffler's diphtheria serum we obtain a whitish growth, reminding one much of the diphtheria growth.

On potato I have not as yet succeeded in obtaining a growth.

On human blood serum which is solidified on the surface of agar, we have a grayish white and abundant growth after forty-eight hours.

It should be here pointed out again that on agar the growth is delicate, grayish, transparent, and sometimes stops growing after a time, never being vigorous if the agar is clear and made of beef extract instead of beef juice. If agar is browner and made with beef juice the growth after a time is seen to be white, almost of an opaque pearly color; after a time, this difference in growth of agar tubes I could well convince myself of when recently working with pure culture obtained by plate colonies. This latter peculiarity will explain why Czaplewski and Hensel talk of a delicate growth on white


agar when mentioning my agar appearances. Cultures and threads which have been allowed to stand in closed tubes for six months are found to be dead and cannot be reinoculated on other media.

The bacterium or bacillus which I have isolated in pure culture and which has the above cultural characteristics, grows anaerobic as well as aerobic.

If stained with LoeflBer blue it appears as an exceedingly minute, delicate, thin, short bacillus form, much thinner than the diphtheria bacillus and not more than i to * its length. It measures 0.8 to 1.7 micro-millimeters in length, and 0.3 to 0.4 micro-millimeters in breadth. When stained with Loeffler blue it has a finely punctate appearance like the diphtheria bacillus, but here the resemblance stops, for it is a much more minute bacillus. In pure culture it is not decolorized by Gram stain. Old cultures on hydrocele and agar show clubshaped forms, the bacillus has a deeply tinged extremity like a club — in other words, involution forms exactly similar to the bacillus diphtheria3. Of course the involution forms are exceedingly delicate and show much smaller than the bacillus diphtherias.

The nameof " pol-bacterium " has been proposed for this bacterium by Czaplewski and Hensel in their article in the Centralblatt fiir Bakteriologie. The pol staining of this bacterium cannot be compared to such distinct pol-stain as that of a chicken-cholera bacillus (Kitt), rabbit septicemia (bacterium bipolar), where the extremities of the bacterium are deeply stained and rounded, and there is a distinct square space in between the poles unstained. The staining of our bacterium is exactly identical with that of the influenza bacillus when stained in pure culture with method blue of Loeflier. The bacterium or bacillus of pertussis stains deeply at the extremities and there is an irregular space or two irregular spaces in the long axis of the bacillus unstained or lightly tinged when stained with methyl blue of Loeffler. Some of the extremities are rather swollen, most of the extremities or poles are round, others are lancet shaped. I have never been able to convince myself by any known methods that this bacillus has spores or flagella.

AfotiUti/. In my first communication I said this bacillus was motile. By this 1 simply meant that in the hanging drop it was seen to have a rapid bobbing circular motion in a very circumscribed area of its own. In some fresh bouillon cultures this very limited motion was active for awhile and then ceased at the room temperature. I think that some would be inclined to deny that this was a movement inherent in itself inasmuch as the bacilli never traversed the microscopic field. I am quite willing to admit that this movement might be classed with cocci movements (Brown's molecular movements).

Animal Experiments. In my first paper I showed how fruitless animal experiments with this bacillus were. It is patho(^euic to mice in large amounts of a J to 3 cc, but in no instance was I able to reproduce symptoms of a disease similar to whooping cough in the lower animals. I think as I did then that accidental inoculation of the human subject could alone enlighten us. It would be going too far to make any such experimental inoculations.


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From tlie above it will he seen that from the sputum of pertussis cases in the convulsive stage, Gzaplevvski and He.usel and I, independently of each other, have isolated pure for the first time a bacterium which is constant and found inuo other sputum. This bacterium fs especially characterized by a minuteness comparable only to the influenza bacillus (Pfeiffer) or that of septicemia of mice (Koch). In staining the dotted (not granular) appearance spoken of by me and compared to that of the bacillus of diphtheria, can best be brought out by the LoefHer alkaline blue stain. Fuchsin stains more coarsely and more uniform. The swollen end forms, or as I call them the involution forms, can also be brought out by LoelBer blue stain. I wish to point out here also that both in my first paper and in this I worked with pure cultures only (obtained by means of plate colonies). In this perhaps we find a reason why authors who have preceded the communications of myself and Czaplewski and Hensel differ so widely in what they saw. They failed to obtain the bacterium in pure culture. It may be remarked in passing that in my second cases as well as in some of my first cases there could be found among other bacterial forms a bacillus closely resembling the bacterium isolated in this work. This latter is somewhat thicker, grows in longer chains and fluidifies gelatin. I am inclined to think that observers have hitherto been much baffled by this bacillus, which I think with Czaplewski and Hensel is simply accidental. Such must have been the case of Cohn and Neumann.

I have tried to isolate my bacillus or bacterium in the early stages of pertussis before the convulsive paroxysm has ajipeared, and have not succeeded thus far in separating it from the saliva.

What significance can we attribute to the bacterium which is the theme of this paper? I doubt whether this can be solved e.x;cept by direct experiment on the human subject. I


may not be going too far to predict that the bacterium will aid us in understanding the mode of contagion in pertussis. It may be the first definite step in showing that in the sputum of the pertussis sufferer lies the danger of the communication of the affection to others.

Discussion.

Dr. OsLER. — I would ask Dr. Koplik if he has followed a case through from beginning to end and whether there is any difference in the abundance of bacilli during the early and late stages. Some have held that the disease was more infectious in its early stage.

Dr. Koplik. — I would say that I have tried to make a diagnosis of pertussis before the convulsive stage appeared. I could not find the bacillus in the mouth. The bacilli seem to be most abundant in the convulsive stage, but I did not follow up the study to see whether they persisted in the stage of convalescence.

Dr. Welch. — I notice that Dr. Koplik spoke of the staining in his first paper as granular, and Czaplewski supposes that he means polar staining. In Czaplewski's photograph the polar staining is none too definite, and he uses almost altogether carbolic-geutiau-violet, which gives an irregular staining with many bacteria. I would ask if this is a polar staining like that of chicken cholera, or an irregular staining as of the diphtheria bacillus.

Dr. Koplik. — I would classify it as more like the irregular staining in diphtheria. I think that the bacteria are more like the diphtheria organism than a real jjolar bacteria.

Dr. Sternberg. — It seems to me that the photograph does not show an extremely minute organism such as the influenza bacillus for example.


SUPPLEMENTARY REPORT ON THE STERILIZATION OF INSTRUMENTS BY FORMALDEHYDE.

By H. 0. Keik, M. D.


The December number of this Bulletin contained an account of the work performed by Dr. Watson and myself with formaldehyde gas, and we stated then that Meyrowitz of New York was making for us an apparatus especially adapted for the use of this method of sterilization. The accompanying cut represents the sterilizer referred to and which I am now using in my daily work. It is of a size suitable for the ophthalmologist, otologist, laryngologist, or other surgeon who uses comparatively small instruments. Should the general surgeon or the obstetrician desire to adopt the method, a larger sized sterilizer can be readily made and special appliances may be inserted for holding the particular instruments used by him ; as for instance there is figured in the illustration a small tray for carrying such delicate instruments as the cataract knife, etc., so as to prevent their cutting edges from coming into contact with anything.

The sterilizer which I have adopted for myself is 7x13x13 inches, giving an air space of a little more than 1000 cubic inches. The shelves are made of lieavy, wide-meshed wire gauze, the upper one extending entirely across the chamber, while the lower two are only eight inches long, extending from


the right side to an upright standard four inches from the left wall, thus leaving a space four inches wide by eight inches



high which is reserved for the Sobering lamp used in vaporizing the pastilles.


April, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


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lu the rejiort of our work we called atteutiou to two features in the sterilization of instruments by this method which we thought required further study. The first related to the question of the deposit of paraform on the instruments and the possibility of such a deposit retarding the healing of wounds. The second was the possible effect of the gas upon the cutting edge of the instruments.

I think we are able now to give positive answers to both problems. 'Since receiving my new apparatus I have rejieated all the bacteriological experiments quoted before and with the same results published. I have further exposed instruments to five and six successive sterilizations by the gas, without any washing or cleansing whatever, and at the end of the experiments I was not able by the naked eye to discover any deposit whatever, nor was there any taste of the gas when the instrument was ajiplied to the tongue. A cataract knife so exposed was used in makinsr a corneal section on the rabbit. Healiusf


of the wound took place as usual when a sterile knife is used. Blunt instruments so exposed and then applied to my own conjunctiva produced no irritation.

As to the question regarding the edges of the knives, I tested very cai'efully their sharpness by means of the kid drum, both before and after sterilization, and 1 am not able to discover that the gas affects this in any way. To see whether or not the gas would affect instruments made of other material than steel, I repeatedly exposed the following instruments to the action of the gas: knives with aluminum handles, knives with ivory handles, a hard rubber syringe, soft rubber catheters, a Politzer air bag, and a nickel-plated syringe. None of these objects were in any way affected by the gas.

My conclusions are then that we have in this method a rapid, cheap, easy and sure method of sterilizing instruments without in any way injuring them.


CORRESPOi^DENCE.


DOES WILHITE'S STOKY OF THE NEGRO BOY INCIDENT IN THE DISCOVERY OF ANESTHESIA "LACK PROBABILITY"?

Letter from Dr. Wilhite. To THE Editor: —

My attention has been called to the article published in the August and September issue of this Bulletin from the pen of Dr. Hugh H. Young, Assistant Resident Surgeon Johns Hopkins Hospital, entitled "Long the Discoverer of Ansssthesia."

The writer has in a very interesting manner restated a part of the much discussed history of anaesthesia. I shall then not tax the reader's patience by another recital. Having been an interested spectator as well as a listener at the semi-centennial in Boston, October 16, 1896, of the aUeged first discovery of anaesthesia — at which meeting quite a number of distinguished men of the medical profession, representing different parts of the United States and elsewhere, demonstrated to their entire satisfaction and others that Morton was entitled to the glory aloyie of this discovery — I would have been content to let the matter rest, so far as I am interested, but for the article of Dr. Young, wherein some reflections are cast upon the memory of my deceased father. Dr. P. A. Wilhite, whose statements in New York, 1876, gave rise to the article of Dr. J. Marion Sims, published May, 1877, in the Virginia Medical Monthly. From my youth I have been conversant with the facts as related by my father ; and as he was the life-long friend of Dr. C. W. Long, as well as an enthusiastic supporter of Long's claims to the discovery of anajsthesia, I have been puzzled to understand why twenty years after Dr. Sims' article has appeared, and after Sims, Long and Wilhite have passed beyond the realm of controversy, labored efforts should now be put forth to throw doubt upon Wilhite's statements that first awakened interest in Long's claim, when the only errors


of which Dr. Long himself complained to Wilhite were the mistake made in the date when he and others entered Long's office, and of being present at the first or second operation by Dr. Long, and of saying that the first inhalation of ether in Jefferson was before the same persons. Dr. Young is charitable enough to admit that Long never mentioned this incident as being one of the mistakes in Wilhite's statement. I feel that injustice to the memory of Dr. Wilhite has been done, and that I ought not to permit some of the statements made by Dr. Young on this subject go unnoticed.

In a private letter from Dr. Young I am led to believe that it was not intentional on his part to do injustice in the matter to Dr. Wilhite, and that "his information came largely from papersof Dr. L. B. Grandy, of Atlanta." Since his information comes from Dr. Grandy, whose article was published in the Virginia Medical Monthly, 1893, and since he has courteously invited me to criticise his article and present documentary proof concerning Dr. Wilhite's claims, I will not be regarded a naked trespasser in this fertile field of controversy. Now, let me state at the outset. Dr. Wilhite never claimed to be the 'discoverer of anaesthesia, only so far as being the first one to produce the full ancesthetic effect of sulphuric ether accidentally, and it was only at the earnest solicitations of friends that he placed himself before the medical profession in 1883 to receive such honor as might be due him ; neither did he in any way seek to detract one iota from the honor he believed justly due his old preceptor and friend, Dr. Long. What he claimed then was that on one occasion while a boy at a country frolic in Georgia, he with others caught a negro boy, and while the others held the boy, he (Wilhite) administered to him sulph. ether, rendering him unconscious, etc., so much so that a doctor was sent for to revive the negro boy, and that when studying medicine under Dr. Long he related to him the circumstance. It would seem from recent attacks that Dr. Wilhite's offending consisted mainly in making a statement from "recollection" to Dr. Sims in New York that he was a student under Dr. Long and witnessed the first operations, and further, when a boy about seventeen years old he accidentally etherized a negro boy at a frolic in 1839, when the


84




year, as we shall see, was 1841. lu order to make it ajjpear that the 'story "lacks probability" the date of a letter is shuffled from January 27, 1877, to June 27, 1877, which Dr. Young states is a reply to a letter from Dr. Long, of May 20, 1877, and his daughter is quoted as giving the information that her father " repeatedly told her that he had never heard of it before it appeared in Sims' article." (I shall now take the liberty to refer to his (Dr. Y.) source of information by reference to Dr. Grandy's article, etc.) Dr. Grandy in his article, speaking of Mrs. Taylor's statements, says : " She tells me that the above story was related (italics mine) to Dr. Long by Dr. Wilhite himself in the presence of several of the family, when Wilhite was on a visit to her father's house in the spring (italics mine) of 1877. After hearing it. Dr. Long replied, " Doctor, this is the first time I ever heard of it." Now I submit that Dr. Wilhite's visit to Long, in Athens, was after the publication of Sims' article. Dr. Young says: "The ether controversy was never re-opened and Long's work was unknown to the world until 1877, when J. Marion Sims, hearing of him throtigh accident (italics mine), investigated his claims, was fully convinced of their merit, and vigorously demanded their recognition by the medical profession. His paper appeared in the Virginia Medical Monthly, May, 1877." Then he says again : " This article which obtained for Long the first recognition of any consequence was the outcome of a conversation which Sims had with a Dr. P. A. Wilhite, of Anderson, S. C. (italics mine). He summarizes the statements of Wilhite to Sims, and adds : "Dr. Sims at once communicated toith Dr. Long and soon convitued himself of the truth of his claim, but tin fortunately failed to investigate Wilhite's satetments, but embodied them in full in his article, giving Wilhite the credit of first inlentionallg produci7ig profound ancesthesia with ether " (italics mine). How does Dr. Young know that Dr. Sims never investigated the negro boy story? Does he not state: "Sims sailed for Europe soon after the publication of his article, and Long died in a few mouths, and Wilhite's statements went unchallenged for many years " ? Let us see what Grandy said in 1893. "Sims' article appeared in May, 1877, and Long at once noticed the errors and the absence of promised corrections. He requested Sims to correct the mistakes, but the latter replied that the 'misplacement of a few names and dates would not alter the main facts in the case.' He sailed for Europe in a few days and the matter was dropped." Now as a matter of information and to know when Sims did sail for Europe, I have in my possession a letter from his son which reads as follows :

New York, September 28, 1897. 30 West 58th Street. My Dear Doctor:— On account of nay absence from the city your letter of the 2l8t instant was not received until to-day. In May,

1877, my father was to have sailed for Europe on the Celtic

He and I went to San Francisco in June of that year. He returned here and sailed for Europe some time in July, about the latter part. . . . Believe me, yours sincerely,

(Signed) H. Marion Sims.

Why would Sims have needed to investigate Wilhite's statements further than to write to Long for the facts ? Did not Long send them? See the letter hereinafter quoted. Dr.


Young further states : " The negro boy story lacks probability, as Wilhite did not enter Long's office until 1844, two years after the first operation, as the following letter from Long to Wilhite shows." Now I admit that the letter shows this : Wilhite did not enter Long's office until 1844 and therefore he was not a student in his office in 1842 when the first operations were performed. I challenge Dr. Young to point to one word or sentence in that letter quoted to show that the negro boy story "lacks pi-obability." In order that the -reader may see the point 1 make, I quote the letter as published by Dr. Young:

Athens, Ga., May 20, 1877. Dr. p. a. Wilhite.

Dear Sir: — I received Dr. Sims' article on aniesthesia yesterday and find several mistakes. Dr. Sims states that yourself, Dr. Groves and Drs. J. P. and H. R. J. Long were students of mine and witnessed the operation performed on Venable, 1842. Your recollection failed you at this time, as it was several years, at least two, before either entered my office. You will see that you were mistaken in giving Dr. Sims this information. You also make a mistake in saying that the first inhalation in Jefferson of ether for its exhilarating effects was before the same persons. . . . I wrote to Dr. Sims informing him of the errors and asking him if he considered the mistakes of sufficient importance to be noticed, etc.

(Signed) C.W.Long.

Dr. Young has the candor to say, "In the letter to Wilhite, Long makes no comment upon the negro boy incident." Then why should he say it "lacks probability" from that letter? He, I submit, does injustice by quoting a letter of Dr. Wilhite in that connection to Dr. Long, making it appear that the letter bore date June 27, 1877, and states that it was a reply to Dr. Long's letter of May 20, 1877. I will quote this letter later on in its proper connection, and I am satisfied that he will see its inapplicability to his assertion. Now his proposition is that the negro boy incident "lacks probability." That is the question at issue and he has assumed the affirmative, and the burden of proof rests upon him. I am not called upon to prove a negative. The only thing he has relied upon is the letter quoted and the statements of Dr. Long's daughter, "but his daughter informs me that he repeatedly told her that he never heard of it before it ajipeared in Sims' article." Before impartial judges I submit he has not made out his case and established his proposition. The letter does not do it, for even admitting for the sake of argument that Long never heard of it until he saw it in Sims' article, or never heard of it himself as told to him in the spring of 1877, does not establish its improbability. I might rest the matter here but for the imputation cast upon Dr. P. A. Wilhite's veracity by the proposition, and this I must be permitted to defend. It needs none in South Carolina where he was known, but your Bulletin is not local. It goes among gentlemen who did not know him. It is true that he was a country physician; but in this dawn of the twentieth century the old Pharisaical question, "Can anything good come out of Nazareth?" should be discarded and the Nazarene's command, " Render unto CiBsar the things that are Csesar's," should take its place.

" Honor and fame from no condition rise ; act well your part, there all the honor lies," might have been justly said of Dr. P. A. Wilhite in his limited sphere of action. He spent his life in


April, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


85


the interest of suffering humanity, and when the summons of death came, June 25, 1893, "he wrapped the drapery of his couch about him like one who lies down to peaceful dreams." Neither envy of men nor their sneers will disturb his repose. He eschewed politics and practiced medicine in Anderson, S. C, for nearly forty years upon his merits. The People's Advocate, a newspaper published in the city of Anderson, June 37, 1893, said : " In the death of Dr. P. A. Wilhite, Anderson loses one of her best citizens, liberal and progressive in his nature and upright in character. . . . He was one of our most noted physicians, was esteemed by all classes, and the whole city is in sorrow over his death." . . . The Anderson Intelligencer said: "Dr. P. A. Wilhite, one of the oldest and most skillful and most highly resjjected physicians in this portion of South Carolina, departed this life at his residence this morning. ... In 1878 Dr. Wilhite was appointed a member of the State Board of Health, then created by act of the Legislature of this State, and remained an active and influential member of the Board until his death." .... I might add further extracts from the press, etc.; suflice it to say that neither of these notices was written by relatives, but such is a part of testimony and tribute paid his memory publicly by those with whom he lived and for whom he lived for upwards of forty years. He was born in the State of Georgia about two miles of Danielsville, June 6, 1833 (" Dr. Long in Danielsville"), Dr. Long being about seven years his senior. Dr. Grandy says, " Up to the time of Dr. Long's death the relations between himself (Dr. L.) and Dr. Wilhite appeared to have been very friendly." His daughter had stated that Dr. Wilhite was a visitor to Dr. L. in the spring of 1877. The writer well remembers this visit, as he was an inmate of Dr. Long's house for a long time as a boarder, was then a student in Athens and was frequently in Dr. Long's private place of business, as well as a visitor in the family circle, and he knows of his own personal knowledge that the relations of the two men were friendly and cordial. This was before and after Sims' article appeared, and therefore 1 insist the letter quoted by Dr. Young from Wilhite to Long as of June 37, 1877, is incorrect, for it was not far from about that time when Wilhite visited Long. During this visit I was with my father and Long a great deal of my time and heard them discussing the facts, and to the best of my recollection there was no disagreement as regards the negro boy incident. The letter quoted by Dr. Young from Long to Wilhite shows that Long had then (May 30th) received and read the article, had written to Wilhite about the inaccuracies of dates and persons present, and had never once mentioned the negro boy incident, as Dr. Y. says. The reader will observe the .... (omission) in the letter quoted. Just what was left out I do not know. Until Dr. Grandy's article appeared the statement of Wilhite has not been questioned so far as I know by Long's friends. That Wilhite enjoyed the personal friendship and esteem of both Long and J. Marion Sims is abundantly shown by the visits paid them and their private letters still in our family.

That Wilhite was mistaken as to the true date of etherizing the negro boy, and as to the time he entered Long's office, there is no doubt. He made the statement from memory after


a great number of years in a casual conversation without any memoranda before him. Now let me quote some of the correspondence that bears on this subject :

267 Madison Ave., New York, January 12, 1877. My dear Dr. WmUe:—! wrote to Dr. Crawford W. Long, of Athens, three weeks ago, asking him to give me some notes of himself and special data about his discovery of ether as an anaj.-thetic. He does not reply to my letters. Will you have tlie kindness to write to him and say that I am to prepare a sketch of his life for Johnson's Cyclopedia and would like to have all the facts as soon as possible. Please help me in this matter, and with kind regards to all, believe me, dear Dr. Wilhite,

Most truly yours, (Signed) J. Marion Sims.

Admitting the genuineness of the letters published by Dr. Grandy, Dr. Wilhite wrote upon receipt of this letter as follows :

Anderson, S. C, January IG, 1877. Dr. C. W. Long.

Dear Doctor : — I have just received a letter from Dr. J. Marion Sims of New York, stating that you will not write to him, or at least that he wrote to you about three weeks ago and received no reply. If you don't do so soon it will be too late. He lias been preparing an article for publication, and wants to place you right before the world. You have been apprised,! suppose, of the nature of the article. Why you have been connected with, and will be the leading spirit in the article, tiappened (italics mine) in this way : While I was in New York last summer at one of Dr. Sims' private operations, several prominent physicians being present, I tiappened to remartc that I witnessed the first or second operation ever performed under an ancesttietic. Every one said I was mistaken, and particularly Dr. Sims .... After that I met Sims at his office and gave him such particulars as 1 could recollect of your first operation and also urged yourclaims to the priority. He at once wrote you on the subject and has since become very much interested in the matter. Now, Doctor, it is but justice to you (italics mine), as it is due the world, that you give Dr. Sims such information as he asks for at once, as he is going to all this trouble only to place the proper credit of this great discovery on the man who justly deserves it. 1 honestly hope you will comply with the Doctor's request as soon as possible .... As I have been the means of giving this investigation of thi-i subject its present shape, I am exceedingly anxious that you should give all the information you can, that you may, and justly too, receive the credit of this great discovery. If you will act it will certainly be so. Dr. Sims also wants a short history of your life, which don't fail to give. Hoping to hear from you, I remain,

Y'ours, etc.,

P. A. Wilhite.

I have italicized some of the letter to call attention to the fact that Wilhite was urging Dr. Long to give the facts. The reader will notice that in publishing this letter Dr. G. did not publish it all, as shown by the .... in two places. Dr. G. says to that long letter Dr. Long replied. Here is a copy of his reply never before published and is in my possession :

Athens, Ga., January 22, 1877. Dr. p. a. Wilhite.

Dear Sir : — Your welcome letter of the Itith instant was received a few days ago and I have been too busy to answer it earlier. I regret that my situation was such that I could not write to Dr. Sims earlier. I made a full explanation in a note mailed him before yours was received. This morning in sending off some certificates obtained some years since I find a number lost, yours among


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the number. Now, Doctor, I wish to obtain yours again as early as possible to send to Dr. Sims.

I see from your letter that you stated to Dr. Sims and other physicians that you witnessed an operation by me under an anaesthetic before any published account of the use of ether to produce this effect.

My recollection is that you entered my office late in 1844, and that early in January, 1845, you were present and witnessed me perform an amputationof a linger of a negro boy belonging to Ralph Bailey, Sr., the boy etherized at the time. I am not positive this was the operation, but as I have the certificates of Mr. Bailey and his son and sons-in-law, who werepresent at this operation, I think this must have been the operation you a!lu<led to. I have mentioned these facts to refresh your memory if you have forgotten names and dates. The correct date of the operation was 8th of January, 1843. If this was the operation alluded to you can from these circumstances give correct report of the operation.

Tou may recollect some other operation ; if so, state the facts in regard to it ... .

Permit me to thank you for the interest you take in estailtshing my claim. If it is established you will have been the mover in it. (Italics in this letter mine.) Yours respectfully,

(Signed) C. W. Long.

Admitting the letter as published by Dr. Graudy, AVilhite replied. I will put this letter iu a parallel column with the letter Dr. Young quotes as beiug written June 27, 1877, in reply to Dr. Long's letter of May 20, 1877.


(Young)

Anderson, S. C, June 27, 1877. Dk. C. W. Long.

Dear Doctor : — Yours of the 22nd instant is at hand, and I have also just received a letter from Dr. J. M. Sims which I will answer today ....


In my statement I did make a mistake in regard to my being present at the first or second operation, which mistake I will correct. But if you still prefer I will send a certificate .... Let me know and I will give you any information or assistance in this great matter. Yours truly, etc.,

(Signed) P. A. Wilhite.


(Grandy)

Anderson, S. C, Jan. 27, 1877. Dr. C. W. Long.

Dear Doctor : — Yours of the 22nd is at hand, and I have also just received a letter from Dr. Sims which I will answer to-day. In regard to the certificates you spoke about it will not be necessary, I think, as Dr. Sims has my statement written out in full. He was particular to get all the points and facts I could recollect.

In ray statement I did 7nake a mistake about my being present at the first or second operation, which mistake Iwill correct (italics mine, L. B. G.).

If you still think proper I will send a certificate. Let me know and I will give you any assistance in this great matter. Yours truly,

P. A. WlLHITE.


I think when Dr. Y. takes the letter of Sims to Wilhite, dated January 12, 1877, Wilhite's letter to Long, dated January 16, 1877, Long's letter in reply to Wilhite's, dated January 22, 1877, and Wilhite's letter to Long, January 27, 1877, in reply to the 22nd letter, he will perceive at a glance that Wilhite could not have written a letter June 37, 1877, iu reply to the letter May 20, 1^77. The internal evidence of the letter and the connection show this.

8inis' article had been published before May 20th, and wliy should Wilhite a month afterwards (June 27, 1877) be writ


ing in reply "yours of the 22d instant" ? Did Long write to Wilhite, June 22, 1877? We have no such letter in the correspondence. Then it would have been a remarkable coincidence for Long to have written January 22nd and also June 22nd, and for Wilhite to have answered January 27th that be had just received a letter from Sims which he would answer that day, and also June 27th in the same words.

After all this correspondence I must be pardoned for again asking the question. How does Dr. Young know that Sims never investigated the Wilhite statements ? I'pon what hypothesis does he rest his proposition that the story of the negro boy " lacks probability " ? The proof is not shown in the published letters. W^hether Wilhite told Long about the negro boy incident or not, was it a fact? Dr. Sims accepted it as a fact on Wilhite's own statement. It was sufficient with him, and it would have been sufficient with his old friend and preceptor Long. Has uot Long requested him to give any additional operation and extended his thanks for his interest, etc.? But these men are all dead and gone. Wilhite (seemingly) being an obscure country physician, it is proposed to brush away in a flippaut manner his statements from the record. I submit to all unprejudiced minds that it is immaterial, as Sims said to Long about certain dates, whether Wilhite was a student in Long's office in 1842 or 1814, so far as the facts of Dr. Long's work is concerned; whether Wilhite was seventeen years old or nineteen years old ; whether it was 1839 or 1841 when he accidentally etherized the negro boy. The sole question is, did he do it the last year mentioned?

Dr. Young says that unfortunately Sims did not investigate Wilhite's statement. Then what did Dr. Sims write to Dr. Long for the facts for ? Why did he write to Wilhite to urge Long to send all the data or facts ? Why did Long ask Wilhite to mention any other additional operation? Suppose Sims had carefully investigated Wilhite's statements independently of his personal confidence he had in his veracity, what would have been the result of the investigation ? Fortunately for the memory of Dr. P. A. Wilhite, the South Carolina Medical Association appointed three of its honored body. Dr. J. R. Bratton, Yorkville, S. C. (died 1897), Dr. B. W. Taylor, Columbia, S. C, and Dr. C. R. Tabor, Fort Motte, S. 0., a committee to investigate the matter. Upon the advice of friends, there still being living wituesses to that incident in no way interested in the matter, Wilhite procured their affidavits, which, with his own statement under oath, he produced before the committee (Trans. S. C. Med. Ass., April, 1883). The original affidavits of his witnesses are now in my possession, and they were not written by Wilhite to fit his case. Fac-simile or photograph copies can be procured if Dr. Y. doubts my statement. Upon this testimony the committee made its report to the S. C. Medical Association, 1883, and published in its proceedings. This is a copy of the affidavits:

I hereby certify that in the year 1841 (exact date I do not remember) I did administer to a negro boy, about twelve years of age, sulphuric ether until he was completely an:esthetized, in which condition he remained for more than an hour. This occurred at the residence of Mr. J. N. Wier, in Clark County, Georgia. It was customary iu those days for the young ladies and gentlemen to


April. 1S98.1


JOHNS HOPKINS HOSPITAL BULLETIN.


87


congregate and have what were called ether frolics. It was on one of these occasions that I administered the ether to the negro boy, who was held by Mr. Robert Wier. I administered the ether on a towel until the boy became fully anaesthetized. When this happened we all became very much alarmed at his condition, he being perfectly insensible, with a slow and stertorousbreathing. Nothing that we did aroused him — slap him, pinch him, roll him over, etc.; so we came to the conclusion that we had killed him. Dr. Sidney Reese, who lived five miles away, was despatched for immediately. The doctor came in about an hour and a half, during which time the boy displayed very little evidence of waking up. After the proper means were applied he was aroused from his state of insensibility.

Personally appeared Dr. P. A. Wilhite before me and makes oath that the statements herein made are correct according to the best of his recollection.

Sworn to and subscribed before me, at my office, Anderson County, S. C, this the 29th day of May, 188.3.

John W. D.^niels, P. A. Wilhite.

Clerk of Court Common Pleas, Anderson County, South Carolina.

This testimony of Dr. P. A. Wilhite is fully corroborated by the affidavit of Samuel B. Wier, which is as follows:

State of Georgia, \

Jackson County. /

I hereby certify that in the year eighteen hundred and forty-one I was present and participated in a social collection of young gentlemen and ladies at John Wier's, at what was called an ether frolic, ami on that occasion I saw a negro boy put to sleep with suli)huric ether, administered by P. A. Wilhite, one of the young men present, now Dr. P. A. Wilhite, of Anderson, S. C. The boy was held by Robert Wier, while Wilhite gave the ether, until the boy became unconscious. The boy remained in that condition for some time, and not waking up, as they thought he should, and breathing very heavily and being perfectly limber, the party became alarmed, believing that Wilhite had killed the boy. A physician was sent for, who arrived in about two hours. Dp to that time the boy had shown but little evidence of waking up.

Dated December Hth, 1882.

(Signed) Samuel B. Wier.

I hereby certify that I was present when the above certificate was signed by Samuel B. Wier. I have known him for twenty-five years and know him to be a gentleman of honor and truthfulness. (Signed) Green R. Duke,

Dept. U. S. Marshal.

State of Georgia, \ Jackson County, j

I, J. L. Williamson, Clerk Superior Court of said county, do hereby certify that S. B. Wier is a citizen of said county and that I know him to be a gentleman of honor and truthfulness. Dated December Uth, 1882.

(Signed) J. L. Williamson,

Clerk S. C.

State of Georgia, I Clark County. J

I, the undersigned, hereby certify that I was present in the year 1811, the exact time not recollected. A collection of young people met at my house for the purpose of having a little fun and an ether frolic, and on that occasion a negro boy was put to sleep with sulphuric ether, administered by P. A. Wilhite, one of the young men present, now Dr. P. A. Wilhite, of Anderson, S. C. The boy was held by one of the young men, and the ether was administered until the boy became perfectly unconscious. Remaining in thatcondition for some time, and showing no signs of waking up, and breathing very heavily, we became alarmed, believing that Wilhite


had killed the boy. A doctor was sent for, he (Dr. Reese) arrived in about two hours, and up to that time the boy had shown but little evidence of coming to consciousness.

Dated December 12, 1882. (Signed) Mrs. L. C. Wieb.

I hereby certify that I was present when the within certificate was signed by Mrs. L. C. Wier. I have known her for fifteen years and she is a lady of high standing and unquestionable veracity.

December 12, 1882. (Signed) Green R. Duke,

Deputy U. S. Marshal.

(The committee of the S. C. Medical Association omitted by oversight this last certificate and omitted giving the full name of Mrs. Wier.)

In conclusion let me say I have tried to avoid saying anything that might appear personally offensive to any of the profession or any one connected therewith. I have claimed the liberty to insert in this statement certain points made by Dr. G., showing the errors of the article of Dr. Young, for each claimed to have access to private papers of Dr. Long.

Dr. Wilhite never by word, deed or act, privately or publicly, sought to claim any honor in this matter for the boyish frolic, etherizing the negro boy in 1841, except what was justly due him; neither do I; and as he, if living, would not seekto pluck one leaf from the laurel of Dr. Long, neither will I seek to rob him or any one else who may have a better claim to the crown. I submit that if human testimony of disinterested witnesses has still any weight or force with gentlemen in the forum of discussion, then no one ought to rise up and make the assertion that Wilhite's statements "lack probability." It was not a figment of his imagination, but a veritable fact. Dr. Long lived over a year after the statement of the negro boy incident as published in Sims' article, and continued in the harness up to his death. If he discredited the statement, he lived in Georgia but a few miles from the place where the incident was stated to have occurred. If it had been a fake, how easy would it have been for him to have gotten the testimony to establish its incredibility had the story been untrue.

With this I must leave the matter where Dr. Sims left it, having faith that an unprejudiced profession as well as the public will in the end render a righteous verdict and see as I do that for his labor of love for Long there is in return now ingratitude. J. 0. Wilhite, M. D.

125 North Main Street, Anderson, S. C, November 1, 1897.

Letter from Dr. Young. To THE Editor:

In the paper of Marion Sims, Wilhite is quoted as saying that previous to the discovery of anfesthesia by Long he was a student in Long's office; that when Long was discussing the possibility of producing anaesthesia with ether, he "encouraged him" by relating how he had unintentionally etherized a negro boy; and when Long, thus persuaded, did administer ether to Venable and operate on him, he, Wilhite, assisted in the operation ; thus modestly taking to himself a large part of the credit of the "great discovery."

The papers in my possession show conclusively that Wilhite did not enter Long's office until two years after Long's discovery; that he was not present at the first operation ; that he


88




was a boy younger by seven years tban Long, and therefore probably not Long's confidant and adviser.

The only remaining statement was the story of etherizing the negro boy, which Wilhite claimed to have done in 1839.

Numerous witnesses testified that the custom of inhaling ether in that part of Georgia began in the winter of 1841 and 1842 and was originated by Long, who had learned of the exhilarating properties of ether at the Medical College in Philadelphia, at least two years later than Wilhite, then a young schoolboy, claimed to have used it.

To say therefore that " the negro boy story lacked probability " seemed to be putting it mildly.

My conviction was further strengthened by finding that L. B. Grandy, first in an article in the Virginia Medical Monthly, October, 1892, and again in the New York Medical Journal, July 20, 1895, had vigorously attacked Wilhite's statements, declaring that they were " fiction, pure and simple— /«fcMS in unofahus in omnibus," and no one, not even his son, bad contradicted Dr. Grandy. Was I not justified therefore in assuming that it was an acknowledged fact that the negro boy story lacked probability? I think so.

Permit me to add that the unimportant inaccuracy of date in my paper, which he attributes to most sinister motives, was due merely to the indistinctness of the manuscript. After debating for a long time I decided that the word was intended for "Jun." and not "Jan.," a mistake, as it now appears, but of no practical import.

Dr. Wilhite's paper is valuable because he brings witnesses to prove that his father really did unintentionally, but nevertheless actually, etherize a boy to complete narcosis, a very interesting point in the history of anaesthesia. But that he had absolutely nothing to do with the discovery of anaesthesia by Long in 1842 must still be considered certain.

Hugh H. Young.


NOTES ON NEW BOOKS.

The American Yeir-Book of Medicine and Surgery. Edited by George M. Gould, M. D. (Philadelphia : W. B. Saunders, 1898.)

The excellence of the editorial work done by Dr Gould is so often exhibited and so well recognized that but few words of praise are needed from us for this work.

Although there has been some change of cullaborators since the last Year-Book appeared, there has been no falling off in the work done, and all the assistants should be congratulated for their help in producing so useful a book and one which requires so much care and labor to make it of value.

As time advances the editing of this Year-Book will become more and more difficult, for there is a large increase yearly in medical articles and journals. This makes a proper selection harder and harder, ami as the personal equation must enter into such selections, they become in a certain degree less and less valuable. No one knows beforehand what apparently insignificant point in some article may prove of significance before the next year is passed, and 80 articles may be omitted from consideration which a year later will prove to have been really important contributions. To remedy tills, we believe lists of articles which have not been touched upon on all important branches should be appended at the end of each chapter. This scheme mfiy not be feasible but if some such sheme is not devised, the value of the Year-Book, whicli is, after all, only


thatof a good reference book, will diminish yearly. Had we Central Ibl, after " in this country there would be less need of a Year-Book, and these " Centrallblatter " have theirdistinct ailvantage in being to a greater or lesser extent limited to special branches of medicine, surgery, etc., so that the practitioner is not obliged to purchase a large Year-Book, only a portion of which interests him, but with his " Centrallblatt" is able from week to week to pursue any special subject in which he may be interested. Why would it not be possible to publish the several sections of the Year-Book separately? We believe they would have a large sale, whereas the price of the Year-Book must keep it out of reach of many practitioners who would be glad to own this work of reference. While the "Centrallblatter " keep us really up to date in the different branches, the Year-Book is always about six months behind ; another factor which lessens its value to the busy and progressive student. He must get the last six months' information elsewhere.

We value the Year-Book and think the remarks of the collaborators of special importance in pointing out both good and bad work, or, better, in showing up errors of judgment. Such remarks should be of real service to younger practitioners who desire to write.

The profession at large should be sincerely grateful to Dr. Gould for the Year-Book, which is issued solely for the benefit of practitioners who are too busy to look up papers in which they may be interested , or too far distant from a good fountain of medical information to know what articles on any medical subject have lately appeared.

Essentials of Bacteriology. By M. V. Bail. ( W. B. Saunders, Philadelphia, Pa., 1897.)

Nothing in technical literature affords more depressing reading than a " compend," and the more widely removed the student from a practical acquaintance with the raw material out of which the subject itself is constructed, so much the more ineffective will be the efforts of any writer to provide him even temporarily with a short cut to knowledge Certain compends may perhaps be defended. In studying anatomy, for instance, the student has probably dissected, though perhaps more or less hurriedly, the whole or at least the greater part of the human body and has familiarized himself with the details, so that he has obtained a mental picture of the various organs and their relations. It is possible, then, that under these circumstances a compend may remind him of many half- forgotten facts, and he may retain this information until the emergency, represented by an examination, is over. But with the scanty opportunities nfforded by most of our medical schools in this country for obtaining any adequate practical acquaintance with bacteriological methods, the need or a<lvantage of a compend is hardly apparent. To any one who has had an opportunity of studying bacteriology in the only way in which it can be learned, namely, by practical work in the laboratory, the scope of the book is altogether too narrow to be of much service. To the student who has had no such opportunities it can have but little meaning, and even a word-for-word knowledge of its contents would hardly enable him to pass a properly conducted examination upon bacteriology.

The author acknowledges his indebtedness to several text-books dealing with the subject both in English and in foreign languages, but among his list we miss the names of some of the most trustworthy authorities. The definitions are terse, but not always free from obscurity or even error.

As a shoit text-book for the beginner, or as an aid in ihe case of the more advanced student to the revival of forgotten knowledge, any compend upon bacteriology must be found wanting.

In view, therefore, of the insuperable difficulties with which he has had lo contend, the author must not be criticized too severely for shortcomings which are necessarily involved in the nature of the subject with which he has h:id to de;il.


April, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


89


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


THE JOHNS HOPKINS HOSPITAL REPORTS.

Volume I. 423 pages, 99 plates.

Report in PntholosTT*

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

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Mall, M. D.

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

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

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

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

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

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


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

Report in Medicine.

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

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

Report in Medicine.

Tubercular Peritonitis. By William Osler, M. D.

A Case of Raynaud's Disease. By H. M. Thomab, M. D.

Acute Nephritis in Typhoid Fever. By William Osler, M. D.

Report in Gynecologry.

The Gynecological Operating Room. By Howard A. Kelly, M. D.

The Laparotomies performed from October 16, 1889, to March 3, 1890. By Howard

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

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

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

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

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

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

Hemorrhage from the Uterus, etc. By Howard A. Kelly, M. D. Carcinoma of the CervU 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 Hukter 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 Snrg-ery, 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 Nenrologry* I.

A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Haematomyelja. By August Hoch, M. D.

A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By Hekry M. Thomas, M. D.

Report in Fatbolo^y, I.

Amtfibic Dysentery. By William T. Councilman, M. D., and Henri A. Lafleub, M. D.


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

Report in Patholog-y.

Papillomatous Tumors of the Ovary. By J. Whitridge Williams, M. D. Tuoerculosis of the Female Generative Organs. By J. Whitridoe Williams, M. D.

Report in Pntliolog^y.

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

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

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

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

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

Report in Gynecology.

The Gynecological Operating Room; An External Direct Method of Measuring the Conjugdta Vera; Prolapsus Uteri without Diverticulum and with Anterior Enterocele; Lipoma of the Labium Majus; Deviations of the Rectum and Sigmoid Flexure associated with Constipation a Source of Error in Gynecological Diag' nosis; 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 CcBliotomy. 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 Haematokolpos and Haematometra. By Howard A. Kelly, M. D.

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

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

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

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

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

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


Volume IV. 504 pages, 33 charts and illustrations.


Report on Typhoid Fever.


Report in Nenrologry.

Dementia Paralytica in the Negro Race; Studies in the Histology of the Liver; The Intrinsic Pulmonary Nerves in Mammalia; The Intrinsic Nerve Supplv of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of "the Submaxillary Gland of ^fll< musculu.<: The Intrinsic Nerves of the ThvToid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley, M. D.

Report in Snrgrery.

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 Gynecologry.

'ith a report of twenty-seven cases; Post-Operative Septic Peritonitis:

By T. S. CtTLLEN, M. B.

Report in Pnthologry.

Deciduoma Malignum. By J. Whitridge Williams, M. D.


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

CONTENTS

  • The Malarial Fevers of Baltimore. By W. S. Thayer, M. D., and J. Hewetson, M. D. A Study of seme Fatal Cases of Malaria. By Lewellys F. Barker, M. B.
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Volume VI. 414 pages, with 79 plates and figures.

Report in Xenrology.

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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 II.-— Serum Poisoning.— Experimental Lesions induced by the Action of the Dog's Serum on the Cortical Nerve Cell; Part III.— Ricin Poisoning.— Experimental Lesions induced by Acute Ricin Poisoning. 2. Experimental Lesions induced by Chronic Ricin Poisoning; Part IV.— Hydrophobic Toxaemia.— Lesions of the Cortical Nerve Cell produced by the Toxine of Experimental Rabies; Part V.— Pathological Alterations in the Nuclei and Nucleoli of Nerve Cells from the Effects of Alcohol and Ricin Intoxication; Nerve Fibre Terminal Apparatus; Asthenic Bulbar Paralysis. By Henry J. Berkley, M. D.

Report in Pathology.

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

CULLEN, M. B.

Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of

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THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1

FACULTY.


DmiEL C. Gn-MAN, LL. D., President.

WmiAM H. Welch, M. D., LL. D., Dean and Professor of Pathology.

iRi Remsen, M. D., Ph. D., LL. D., Professor of Chemistry.

William Osler, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice

of Medicine. Henri M. Hcird, M. D., LL. D,, Professor of Psychiatry. William S. Halsted, M. D., Professor of Surgery. Howard A. Kellt, M. D., Professor of Gynecology and Obstetrics. Franklin P. Mall, M. D., Professor of Anatomy. John J. Abel, M. D., Professor of Pharmacologj'. William H. Howell, Ph. D., M. D., Professor of Physiology.

William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology. John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine. Alexander C. Abbott, M. D., Lecturer on Hygiene. 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. Booker, M. D., Clinical Professor of Diseases of Children. John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology. Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology. Henrt M. I'lioMAS, M. D., Clinical Professor of Diseases of the Nervous System. Simon Fleiner, M. D., Associate Professor of Pathology. J. Whitridge Williams, M. D., Associate Professor of Obstetrics. Lewellys F. Barker, M. B., Associate Professor of Anatomy. William S. Thayer, M. D., Associate Professor of Medicine. John M. T. Finney, M. D., Associate Professor of Surgery.


George P. Debter, Ph. D., Associate in Physiology.

William W. Rdssell, M. D., Associate in Gynecology.

Henry J. Berkley, M. D., Associate in Ncuro-Pathology.

J. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.

T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.

Robert L. Randolph, M. D., Associate in Ophthalmology and Otology.

Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.

THOM.is B. Futcher, M. B., Associate in Medicine.

Joseph C. Bloodgood, M. D., Associate in Surgery.

Thomas S. Cullen, M. B., Associate in Gj-necology.

Ross G. Harrison, Ph. D., Associate in Anatomy.

Fr.\nk R. Smith, M. D., Instructor in Medicine.

George W. Dobbin, M. D., Assistant in Obstetrics.

Walter Jones, Ph. D., Assistant in Physiological Chemistry.

.\DOLPH G. Hoen, M. D., Instructor in Photo-Micrography.

Sydney M. Cone, M. D., Assistant in Surgical Pathology.

Lotris E. Livingood, M. D., Assistant in Pathology.

Henry Barton Jacobs, M. D., Instructor in Medicine.

Charles R. Bardeen, M. D., Assistant in Anatomy.

Stewart Paton, M. D., Assistant in Nervous Diseases.

Norman McL. Harris, M. B., Assistant in Pathology.

Harvey W. CnsniNO. M. D., Assistant in Surgery.

J. M. Lazear, M. D., Assistant in Clinical Microscopy.

J. L. Walz, Ph. G., Assistant in Pharmacy.


GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from its close affiliation with the Johns Hopkins Hospital.

The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.

Men and women are admitted upon the same terms.

In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital. While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. 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 sunjical dressers in the wards of the Hospital.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school receives :

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.

2. Graduates of approved colleges or scientific schools who can furnish evidence: (a) That they have acquaintance with Latin and a good reading knowledge of French and German ; (b) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.

The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in each subject.

3. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above indicated.

Applicants for admission will receive blanks to be filled out relating to their previous courses of study.

They are required to furnish certificates from officers of the colleges or scientific schools where they have studied, as to the courses pursued in physics, chemistry, and biology. If such certificates are satisfactory, no examination in these subjects will be required from those who possess a degree in arts or science from an approved college or scientific school.

Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass, at the beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (2) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University, and (3) to furnish satisfactory certificates that they have had the requisite laboratory training as specified above. It is expected that only in very rare instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.

Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.

ADMISSION TO ADVANCED STANDING. Applicants for admission to adv.anced standing must furnish evidence (I) that the foregoing terms of admission as regards proliinluary training have been fulfilled, (2) that courses equivalent in kind and amount to those given here, preceding that year of the course for admission to which application is made, have been satisfactorily completed, and Cli must pass examinations at the beginning of the session in October in all the subjects that have been already pursued by the class to which admission is sought. Certificates of standing elsewhere cannot be accepted in place of these es.iminations.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates in medicine. The attendance upon these courses has steadily increased with each succeeding year and indicates gratifying appreciation of the special advantages here afl'orded. With the completed organization of the Medical School, it was fotmd necessary to give the courses intended especially for physicians at a later period of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the majority of those desiring to take the courses than the former one. The special courses of instruction for graduates in medicine are now given annually during the months of May and June. During April there is a preliminary course in Normal Histology. These courses are in Pathology, Bacteriology, Clinical Microscopy, General Medicine, Surgery, Gynecology, Dermatology, Diseases of Children, Diseases of the Nervous System, Genito-Urinary Diseases, Laryngology and Rhinology, and Ophthalmology and Otology. The instruction is intended to meet the requirements of practitioners of medicine, and is almost wholly of a practical character. It includes laboratory courses, demonstrations, bedside 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 oflercd. The number of students who can be accommodated in some of the practical courses is necessarily limited. For these the places are assigned according to the date of application.

The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the

REGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.



Vol. IX.- No. 86

BALTIMORE. MAY, 1898.

Contents

  • Typhoidal Cholecystitis and Cholelithiasis. By Harvey W. Gushing, M.D., 91
  • The Presence of the Bacillus Typhosus in the Gall Bladder Seven YearsafterTyphoid Fever. By G.Brown Miller, M.D., 95
  • The Transplantation of the Rectus Muscle in Certain Cases of Inguinal Hernia in which the Conjoined Tendon is Obliterated. By Jos. C. Bloodgood, M. D., 96
  • Hydraulic Pressure in Genito-Urinary Practice, especially in Contracture of the Bladder. By Hugh H. Young, M.D., -100
  • A Case of Carcinoma Metastases in Bone from a Primary Tumor of the Prostate. By Sydney M. Cone, M. D., - - 114
  • Glossitis in Typhoid Fever, with Report of a Case. By Thomas McCrae, M.B., 118
  • Proceedings of Societies :

Hospital Medical Society, 119

The Bacteriology of Yellow Fever [Dr. Sternberg].

Notes on New Books, 120

Books Received, 122


TYPHOIDAL CHOLECYSTITIS AND CHOLELITHIASIS

REPORT OF A CASE WITHOUT PREVIOUS HISTORY OF TYPHOID FEVER, AND DISCUSSI0N"0F A POSSIBLE AGGLUTINATIVE REACTION IN THE BILE AND ITS RELATION TO STONE FORMATION.


By Harvey \V. Gushing, M. D., Resident Sv.njeon in the Johns Hopkins Hospital.


Suppurative cliolecystitis, since the time of Louis, has been recognized as one of the complicatious of typhoid fever. That it is definitely caused in most cases by infection with the bacillus typhosus was not demonstrated until long after Eberth and GafEky's discovery of that organism and the recognition of it as the aatiological factor in many of the other suppurative sequela3 of enteric fever.

Since the original report by Gilbert and Girode* (1890) of a case of cholecystitis caused by the invasion of the bacillus typhosus, as demonstrated by cultures, a series of most important observations, concerning the relation of typhoid fever and gall-bladder affections, has been made by investigators in various places. The quite constant occurrence of the bacilli in the gall-bladder in cases of experimental inoculation .typhoid in rabbits was first noticed by Blachsteinf (1891) in Professor AVelch's laboratory, and attention was called to the persistence of the organisms in this situation in these animals


Gilbert and Girode, Contribution a I'etude bacteriologique des voies biliaires. Comptes rendus de la Society de Biologie, 1890.

f A. G. Blachstein, Intravenous inoculation of rabbits with the bacillus coli communis and the bacillus typhi abdominalis. Johns Hopkins Hosp. Bulletin, 1891, Vol. II, p. 96.


subsequently by Professor Welch* himself. In one case the observation was made on the 128th day after the inoculation, the bacilli having disappeared from every other organ of the body. This demonstration in 1891 led to the routine examination bacteriologically of the bile in fatal cases of typhoid at this hospital, and Dr. Flexner found in 50 per cent, of the cases a pure culture of typhoid. Clinically these organisms may be present without producing any apparent symptoms. A variety of changes, however, may be set up at any time following their invasion, from simple catarrh with stone formation, to ulceration, perforation or general peritonitis ; a sequence such as is more commonly seen in appendicular disease, the two having many features in common.

Acute suppurative cholecystitis, as recently emphasized by many writers (Mason,t OslerJ and others), is a not uncommon


Wm. H. Welch, Additional note concerning the intravenous Inoculation of the bacillus typhi abdominalis. Johns Hopkins Bulletin, 1801, Vol. II, p. 121.

f A. L. Mason, Gall-bladder infection in typhoid fever. Trans, of Assoc, of Am. Phys., 1897, Vol. XII, p. 23.

nVm. Osier, Hepatic complications of typhoid fever. Trans, of Assoc, of Am. Phys., 1897, Vol. XII, p. 378.


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[No. 86.


complication of a late stage of typhoid fever of the usual clinical type. In some of these cases there has been an associated cholelithiasis, but from a study of the reports obtainable it would seem that only a small percentage of cases with this complication during the fe?er were associated with gallstones ; a percentage no greater than could be accounted for by preformed stones.*

There seems, however, to be a distinct group of cases in which acute cholecystitis has appeared, not during the fever, but some mouths after it, and in all of these has there been an associated cholelithiasis. Bernheimf (1889) first called attention to the frequency of gall-stone attacks following typhoid, and DufourtJ (1893) found a history of tyj^hoid, preceding gall-stone attacks by a few months, in 19 cases. A review of the cases of cholecystitis admitted in this Hospital to Prof. Ilalsted's service and subsequently operated on and gall-stones found, shows that 10 out of 31 gave a previous history of typhoid, the interval varying from a few months to twenty years.§ In none, however, but the present case was Eberth's bacillus demonstrated.

Further, in 1890, Professor Welch|| demonstrated the presence of micro-organisms in the centre of gall-stones and suggested that they might have been the starting point for the deposition of the biliary salts. It has been mentioned, how


Prof. Oaler (loc. cit. p. 396) suggests that preformed stones may be an setiological factor in the production of cholecystitis during the fever, as they would render the ducts more receptive of infection. Naunyn (A Treatise on Cholelithiasis, 1896) and Hunter (A Discussion on Cholelithiasis, etc., Montreal Medical Journal, December, 1897) believe in the possibility of a rapid formation of stone following infection. Gilbert et Fournier (Du rule des Microbes dans la genese des Calcules biliaires: Compt. rendus heb. de la Soc. de Biologie, 1896, p. 145) have called attention to the fact that there may be different groups of calculi of various ages, old stones which have sterile centres and recent new formed stones from the nuclei of which positive cultural results may invariably ije obtained. The presence of old stones therefore at times may possibly court the infection whicli leads to the formation of a new group of calculi and associated cholecystitis. Statistics, however, seem to indicate, that of the acute cases, both those operated on during the course of the fever, and those dead of the fever in which acute gall-bladder infection has been found at autopsy, only a small percentage are associated with the presence of calculi. Courvoisier (Casuistisch-statistische Beitriige zur Pathologie und Chirurgie der Gallenwege, Leipzig, 1890) gives in 10 fatal cases of typhoid cholecystitis only two with gall-stones. Hagenmuller (Cholecystitis in Typhoid Fever, These de Paris, 1876) in a oompreliensive study reports 18 cases with death in 16 from fatal peritonitis, of which number there were only two with gall-stones.

f Bernheim, Art. Ictere du Diet. Dechambre, 1889.

t Dufourt, Infection biliaire et lithiase, sc. Eevue de M^d. 1893, p. 274.

§ This long interval would, however, not necessarily rule out an association with the primary infective agent, for in v. Dungern's case (Ueber Cholecy stitis Typhosa, Munch. INIed. Woch. , June 29, '97) fourteen years elapsed between the original attack and the perforative cholecystitis when the bacillus typho.sus was isolated.

II Also Naunyn (" Treatise on Cholelithiasis," New Syd. Soc, 1890, p. 51). Also Hanot (quoted by Dauriac, Gaz. Heb. de Med. et de Chirurg., July 25, 1897). Cf. also Gilbert et Doniinici (La lithiase biliaire est-elle de nature microbienne? Soc. de Biologie, 1894, p. 485).


ever, that calculi are usually not associated with early cases of acute typhoidal cholecystitis despite the great abundance of organisms in the viscus. In the one case, which we have observed in this early stage at operation, the organisms have been free and very motile; in the later cases, however, a distinct clumping of the bacilli in the bile has been noted. Attention was called to these clumps of bacilli by Blachstein, though no importance was attached to them. Richardson* found this condition in a single case and regarded it as a gigantic serumreaction in the gall-bladder. Nichols, working in Professor Welch's laboratory on experimental typhoid in rabbits, has noted the very early appearance of the bacillus in the gallbladder after intravenous iuoculatiou, and the subsequent distinct clumping of the organism in those animals which have later come to autopsy.

These observations naturally lead to the hypothesis that a reaction akin to an agglutinative reaction of the organisms, as Richardson has suggested, may take place in the course of time in the bile, the clumps being the starting point for the deposition of the bilirubin calcium salts and the origin of stone, the symptoms of which occur subsequent to convalescence.

The occurrence of this post-typhoidal cholecystitis, therefore, fuay be readily explained by the above series of observations, summarized as follows : (1) the bacilli during the course of typhoidal infection quite constantly invade the gallbladder; (2) the organisms retain their vitality in this habitat for a long period ; (3) in the course of time the bacilli are almost invariably found to be clumped in the bile, suggesting the occurrence of an intravesical agglutinative reaction ; (4) these clumps presumably represent nuclei for the deposit of biliary salts, as micro-organisms may with regularity be demonstrated in the centres of recently formed stones; (5) gall-stones being present in association with the latent, longlived, infective agents, an inflammatory reaction in the viscus of varying intensity may be provoked at any subsequent period.

The writer has been able to collect but i cases of posttyphoidal cholecystitis associated with stones, in which the bacillus typhosus has been cultivated from the bile at operation. To these, two additional cases are given (cf. Table I).

This sequence apparently may not be limited solely to infection with Eberth's bacillus. In Blachstein s report a similar clumjiing was observed in the bile of rabbits after inoculation with the bacillus coli communis. Dr. Flexner found the bacillus coli communis present in the bile in a small percentage of fatal cases of typhoid in the human, and in a few of the hospital cases of post-typhoidal operation for gall-stones a pure culture of colon has been isolated from the gall-bladder. Gilbert and Fournier,t as a result of their experimental researches, have divided biliary lithiasis into two great pathological groups: lithiasis due to colon, by far the most common, and lithiasis due to typhoid. Mignot


•A case of cholecystitis due to the typhoid bacillus. Boston Medical and Surgical Journal, Dec. 16, 1897.

I Gilbert et Fournier. Lithiase biliaire exp(5rimentale. Compt. rend. Soc. de Biol., Nov. 5, '97, p. 936.


May, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


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and these writers have reproduced, experimentally, iu gniueapigs and rabbits conditions representing cholelithiasis of these two types. The writer recently operated on one of the cases of this colon groiiiJ two years after a preceding typhoid. The gall-bladder contained a multitude of small faceted stones in the centres of which faintly staining bacilli could be demonstrated on covei'-slip preparations, though cultures from the


centres of the stones were negative. The bile contained a few isolated organisms and many small clumps of bacilli. They possessed the cultural properties of the bacillus coli communis. The patient's blood serum gave an active Widal reaction to typhoid in dilution of 1 to 30. It also gave a slow but distinct clumping reaction with the bacillus which was isolated (cf. Table II).


Table l.^CoUeded cases of post-UjpJioidal Cholecystitis associated tvith Gall Stones wJiich have been operated ujmn and the bacillus

typhosus isolated.



Author.


Sex.


Age.


History.


Operation.


Contents of Gali. Bladder.


I.


Gilbert and Girode,

Comptes Rendus

de la Soc. de Biologie,

1893, p. 95.


F.


45


Gall-bladder symptoms during fever. Subsequent gall-stone attacks.


Operator, Ferrier. Cholecystectomy 5 mos. after fever.


Bac. typhosus, pure. Gall stone. Purulent iluid.


II.


DuI)l•L^ (Chantlmesse's Case), Les infections biliaires. . Paris These, 1891.


F.


45


No attack with fever. Sxibsequent gall-stone colic.


Cholecystenterostomy 8 mos. after fever.


Bac. typhosus, pure. Gall stoue.


III.


V. Dungern,

Miinch. Med. Wocli.,

June 39, '97.


F.


46


No attack with fever. Subsequent cardialgia. Periostitis of lower jaw in 13 yrs. with bac. typh. Acute gall-bladder attack in 14th year. Widal reaction positive.


Operator, Kraske.

Cholecystostomy with evacuation of abscess 14 yrs. after fever.


Bac. typhosus, pure. No stone found, but "probably present." Abscess.


IV.


M. W. Rieliiirdson,

Bost. Med. and Surg. Jour.,

Dec. 16, '97.


F.


50


Recent uncertain history of typhoid. Serum reaction positive.


Operator, M. W. Richardson. Cholecystostomy.


Bac. typhosus, pure. Brownish fluid with bacilli in clumps. Gall stone in cystic duct.


V.


Surg. No. 3835, Jan'y 38, '95.


F.


37


Uncomplicated typhoid 3>.f mos. ago. Gall-stone colic with jaundice three weeks ago. Recent peritonitis.


Operator, Prof. Halsted. Cholecystostomy.


Empyicma of ruptured gallbladder which contained numerous small stones. Bacillus typhosus.


VI.


Writer's Case,

Surg. No. 6339,

Mar. 16, '97.


F.


36


No history of typhoid. Serum reaction positive.


Operator, Prof. Halsted. Cholecystostomy.


Bac. typhosus, pure. Brownish fluid, bacilli in clumps, gall stones.


Several other posHyphoid cases have been reported without bacteriological notes. These are omitted.


Table II. — Si7nilar jwst-tijphoidal cases from the Johns Hojikins Hospital stirgical records mj which the bacillus coli communis has

been isolated.




Date.


Sex.


Age.


History.


Operation.


Contents of Gall Bladder.


I.


Surg. No. 3S05.


1895


M.


30


Gall-bladder symptoms during fever. Frequent attacks of colic since.


Prof. Halsted.

Cholecystostomy 14 mos. after fever.


Mucoid Iluid. Thirty calculi. Bac. coli com. pure.


II.


Surg. No. 44 38 .>;,'.


1895


F.


57


Preceding typhoid, subsequent attack of acute cholecystitis 7 mos. ago.


Bloodgood. Cholecystostomy.


Muco-purulent material. Impacted stones. Bac. coli communis.


III.


Surg. No. 4956.


1895


F.


39


Attack during convalescence.


Bloodgood.

Cholecystostomy 7 mos. after fever.


Purulent fluid. Bac. coli communis. Subsequent discharge of a stone.


IV.


Surg. No. 4411.


1895


F.


34


No symptoms during fever. First attack 18 mos. later. Three subsequent ones.


Bloodgood.

Cholecystostomy 3 yrs. after fever.


Bile-stained fluid. Seven stones. Bac. coli communis.


V.


Surg. No. 7619.


1898


F.


34


"Typhoid-pneumonia" (?) First attack 6 mos. later. Subsequent frequent attacks of gall-stones. Serum reaction positive to typhoid.


Gushing.

Cholecystostomy 3 yrs. after fever.


Bile-stained fluid. Countless small faceted stones. Clumps of rod-shaped bacilli. Bac. coli communis pnre.


Cases, in which bacterJuIoKical notes were incomplete, have been omitted.


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[No. 86.


Most extraordinary, however, is it to find in cholecystitis associated with stones, the presence of Eberth's bacillus when there has been no history of previous typhoid fever, and when the gall-bladder infection seems to be primary, as in the case to be reported.

The widespread occurrence of the bacillus typhosus has but lately been fully recognized, and owing to the definiteness of the serum reaction many cases are clinically recognized as typhoidal infection which have few of the classical symptoms and which at autopsy may be found free from intestinal lesions. Guarnieri* (1892) first described an infection of the biliary passages, liver and spleen with the bacillus typhosus in a case without intestinal lesions. The patient, however, had the clinical symptoms of typhoidal infection. Chiari'sj grouping of the cases of typhoid without intestinal lesions gives no division which would include a case the sole apparent lesion of which is in one organ and which clinically never presented any indications of typhoid.

The history of the case is as follows: J

Mrs. C, a3t. 26 ; entered Professor Halsted's service at the Johns Hopkins Hospital, March 5, 1897, complaining of pain in the right hypochondrium.

The family history was negative.

The personal history was also without particular note. She had had the usual infantile diseases, and with the exception of an attack of pneumonia ten years before entrance she had led a vigorous and active life. She had been subject since childhood to attacks of indigestion and prolonged constipation. She is evidently a careless eater and has had for the past three years occasional attacks of vomiting, usually in the morning after eating too heartily the night before. Her diet has been execrable : coffee, 6 or 8 cups a day ; she is especially fond of pastry, acid things, pickles, salads and the like. Her menstrual history is normal. She has been married five years; has had one still-born and one living child now aged 2 years. There has been absolutely no history of any preceding febrile attack. (Patient and friends were closely questioned about this several times. She lived in the country with, no near neighbors; she knew of no one in the vicinity who had had typhoid or any continuous fever.)

Present Illness. Five days before entrance, after an enormous dinner of beefsteak and gravy, the patient was seized at 11 p. m. with pain in the right hypochondriac region. This continued until the next morning, when after eating breakfast she vomited both her breakfast and the dinner of the preceding day. The quantity she thinks was large — at least 2 quarts. Soon after her pain became very severe and required morphine for its relief, and since then she has suffered from more or less constant pain under the right costal margin. It


Guarnieri, Contributio alia patogenisi delle infezione biliari. Revista generale italiana di clinica medica, 1897. Ref. Baumgarten's Jahresbericht, 1897, p. 234.

fChiari und Krause, Zur Kenntnis des atypischen Typhus abdominalis resp, der reinen "Typhosen Sephthiimie." Zeit. fur Heilkunde, Bd. XVIII, S. 471, Oct. 1897.

X Preliminary mention of this case has been made by Dr. Osier, loc, cit., p. 396.


is not paroxysmal and does not radiate. It is described rather as a soreness than as an actual pain. There has been no vomiting since the first attack; no jaundice has ever been observed. The physician who brought the patient to the hospital states that during the attack she has had some pyrexia, which on the third day reached 102°.

Physical Examination. A large, dark-complexioned woman, well developed and nourished; without jaundice. Pulse regular, 90, of good quality. Temperature 101°. Examination of chest negative. The abdomen was full, slightly tympanitic. There is a distinct rigidity of the right rectus muscle and considerable tenderness in the right hypochondrium. An indistinct tumefaction below the costal margin could be felt on deep palpation. Thei'e was tympany over this area. No increase in hepatic dullness; spleen not palpable.

Subsequent History. On the second day after admission the temperature fell to 99°. Her bowels had been freely moved and she was fairly comfortable. Abdominal tympany had disappeared and the spasm in the right upper quadrant of the abdomen was much less. On the third day the temperature was normal ; there was no rigidity, no tenderness. A hard, movable mass was palpable in the right hypochondrium ; tender only on the deepest pressure. The urine contained no albumen, no bile pigment. The patient was up and felt so well that she was anxious to go home. "From this time she was free from subjective symptoms. A smooth roundish mass of about the size and feeling like a movable kidney, readily obtained bimanually and on deep inspiration easily grasped in the hand, persisted in the right hypochondrium. It was absolutely without tenderness.

On the 16th day Professor Halsted operated. A brief report of the operation is as follows :

Cholecystostomy. Greatly enlarged gall-bladder with recent adhesions and containing gall-stones. Evacuation of contents. Permanent drainage.

A vertical incision was made, 15 cm. long, over the site of the tumor and through the right rectus muscle. The peritoneal cavity was opened, disclosing a distended gall-bladder held by recent adhesions to the liver and omentum. Cultures were taken from these adhesions before separating them. Gall-stones were palpable through the bladder walls and in the cystic duct.

The fundus of the gall-bladder was incised and a small amount of brownish mucoid material, unlike bile, was evacuated with fifteen dark green, smooth faceted gall-stones varying in size from a pea to a large chestnut. Cultures were taken from the interior on making the first incision into the gall-bladder. One of the largest stones was impacted in the cystic duct, from which it was dislocated with considerable difficulty. The deeper ducts were free from stones. A purse string catgut suture was taken about the opening in the fundus, into which a drainage tube surrounded by gauze was inserted. The margin of the opening was then anchored to the neighboring peritoneal edges by fine silk mattress sutures. The rest of the abdominal wound was closed in the usual fashion. Her convalescence was uninterrupted. There was a constant profuse discharge of bile. The drainage was


Mat, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


95


omitted on the tenth day and the wound had closed ou the twenty-sixth.

Bacteriological Report. Cultures and cover slips from adhesions about the gall-bladder were negative. Cover-slips from the contents of the gall-bladder show a few rod-shaped organisms with rounded ends.

Eeport on cultures taken from contents of gall-bladder at operation, March 16, '97:

March 17. (A) Cultures taken on agar slants show in 18 hours, twenty or thirty opalescent, separate, whitish colonies. In the water of condensation an abundance of actively motile bacilli. Some very long forms.

March 18. (B) Bouillon inoculation from water of condensation of A gave in two days an abundant cloudy precipitate. No indol reaction obtainable. (C) Gelatine roll from B shows in 24 hours many brownish granular non-liquefying round colonies with a ground glass apjiearance ou surface growth.

March 19. Cultures were taken from a single colony of C and controlled by others from an isolated colony of original agar slant A, as follows: (D) Inoculation on agar shows in 18 hours an abundant opalescent growth of actively motile


bacilli morphologically like typhoid. They decolorize by Gram's method. (E) Sugar agar. No gas production. (F) Potato. An invisible membranous growth. (G) Litmus milk. Slightly acidulated. No coagulation.

March 30. A comparative series of cultures were made from a single colony of the original agar slant A, and as a control an undoubted typhoid bacillus, obtained by Dr. Carter in the pathological laboratory at a recent typhoid autopsy, was used. A variety of media were inoculated from both of these sources with precisely similar results.

April :3, '97. Serum Reactions. The patient's blood serum produces a distinct and rapid agglutinative reaction of the original organism and of the control, both obtained from agar slants four days old.

The blood serum from a case of typhoid fever in the medical wards produces a similar reaction with both organisms. Blood serum obtained from a healthy adult produces no clumping or loss of motility in either case.

Conclusion. A bacillus with the morphological and cultural properties of the typhoid bacillus.

The Widal test is positive both with the serum from the patient and that from a clinically typical typhoid.


THE PRESENCE OF THE BACILLUS TYPHOSUS IN THE GALL BLADDER SEVEN YEARS AFTER

TYPHOID FEVER.

By G. Brown Miller, M. D., Assistant Resident Gynecologist.


The case which I report gave the following history:

Mrs. L. P., white, aged 37 years, was admitted to the public gynecological ward of the Johns Hopkins Hospital, Feb. 1, 1898, complaining of pain in the right hypochondriac region.

Family History. Negative.

Past History. She had croup and whooping, cough as a child, but was otherwise healthy until the present illness.

Her menses appeared at the 16th year and were profuse, painful and regular.

She has been married 14 years; four children; no miscarriages; labors easy; micturition normal; bowels extremely constipated.

Present Illness. In the spring of 1891 she had the first attack of the pain from which she now suffers. This attack began as a severe cramp-like pain beneath the right costal margin. She had some fever but no chills, marked nausea and vomiting (the vomitus consisting of " pure gall "'). This attack lasted 12 hours, and the administration of morphia was necessary in order to give relief from pain. She noticed during this attack an oblong swelling beneath the right costal margin. This tumor, which was tender and sore, gradually diminished in size and within two weeks entirely disappeared. She was much constipated during the attack and her urine was very dark, but cleared up rapidly after it. Another and similar attack followed within a week after recovery from the first.

About one month after this second attack she had an attack of what was called " bilious fever," but which some of her


neighbors thought was "typhoid fever." She had high fever, severe occipital headaches, night sweats and chilly sensations, was extremely nervous and had constipated bowels. She had no pain, no epistaxis ; and no rose spots were remembered. The fever lasted about four weeks, when there was a remission of 4 to 5 weeks, followed by another rise of temperature, which lasted about one month.

. Following this fever she has had up to the date of admission to the hospital attacks of pain similar in character to the first two every three or four weeks. These have varied somewhat as to the severity of the pain, but have been of the same general character. She has now constant pain and tenderness over the gall bladder. She has never been markedly jaundiced.

Examination ofpntieiit. A healthy-looking woman; heart and lungs apparently not diseased; pulse, 90; temperature, 99° F ; abdomen symmetrical. Edge of liver just palpable beneath the costal margin. No tumor nor irregularity was felt, but much tenderness was complained of during deep palpation over the situation of the gall bladder. The right kidney was distinctly felt. Liver dullness one finger-breadth beneath costal margin.

Vaginal examinatiun. Negative.

A diagnosis of "gall stones in the gall bladder and probably in the cystic duct" was made by Dr. Ramsay, resident gynecologist, and an operation was advised.

Operation. She was operated upon, March 19, 1898, by Dr. Kelly, who made the following notes:


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[No. 86.


" Disease. Cholelithiasis, stoues in the cystic duct.

Complications. Extensive adhesions of the colon wallino; off the gall bladder.

Incision in the linea semilunaris, exposing the liver; gall bladder dissected out from adherent colon, exposing a small thick bladder; stones felt low down. Gall bladder incised vertically ; walls very thicli ; one artery cut at upper angle of incision; a small amount of bile and milky fluid escaped; spherical stone 15 cm. in diameter removed with difficulty from the lower part of gall bladder ; below this another stone felt through an opening about 8 mm. in diameter, a thick fibrous septum separating the two stones, which was dilated with the finger, and the second stone was removed with scoop. Below or rather above the gall bladder a hard mass about 3 cm. long and 12 mm. broad was felt running up under liver where it could not be reached except with finger."

The gall bladder was closed, a small gauze drain was inserted just beneath it into the abdominal cavity, and the abdominal incision was partially closed.

Following the operation the patient made a good recovery and was discharged from the hospital, March 34, 1898, apparently well. There was some suppuration along the tract of the drain.

At the time of her discharge she had had no attacks of pain since operation. The wound had entirely healed. Staphylococcus pyogenes aureus was grown from the suppurating drain tract.

Bacteriological Examination of the Contents of the Gall Bladder. Unfortunately cover-glasses of the bile were either not made or were lost after the operation. A smear upon an agar


slant showed after 48 hours a growth of the micro-organism, which proved to be the bacillus typhosus. This gave upon agar a white, semi-transparent growth ; cover-glasses stained with gentian violet showing a micro-organism 2 to 4 times as long as thick, slightly curved with rounded ends and staining rather faintly.

The micro-organism from an 18-hour agar growth was actively motile. Upon potato after a few days a faint, moist appearance only could be seen. Cover-glasses sliowed the same bacillus as upon agar, and some much larger forms were also seen. Irregularities of staining were noticeable. Litmus milk was very slightly acidified but not coagulated. No fermentation took place with glucose-agar. Gelatin was not liquefied, but showed on the surface a thin growth with irregular well marked edges. Widal's reaction was marked, as shown by the following notes made by Dr. Norman B. Gwyu, assistant resident physician :

" An agar smear from patient L. P. agglutinated typically by serum of a typhoid patient. Serum of patient L. P. agglutinates a known typhoid organism rapidly at 1-100 dilution. Reaction is immediate and positive, more like that of an acute attack than of an attack of several years ago."

Summary. The patient had two attacks of pain caused by gall stones in the spring of 1891. These were followed within a month by an attack of what was presumably typhoid fever. The gall bladder became infected by the bacillus typhosus, which caused a chronic inflammation, which continued until the time of operation seven years after the typhoid fever. There was no history of an attack of typhoid fever subsequent to the attack-in 1891.


THE TRANSPLANTATION OF THE RECTUS MUSCLE IN CERTAIN CASES OF INGUINAL HERNIA IN WHICH THE CONJOINED TENDON IS OBLITERATED.

(A PRELIMINARY REPORT.) By Jos. C. Bloodgood, M. D., Associate in Surgery and late Resident Surgeon, The Johns Hopkins Hospital.


The term " obliterated " is used because the extreme condition is more likely to bean acquired one rather than congenital. Undoubtedly the conjoined tendon may be congenitally very narrow or very attenuated. However, the important point to be recognized at the operation is that the conjoined tendon is either obliterated, very narrow, or very attenuated, and that the lower angle of the inguinal canal (Hesselbach's triangle) has lost its strongest support (the conjoined tendon), and that something (the transplanted rectus muscle) must be Substituted for this defect at the operation for hernia.

Thefollowing article will also appear in the Surgical Report No. 3 of the Johns Hopkins Hospital, Fasciculus 3-4, Vol. VII, with the report on the operation for hernia.

A Description of what is meant by the Obliteration

OF the Conjoined Tendon in Cases of

Inguinal Hernia.

On making a careful study of inguinal hernia the writer

has been impressed with the fact that they may be divided


into two groups; the larger group {A) includes those cases in which the conjoined tendon is wide and firm, and the second, a much smaller group {B), includes those cases in which the conjoined tendon is practically completely obliterated.

Grouj) A. In those cases of inguinal hernia in which the tendon is present it is easily discoverable before and demonstrable during the operation. If one inserts the index finger into the external ring, by invaginating the scrotum, the finger meets, after passing the pillars of the ring, a firm wall of tissue, the conjoined tendon, and it is to the outer side of the outer border of this tendon that the finger feels the impulse of the inguinal hernia. At the operation, if one examines the posterior wall of the inguinal canal, this tendon, if present, will be found to extend from the outer border of the rectus muscle to within about 1 cm. of the deep epigastric vessels. In some cases it may be wider, in other cases narrower. This tendon is clearly shown in Quain's Anatomy, 10th edition. Appendix, Fig. 23, p. 52. In Quain's Anatomy it is described as follows (p. 55) : "At the part of the abdominal wall through


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JOHNS HOPKINS HOSPITAL BULLETIN.


97


which the direct inguinal hernia finds its way there is recognized on its posterior aspect a triangular interval, the sides of which are formed by the epigastric artery and the margin of the rectus muscle, and the base by Poupart's ligament. It is commonly called the triangle of Hesselbach. The triangle measures about two inches (5 cm.) from above down, and an inch and a half (3.5 cm.) transversely at its base. In this area the abdominal wall consists of, besides the integuments, 1. the aponeurosis of the external oblique muscle, which is perforated toward the lower and inner corner of the space by the external abdominal ring; 2. the inner portion of the cremaster muscle covering the spermatic cord at the lower and outer part of the space, and above this, the lower fibres of the internal oblique and transversalis muscles passing to their insertion by the covjoined tendon, which, as a rule, extends over the inner twothirds of the lower part of the triangle ; 3. transversalis fascia; 4. subperitoneal tissue, and 5. peritoneum.

The conjoined tendon varies greatly in its development. I u many cases it is very slight and scarcely to be distinguished, while in others its deeper portion, derived from the transversalis muscle, covers the whole breadth of the triangle, reaching outwards along the deep femoral arch as far as the internal abdominal ring."

The observations by the writer on the variations in the width of the conjoined tendon and its complete obliteration in some cases were made p

without the knowledge

of the statement just quoted in Quain's Anatomy, and he was very glad to find a confirmation of his observations. The writer is not familiar with any other surgeon or anatomist who has dwelt upon the importance of the obliteration of the conjoined tendon as the chief cause of recurrence in these cases of hernia.

In cases of hernia in which the conjoined tendon is wide and firm the rupture takes place between the outer border of the tendon and internal oblique muscle. It may be either of the direct or indirect variety. It then extends down along the inguinal canal and protrudes from the external ring.



In these cases the problem is a simple one; it is only necessary to suture the tissues down to or just beyond the outer border of the tendon. There is no tendency to recur in the lower angle of the wound just above the pubes and to the outer side of the outer border of the rectus, because at this position the protrusion of the peritoneum is prevented by the conjoined tendon. If one does not transplant the cord a hernia may take place along the cord, protruding between the outer border of the conjoined tendon and sutured tissues. If one transplants the cord (as in Halsted's or Bassini's operation) the probability of a recurrence at this position (the lower angle), at least as far as our cases are concerned, is practically nil.

The probability of a recurrence if the cord is transplanted (as in the Halsted or Bassini operation) is very much less than in the older operations in which the cord was not transplanted. Theoretically (in my opinion) the position of the cord in Halsted's operation is better than the position of the cord in Bassini's operation, as the cord is made to protrude through the thickest part of the abdominal wall (aponeurosis of the external oblique and divided internal oblique muscle); practically the results after Halsted's operation in which the wounds have healed per primam are better than in any list of cases yet published, although only very slightly better than after Bassini's operation (143 cases — 3 very small recurrences at the position of the cord).

Grovp B. In cases in which the conjoined tendon is obliterated, if one inserts the index finger (invaginating the scrotum), after passing through the external ling, the finger does not meet any obstruction, but can be introduced without difficulty into the abdominal cavity for some distance; in this position, to the medial side the finger feels the sheath of the rectus muscle; by curving the finger downwards and backwards the posterior surface of the symphysis pubis can be easily palpated. The opening into the abdominal cavity extends from the outer border of the rectus and from the arch of the pubes, upwards and outwards to the internal oblique muscle. Before operation the number of fingers which can be intro


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JOHNS HOPKINS HOSPITAL BULLETIN.


[Xo. 86.


duced is limited by the size of the external abdominal ring. In some cases it is but one finger, in others two or more fingers. At the operation, however, after the division of the aponeurosis of the external oblique from the position of the external ring upwards, one can usually introduce the entire hand into the abdommal cavity ; in these cases the conjoined tendon is either thin and relaxed or completely obliterated, and the posterior wall of the inguinal canal from the outer border of the rectus upwards and outwards to the internal oblique muscle, and downwards and outwards to Poupart's and Gimbernat's ligament, is formed only by the thin and easily stretched transversalis fascia and areolar tissue.

The following figures, taken from the "Second Report on Hernia" which the writer is about to publish, demonstrate theimportanceof the obliteration of the conjoined tendon as a factor (perhaps the chief factor) in the recurrence of the hernia. As stated before, the larger group includes those cases of hernia in which the conjoined tendon is wide and firm. In this group (A) there have been 211 cases with 7 rec u r r e n c e s . In 6 cases (about 3 per cent.) the recurrence has taken place at the position of the transplanted cord, to the outer border of the conjoined tendon; all of these recurrences occurred i within one year, and

each one is a very small affair. In one case (4 per cent.) the recurrence took place 5 years after operation, in the lower angle of the wound. After a severe illness associated with a constant cough, in this case the conjoined tendon gave way.

In the smaller group (J5) in which the conjoined tendon was obliterated there are 10 cases, with 5 recurrences (50 per cent.) ; each i-ecurrence took place in the lower angle of the wound within a few months or a year, and the recurrent hernia is larger in each case than those in group A. In two cases the rupture descended into the scrotum.



Suppuration in both groups A and B has also been associated with the recurrence of the hernia.

In the larger group (A) the following figures show the relation of suppuration to recurrence, but also support the conclusion in regard to the conjoined tendon.

Wounds which Healed Per Primam.

(1) Halsted's typical operation, 143 cases, 3 recurrences.

Each recurrent hernia small and situated at the position of

the transplanted cord.

(2) Cases in which the cord has been excised, 43 cases, 1 recurrence. In this ( use the recurrence lias taken place through a split in the aponeurosis of the external oblique, to the outer side of the conjoined tendon.

Wounds which Suppurated. 1 1) Halsted's typical operation, 20 cases, 3 recurrences. 1 n two cases the reriirrent hernia is situated at the position of the transplanted rord, in one at the lower angle of the wound, described before.

(2) Cases in which the cord has been excised, 5 cases, no recurrences.

In the 10 cases included in the smaller uroup (i>) there have iiLL'u 3 recurrences among 7 cases in which the wound healed per primam, and 2 recurrences in the 3 cases in which the wound suppurated; in these 2 cases the recurrent hernia descended into the scrotum, and they represent the only complete recurrences in the entire series of 231 cases.

Impressed by the large proportion of recurrences in the few rases (3 recurrences in 7 cases) in which the conjoined tendon was obliterated, and with a hope of solving the additional problem presented by the obliteration of this tendon, the writer has devised, and in 8 cases performed a plastic operation on the rectus muscle, bringing this muscle down and suturing it with the other available tissues to Poupart's ligament and to


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JOHNS HOPKINS HOSPITAL BULLETIN.


99


the aponeurosis of the external oblique from the arch of the pubes up to the position of the transplanted cord. The procedure is a very simple oue, and the inclusion of the transplanted rectus in this portion of the wound must add strength. In the past we have learned the proper introduction and utilization of muscular tissue in laparotomy wounds. Every surgeon is familiar with the numerous hernias after laparotomies in which the incision has been made in the linea alba, in which cases only the fascia was sutured. In -i of our own operations for umbilical hernia in which only fascia had been sutured there have been 3 recurrences ; in those cases in which the rectus muscle had been exposed and sutured there have been no recurrences. After a careful observation of all the laparotomies performed by us in this hospital for a period of over eight years we find that there has been but one hernia in a laparotomy wound, which has healed per primam throughout, and in which muscle as well as fascia has been approximated. So impressed have we been with the importance of including muscle in the suture after laparotomy wounds that it is our rule in medium laparotomy to cut through the inner border of the rectus muscle rather than through the linea alba, and through the outer border of the rectus rather than through the semilunaris; and Prof. Halsted in his original conception of his ojieration for inguinal hernia divided the internal oblique muscle with this object in view. He states in his original communication, "I make and close the wound in operations for hernia on the same principle as in any other laparotomy wound." The writer F therefore claims no originality whatever in the use of the muscle to strengthen the hernial wound, but simply the original idea of transplanting the rectus to strengthen the wound in certain cases of hernia. The procedure is a very simple one; the method of ojoeration with this exception is the same as that followed in the typical Halsted operation. Before inserting the deep sutures the sheath of the rectus muscle is exposed; this is easily done by retracting upwards and inwards the aponeurosis of the external oblique and internal oblique muscles. The sheath of the rectus is divided in the direction of the muscle bundles from its insertion in the symphysis pubis upwards for a distance of 5 cm. After the division of the sheath the outer border of the



belly of the muscle bulges out; it is caught with two or three sutures of heavy black silk which are used as retractors to draw the muscle outwards and downwards. The operation at this stage is shown in Fig. 2. The deep sutures of silver wire are then inserted in exactly the same manner as described in Halsted's operation, with the addition that the four sutures below the transplanted cord include the sheath of the rectus and the muscle (Fig. 4); when these sutures are tied the rectus muscle is approximated to Poupart's ligament and the aponeurosis of the external oblique, from a position just below the transplanted cord down to the symphysis pubis, in addition to the divided and transplanted internal oblique muscle. Fig. 4 and Fig. 5 clearly demonstrate that the transplanted rectus strengthens the lower portion of the wound, which has been weakened by the obliteration of the conjoined tendon, better than any other available tissue could do.

The writer had this idea in mind for over a year, but not until April, 1897, did a case present itself in which the conjoined tendon was obliterated and in which he considered it necessary to transplant the rectus.

These drawings were made by Mr. Max Brodel from careful dissection on the cadaver and from operations.

explanatiok of the

Plates. Fig. 1. Halsted's operation, second stage. The aponeurosis of the external oblique has been divided, exposing the inguinal canal and j the internal oblique muscle. The dotted lines on the _^-, ! muscle represent the direc' i tion and extent of its divi J sion.

Fig. 2. The sac has been

excised and the peritoneal

cavity closed. The internal oblique muscle has been divided

and the rectus exposed and transplanted ; at this stage the

wound is ready for the insertion of the deep sutures.

Fig. 3. Halsted's operation, deep sutures inserted. This drawing demonstrates that there has been no attempt to completely close the external ring, and even if this should be done, there is no available muscle to approximate, unless the rectus is transplanted. If the conjoined tendon is wide and firm it is not necessary to completely close the external ring. Recurrence is prevented in the lower angle (Hesselbach's triangle) by this tendon.

Fig. 4. The transplanted rectus muscle included by the


J


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JOHNS HOPKINS HOSPITAL BULLETIN.


[Xo. 86.


deep sutures. In this drawing the cord has been excised in order to represent the operation more clearly. This drawing clearly demonstrates that the rectus muscle fills the lower angle of the wound, the part included by the lower two sutures. It also shows that the rectus strengthens the entire wound up to the position of the transplanted cord.


Fig. 5. Diagram of the position of the transplanted rectus muscle demonstrates the slight change in the direction of its fibres.

KoTE.— April, 1898. During the last few months Prof. Halsted in one case and Dr. Gushing in three cases have transplanted the rectus muscle.



~ ttctc/iment ot fiectu to i=y/r? . pu i> .


Diugram of the position of the transplanted rectus muscle, demonstratins t slight change in the direction of its fibres.


HYDRAULIC PRESSURE IN rxEXITO-URINARY PRACTICE, ESPECIALLY IN COXTRACTURE OF THE

BLADDER.


By Hugh H. Young, M.I)., Instructor in Genito- Urinary Surgery, Johns Ilojikins Unirersity.


Since the opening of the Johns llojikins Hospital in 1889 it has been the custom to treat cystitis by intravesical irrigations of various solutions. The irrigations have been performed without the use of a catheter, hydraulic pressure alone being used to force the irrigating fluid back into the bladder, which when full is emptied by the simple act of micturition.


This method was a direct sequence to Dr. Halsted's method of treating gonorrhoea by copious irrigations of antiseptic solutions which he promulgated in New York in 1883. AVhile irrigating the urethra he found that some of the fluid would be forced back into the bladder if the irrigating bag were held suflicientlv hiah.


Mat, 1898.1


JOHNS HOPKINS HOSPITAL BULLETIN.


101


The iicorn nozzle (Fig. 1) which he had devised for urethral irrigation was used, but held crowded into the meatus until the fluid was forced into the bladder by hydraulic pressure.

According to this method many cases of cystitis have been treated at the Johns Hopkins Hospital with remarkably satisfactory results.

While treating a number of these cases I found Dr. Halsted's acorn urethral nozzle unsatisfactory for intravesical irrigations, because it is so blunt that it cannot be wedged into the meatus tight enough to prevent the escape of fluid around it. To obviate this I had a nozzle* made with conical point of much more gradual slope, which can be tightly wedged into the meatus without hurting the patient. This has proved very satisfactory (Fig. 2). By the use of tins nozzle we have never found a case in which the bladder could not be irrigated without a catheter.

I have lately found that somewhat similar nozzles have been devised by Janet and Valentine.



Fig. 1. — IlalsU'd's Acorn Urethral Nozzl


Fig. 2. — Nozzle for Intravesical Irrigations


Case I. During the. summer of 1896 a patient was admitted to the hosjiital suffering with chronic pyonephrosis and cystitis. He was very weak and emaciated, and his urine, which was loaded with i)us and mucus, was voided every half-hour in small amounts. An examination of his bladder showed that it was greatly contracted, holding only 40 cc. (about an ounce). The mucous membrane was rough, corrugated, very tender and bled easily.

After bladder irrigations were begun it occurred to me that benefit might be obtained by dilating his bladder by hydraulic jiressure, thus lessening the disagreeable frequency of urination.

At first only 40 cc. could be forced into the bladder, but its capacity soon began to increase, and at the end of ten days his bladder held 150 cc. (5 oz.), and urination was not nearly so frequent. His cystitis was also improved.


Made by Whitall, Tatum &. Co., Pbila.


Unfortunately I was prevented from continuing the treatment longer, and though the results were very promising the outcome was still uncertain. The next case, however, surpassed my most sanguine expectations. I will report it at length.

Case II. — Severe chronic cystitis, 30 years' duration. Contracture of bladder, constant dribbling urine for three years. Capacity of bladder 30 cc. Dilatation to 290 cc. by hydraulic pressure. Return of continence of urine.

I. H., set. 65. American. Occupation, huckster. Admitted Dec. 17, 1896, on account of continual dribbling of urine.

Family History. Negative.

Previous History. He denies syphilis and gonorrhoea.

Present Trouble. Thirty years ago he injured his perineum in a fall, following which he says he had extravasation of urine, required frequent catheterization and was very sick for several months. At the end of seven months perineal section was performed in New York (probably for stricture of urethra following traumatism). After that he passed sounds on himself about twice weekly for twenty years. Cystitis, which was continuously present, became greatly aggravated six years ago, frequency of micturition increased greatly, and for the past three years there has been a constant dribbling of urine.

Status PriBsens. The urine dribbles continually, patient wearing cloths between thighs to absorb it. The odor is very offensive even ten feet away. Patient suffers severe pain in bladder and urethra and is perfectly miserable. He is unable to work and is shunned by his friends.

Examination. He is a thin, emaciated old man, with clothing wet from urine with a very foul ammoniacal odor, which appears to dribble continually.

A searcher passes into bladder readily, but reveals several irregularities in the urethra.

Bladder very small, not admitting the rotation of searcher. When fully distended with fluid it holds only 30 cc. ( 5 i), any further distension causing pain. Prostate not enlarged. No stone or intravesical growth made out. Mucous membrane of bladder rough. Searcher caused no hemorrhage. Kidneys not palpable.

Analysis of Urine. Heavy gray sediment amounting to onethird of specimen. Reaction intensely alkaline. Much stringy mucus. Albumen in large amount. No sugar. Microscopically mucus and pus cells, triple phosphates. One week after admission daily forced dilatation of bladder begun, using a solution of bichloride of mercury, 1 to 150,000.

The tabulation on page 102 shows the improvement made.

Remarks. — In this case cystitis had been present for 30 years. Continued inflammation had probably destroyed the mucous membrane, caused the muscle to be replaced by fibrous tissue, througli the cicatricial contraction of which the capacity of the bladder was steadily reduced until it Ijnally held hardly one ounce and had entirely lost its power of expelling urine. As a result the urine had dribbled constantly for three years before he entered the hospital.

Under forced dilatation the capacity of bladder rapidly increased from 30 to 290 cc. (gi to gx), but the contractile power did not fully return, probably owing to the fibrous replacement of the bladder muscle. There was a constant residual of 60 to 100 cc. and as a result micturition was frequent.

Whether the tonicity would have returned in time we are unable to say, as we have never seen the patient since. Improvement, however, was very great.


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[No. 86.


Date.


Day of Treatment.


Capacity of Bladder.

Largest amount

held on forced

distension.


Interval. Longest time between two

urinations.


Remarks.— Case II.


Dec. 17

" 2G ....

" 30

Jan. 6

" 11

" 16

" 23

" 24

Feb. 20 ....

" 27

March . . . .


1 4 11 16

21

38


Cu. Cm. 30

40 90 200 340

24.5 2.55

215

290 280


Hr.

1

1

3


Min. Dribbling

30 30


Severe chronic cystitis 30 years. Urine ammoniacal, loaded with mucus.

Clothes saturated with urine. Dilatation begun. Irrigation of bicliloride followed by boric twice daily.

Trine clearer, reaction less alkaline.

Reaction acid. Great improvement in general health.

Has ceased to dribble, but bladder is unable to expel ali of urine, 60 cc.

residual, seems to have very little contractile power. At times voids 160 cc. naturally. Urine acid, pus slight.

He feels very badly. Some pyrexia. Refuses dilatation treatment. Treatment resumed. Urine has become alkaline again and is voided at frequent intervals. Great increase in pus.

Bladder seems to have no muscular power. After catheterization he is able to retain urine for 3 or 4 hours, but then he only voids a small amount, and after that voids every half-hour or so, leaving a residual of about 100. Patient is devoid of will and energy, does not try to do better. Is greatly improved in general health. Dribbling has ceased and cystitis much improved. Discharged.


Case III. — Vhronic cystitis 10 years. Contracture of bladder, holding only 40 cc. Micturition every 30 minutes. Under forced dilatation capacity increased to 160 cc, and interval to 4 hours.

Surg. No. 6573. J. T. Age 41. American. Farmer. Admitted May 26, '97.

Complaint. Frequent and painful micturition.

Family History. Negative.

Past History. Denies gonorrhoea and syphilis.

Present Trouble. Ten years ago began to have frequent and

having gonorrhcea. Had no instruments passed into urethra. Had been in good health previously.

Urination continuing frequent and painful, with occasional tinges of blood, patient consulted a physician at the end of a month, who passed an instrument to detect a calculus, but none was found.

Following examination he had chills and fever, lasting two or three days, accompanied by marked aggravation of bladder trouble.

At the end of two years patient suffered severe pain in bladder, and his urine contained a great deal of blood, and dribbles continually.

To relieve distress of patient a perineal section was done in Philadelphia. This operation was followed by marked improve

ment of symptoms. Perineal fistula continued for two years, and patient suffered very little till ten months ago when he again began to pass blood. Urination soon became very frequent and painful, and since then his bladder symptoms have steadily grown worse.

Status Pro'sens. Patient now voids urine every fifteen minutes, though at times half an hour may intervene. He suffers a constant pain located in lower abdomen, worse at end of urination, and then extending into penis. Urine often contains blood, free and clotted, and most at end of micturition. Stream frequently stops suddenly, accompanied by pain running to end of penis. Has never passed gravel.

In anterior part of anus is a fissure which he has had for several years.

Analysis of Urine. June 5th, Smoky, blood-stained deposit of mucus. Alkaline in reaction. Microscopically pus cells, red blood corpuscles and squamous epithelium.

On June 3rd treatment was begun. Bladder distended four times daily with Thompson's fluid.

In six days its capacity was doubled (60 cc), and .in two weeks trebled. Accompanying this, the interval between urinations increased from fifty minutes to one hour and thirty-five minutes. A great change bad taken place in bis general condition ; the con

Date.


Day of Treatment.


Bladdeu Capacitv.

Largest amount

held on forced

distension.


Ukine.

Largest amount

voided at one

time.


Interval. Longest time between two

urinations.


Remarks. — Case III.


June 3

11 8

" 11

" IS

" 2S

July 14 ... " 23 ... " 29 ...

Sept. 23....


1

5

8

ir,

25


Cu. Cm. 40

GO

85

105 130

100 135 ICO


Cu. Cm.

30

40 70

80 110

SO 100 130


11 r.

1 1

3 4


Min. 30

15 40

30


Constant severe paiu iu bladder, causing him to stoop. Urine loaded with pus, mucus and blood. Reaction alkaline.

General health improved. Pain now absent. Can now walk

erect. Urine much clearer. Has gained 8i<2 pounds in weight. Patient discharged ; to continue treatment at home. Patient

lost ground for a time, but soon improved rapidly.

He writes that he feels like a new man, passes no blood or mucus, is free from paiu and has no trouble conducting treatmeut at home.

Irrigations have been discontinued, contrary to orders, for more than a month. He writes that he still holds his urine three or four hours at a time ; has no pain and is very well.


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103


stant pain in bladder, intensified by urination, which was present on entrance, had practically disappeareii, the urine had become acid, and the amount of pus diminished markedly. He had gained 8i lbs. in weight.

At the end of three weeks his bladder held 130 cc, he voided naturally 110 cc, and the ioterval between acts of micturition was two hours and thirty minutes.

The tabulation on the previous page shows graphically the improvement. (See also chart of cases appended).

Remarks. — In this case the bladder was exquisitely tendeiand would stand very little dilatation, the increase in capacity was therefore slower. I have not heard from him for a month, but I believe the capacity will be fully restored.

Case IV. — Chronic cysliiis 5 years. Contracture of bladder, capacity 60 cc. Micturition every 45 minutes. Pott's disease. Intestinal tuberculosis. Under forced dilatation size of bladder increased to 195 cc. and interval to 3 hours 30 minutes. Marked amelioration of cystitis.

Surg. No. 0580. G. L., single. Age 28. American. Laborer. Admitted May 30th, '97.

Complaint. Frequent and painful micturition.

Family History. Measles, pneumonia (?). Deniesliiesand gonorrhoea. Pott's disease 16 years ago, following injury, has never given rise to abscess, gives no pain now, seems to have undergone resolution.

Present Illness. Indefinite history of cystitis for five years or more. Denies gonorrhcea, but acknowledges having bad sounds passed two years previously. Cystitis characterized by burning pain running down to end of penis, intermittent appearance of


blood in urine, free and clotted, increased frequency of micturition, now every thirty to forty minutes. During past year has passed sounds on himself every week, no antiseptic precautions.

Patient has suffered from intermittent attacks of severe abdominal pain, every week or so, for a long time, associated with a continued diarrhffia, mucus and occasional streaks oi blood.

Examination. Well nourished man, with a marked stoop from kyphosis in middle dorsal region.

Chest and abdomen negative. Cystic swelling attached to each epididymis.

Rectal Examination. Prostate enlarged, irregular, with slight no<lular roughnesses. Very tender on pressure.

Bladder. Instrument introduced easily. No urethral stricture. Introduction causes considerable pain in region of prostate. Bladder contracted. On forced distension holds only 60 cc. ( § ij). No stone present. No intravesical growth made out. With finger in rectum and instrument in bladder, prostate feels nodular and extremely tender.

Instrument causes slight hemorrhage.

Tuberculin injected, small l)ut definite reaction following. It is probable that tuberculosis of intestine and prostate is present, along with latent vertebral tuberculosis.

Urinary Analysis, March 30th. Smoky, shreds of mucus, small blood clot, heavy white precipitate. Acid, sp.gr. 1020. Albumen, trace. No sugar. Microscopically red blood corpuscles, leucocytes and epithelial cells in abundance. No casts.

There was manifestly little hope of curing his bladder trouble, but the relief afforded by forced dilatation for only three weeks was wonderful, as shown in diagram.


Date.


Day of Treatment.


Bladder Capacitv.

Largest amount

held on forced

distension.


Urine.

Largest amount

voided at one

time.


Interval. Longest time between two

urinations.


Remarks. — Case IV.


May 30

June 5

" 8

" 10

" 18

" 23

" 27


1

13 18


Cu. Cm.

80 110 130 160 180 196


Cu. Cm. 00

60

90 130 160 180


Hr.

1

3 3 3


Min. 4.5

10

5 35

.55 30


Admitted. Suffers with severe pain in bladder. Urine acid,

with pus and blood. Systematic dilatation begun.

Almost free from pain. Feels greatly improved.

During the latter part of three weeks conti.nued diarrhoea, with pain in anus and prostate. Urine free from blood ; muci less pus. Cystitis considerably improved.


Case \.—t bladder, hold Urine alkalir blonder dilat increased to 4

Mr. G. B.

Complaint. minutes, wit

Family Hi

Past Histor

First and epididymitis months. F in bladder, quency, etc.

Vesical d temporary r

Cystitis so mucus. Pal numerous p local irrigati


evere chronic ng 20 cc. ( 3 V e, with much d to 370 cc. ( -5 hours.

Age 40. Ca Frequency h pain, bloo itory. Negat y. Usual di only attack

and poster Dur months pain on mi

sturbance h smissions. on became n in bladder hysicians an ons through


cystitis for \^ years. Or a ) on entrance. Micturitioi mucus and pus. Under 1 3 xii), and interval betweet

ladian. Drummer. Adn r of micturition, every i and mucus, ive.

seases of childhood, of gonorrhcea fourteen y€ lor urethritis. Discharg later began to have a cturition in end of pen

as continued since that

pery severe, urine foul, often very severe. Has d hospitals, with intern catheter, with only temp


dually contractin I every 15 minute lydraulic pressui acts of urinatio

litted May 4, '9 ten or fiftee

ars ago. Doub e lasted severs sense of fullnes 8, increased fr(

time, with onl

much blood an been treated b al remedies an arary relief.


9 s. •e

n

I. n

e

il

s

y

d

y

d



Following indiscretion in drinking, etc., every few months patient has had acute exacerbations of disease, accompanied by chills, high fever, vomiting, pain and frequent micturition.

The interval between acts of urination has steadily become shorter, and for the past two years patient has voided urine every ten or fifteen minutes. In order to attend to business he has found it necessary to wear a rubber urinal, which has produced a severe balanitis.

Status Prmsens. Increased frequency of micturition, every 10-15 minutes night and day.

Pain. Site in perineum, continual, scalding or burning.

Urine. Always slightly bloodstained, ammoniacal odor, considerable mucus.

Capacity of bladder, rarely passes over 1 ss.

General health fair, but rendered unhappy and miserable by bladder trouble. Unable to attend to business.

Physical Examination. A fairly well nourished man. Facies worried. Chest and abdomen negative. Kidneys not palpable. Eight testicle atrophied, an irregular nodule in epididymis.

Rectal Examination. No enlargement of prostate. Vesiculse seminales palpable. No abnormality. No has fond. No stone


104


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 86.


palpable bimanually, tenderness marked in region of neck of bladder. Cicatrix in perineum from old perineal section.

Bladder. Urine chart shows that about 20 cc. ( 3 v) is largest amount passed, with an interval of 15 minutes between acts of urination. When bladder is filled with fluid by hydraulic pressure without catheter, 22 co. is the largest amount which bladder can hold without severe pain.

Urinalysis. Light yellow, cloudy, large clot of mucus. Strongly alkaline. Microscopically pus cells in great numbers, triple phosphates, numerous red blood corpuscles.

Treatment, May 6th. Systematic dilatation of bladder by hydraulic pressure begun ; with nozzle held tight in meatus, an elevation of four feet easily forces irrigating fluid into bladder.

Patient instructed to allow fluid to distend bladder as much as can be borne without great pain, then to withdraw nozzle and force the fluid out by urination. This is repeated until lOOO cc. is used. This is to be done every four hours by patient, with assibtance of orderly. Thompson's fluid used for irrigation.

The chart shows the progress of dilatation.


April 23, 1898. Patient returns for examination. He has irrigated bladder with moderate regularity once or twice daily up to present time. Solution of boracic acid used. Xo attempt to dilate bladder. He says he has been in fine health, and but for the presence of pus in urine would feel perfectly well. He urinates every four to six hours ; control of bladder, good. Last night did not void for six hours.

Examination. General health good. 200 cc. of urine voided at one time. Urine alkaline, cloudy with pus. Many cocci and bacilli like proteus present.

On forcible distension bladder holds .325 cc. Slight recontraction of urethral stricture at site of previous operation.

Patient voids urine with ease.

It is now one year since the dilatation treatment was begun, and there is no tendency to a recurrence of contracture.

Remarks. — The improvement iu this case was remarkable and is graphically shown on the chart which accompanies.


Date.


Day of Treatment.


Capacitt of Bladder.

Largest amount

held on forced

dilatation.


UlUNE.

Largest amount

voided at one

time.


Interval. Average time between two

urinations.


Remarks. — Cask V

May 3

" 6

" 15

" 21

" 39

Juue 10

" 30

" 39

July 15

" 31

" 29

Aug. 9

Sept. 30


1

9

15

34 36 46 55


Cu. em. 33

23 94 115

130 170 190 250

335 375

340 370 365


Cn. Cm. 20

20 40 70

105 120 1.55 190

150 190

260 260

280


Hr.

1

3 4

3

5 6

4


Miu. 15

25 45

10 10

35

35 30

30

30


Severe pain in bladder and penis. Urine filled with blood, mucus and pus and strongly ammoniacal. Wears a rubber urinal. Has voided urine every fifteen minutes for two years.

Dilatation begun — every four hours. Thompson's fluid.

Injected with tuberculin. No reaction.

Improvement has been rapid. Pain has entirely gone. Appetite is ravenous. One irrigation of silver nitrate given daily (1 to 400). Urine greatly improved.

Vritie acid. Very little sediment. No blood.

Urine acid.

Feels like a new man. Can now walk about town four hours without desiring to urinate ; is entirely free from pain. Urine is almost clear, acid in reaction. Discharged to continue dilation at home.

Home treatment. Lost some ground while traveling.

Conducts his own treatment, using one nitrate of silver irrigation and three Thompson fluid irrigations daily.

He is now practically well.

Still some pus in urine, but patient feels perfectly well.


Case VL—

rate. Capaa dilated in on minutes. Or

G. C, whi

Complaint.

History. C ning cystitis, turition. Hj twenty times

Urine. Pa in large amoi at bottom. 1 passed is IOC stone, bladde tender. Noi holds 140 cc. taken four ti

Table on ps

Is there i


Chronic eysti ty of bladder e month fro eat general im e, set. 32. E

Frequent a ronorrhoea IC

Frequent 1 IS lost fifteei intwenty-fo e, heavy gra mt. No sugi Jrination ev

cc, genera r wall rougl esidual urin

Forced im nes daily by ige 105 show

Ge I ureteral r


ti» 7 months. Contractur 140 cc. Micturition evei n 140 to 500, with inter provement. ngineer.

nd painful micturition, months ago. Three mo tematuria. Increasing f 1 pounds in six months ir hours, burning pain at f sediment, slightly acid, ir. Microscopically pus jry hour, on the average lly less. Examination v, , corrugated, prostate n i. Bladder distended un gations of Thompson's fl patient. 3 progress of case. Also

NERAL Remarks. efluxf AVhen this me


5 of bladder mode y hour. Bladde ual of 4 hours 5

nths later begin requency of mic He now void snd of urination 1012. Albumei cells, mucus clo , largest amoun ith searcher, n< ot enlarged, no til quite painful uid begun, to b(

chart.

thod was firs


r


8

1 t t

t t



might not be forced up the ureter, when the bladder became forcibly distended. If such were the case pus and dangerous micro-organisms would be carried along, and ascending intlammation and pyonephrosis would certainly result.

The valve-like arrangement of the orifice of the ureter produced by its oblique course for H inches in the bladder wall would seem to be a special provision of nature to prevent the backward flow^ of finids from the bladder into the ureters.

In order to determine whether fluid, under considerable hydraulic pressure, would be forced into the ureters I experimented on a cadaver. After the intestines were removed the ureters were dissected out and cut across within a few inches of the bladder. A very strong solution of methylene blue was prepared and forced into the bladder through the urethra from an elevation of fourteen feet.

The bladder rapidly distended, but no fluid ran out of the cut ureters, although the distension was kept up until 1700 cc. (nearly two quarts) were forced in, and the walls became so


adopted the question arose whether some of the irrigating fluid thin that the blue solution shone through, and the threaten


May, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


105


ing aspect of the huge bladder caused most of the bystauders to leave the I'oom.

Wheu the bladder was incised the mucous membrane was found deejjly stained blue, but the stain did not extend -^ of an inch into the ureteral orifices.

In another cadaver, with large sacculated bladder and double hydro-ureters, I found it impossible to force fluid from bladder into ureters.

To further test the matter I made the following observation upon a dog, April 4th :

A small male dog received 1 gr. morphia hypodermically. Very deep colored solution of gentian violet prepared. By hydraulic pressure of 11 feet (above dog) the fluid was forced into the bladder without a catheter until the greatly distended bladder could be seen through abdomen.


Abdomen then cleaned, dog etherized, laparotomy performed. Bladder greatly dilated, and dark purple in color from fluid within, intestines pushed aside, ureter located. It contained perfectly clear urine and not a particle of the violet stain. Kidney exposed, no stain present. Although ureter was watched for some time, no vermicular movement was noticed until fluid was evacuated from bladder, when it was distinctly to be seen. Bladder had remained distended for fully 10 minutes. On another dog under ether we exposed the ureter after laparotomy, and watched it carefully while various amounts of fluid were forced into bladder. There was never any passing of the fluid into the ureter. No reverse peristalsis was made out.

These observations seem to show conclusively that fluid cannot be forced up the ureters from the bladder in the dog




CAPACITY OF Bladder.


Urine.


Interval.



Date.


Day of


Largest amount


Largest amount


Average time


Remarks. Case VI.



Treatment.


held on forced


voided at one


between two





dilatation.


time.


urinations.





Cu. Cm.


Cu. Cm.


Hr.


Min.



Sept. 4




100


1



Burning pain in bladder. Urine faintly acid, very cloudy, heavy sediment of pus and mucus.


" 6


1


140


100


1


5


Forced dilatation begun. Thompson's fluid four times daily.


" 11


5


230


160


1


30


Much relieved-.


" 15


9


380


200


2




" 21


15


340


260


3



Free from pain.


" 2.5


19


390


320


3



Urine acid. Pus less, but still considerable.


" 28


22


400


380


3


30



Oct. 3


27


500


440


4


50



" 4


28


500


460


4


50


Patient discharged. Is free from any bladder symptoms. Holds urine often for 6 hours during night. Has gained 10 lbs. in weight. Feels like a new man. Urine acid, almost clear, very little pus.


In this case forced dilatation had been used daily in dispensary for a week or so before entrance, and I wish to thank Dr. Gaither for the interest he has shown in the method. Partial dilatation had been accomplished. Cystitis was of 7 months' duration, so there was probably less fibrous tissue present, and dilatation was therefore more rapid than in other eases. Improvement, however, was rapid and marked ; relief afforded great ; result, cystitis practically cured.

January 10. Capacity 500 cc, interval 5 hours. Feels perfectly well. Does not urinate at all at night. Can hold urine for 10 hours if necessary. Left hospital November 15th. Took irrigations 4 a day up to December 1st. During December twice daily. Since December 28th once daily. Thompson's fluid.


and in man, and they have been borne out by clinical evidence, for in none of the cases has there been any evidence of ascending infection, although the bladders contained many virulent organisms, some streptococci.*


While this article was in the hands of the printer our attention was called to the work of Lewin and Goldschmidt in regard to reflux from the bladder into the ureter, and their findings are of such importance that I will add them here.

These authors (Virch. Arch. vol. 134, 189.3, p. 33), after anfesthetizing rabbits, performed laparotomy and injected fluid into the bladder under pressure. The ureters were then exposed and cut to see if the fluid had entered them. In nearly'all cases they found that a small amount of fluid slowly injected would enter the ureter of the rabbit.

Their conclusions are as follows :

" The backward movement of the contents of the bladder into the ureter and pelvis can be produced as well by injection as by artificial retention.

"This result always took place in bladders which were still capable of contraction and not strongly distended. The result con


sisted essentially in an over-distension of the ureters, or, on the other hand, an excitation to increased activity expressed in peristaltic or anti-peristaltic waves.

" When the bladder is omr-distended it is impossible to open the ureteral mouths with the injected fluid."

Courtade and Guyon repeated these experiments on rabbits and also on dogs. Their work is discussed at length by Guyon in his Lecons cliniques sur les maladies des voies urinaires. In rabbits the reflux into the ureters occurred in 20 out of 32 times, but in dogs only 5 out of 25 times — or strictly 5 out of 38 trials. Guyon says in substance : " In the rabbit as in the dog, entrance into the ureters is only forced when the walls of the bladder are put in a state of resistance from the beginning of the injection. In both animals, every time that the bladder remained flaccid and was passively distended the ureter was not invaded, no matter how much fluid nor how much pressure was used.

" It is established that early tension of the bladder-wall produced by injection of a small quantity of liquid is the condition when the reflux can be observed. No other condition can accomplish it.

"In the five positive experiments the reflux showed itself after tlie first injection, but never after the second. Once put on its guard, the vesical muscle does not allow itself to be surprised again.


106


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 86.


Hydraulic Urethral Dilatation. — I have had au opportunity to observe the eifect of hydraulic pressure on a urethral stricture in two cases. I may say that it is very easy to


When the contractions of the bladder are total and active, rather than favoring the entrance of the vesical contentB into the ureter, it opposes it.

"The mechanism depends on the fact that there is a band of muscle-fibres surrounding the ureter and wall of the bladder which act as a sphincter, and if these are cut without disturbing the relations of tlie ureteral mouth at all, the reflux can then occur as regularly in the dog as in the rabbit.

" However, we can scarcely fear the refluxin man, provided the intraparietal part of the ureter lias not been changed anatomically." But then, in the face of that statement, on the same page Gnyon says :

" This possibility of reflux is a new objection to the employment of irrigations in cystitis, and is also an indication not to allow painful bladders to strive against their contents.

"With a pathologically accentuated sensibility the bladder is put in tension by very small quantities of liquid.

"The abstention from lavage, the retained catheter, and perineal and suprapubic drainage receive new justification, and physiology again asserts the preponderating role of the tension of the bladder."

Guyon says the reflux is brought about by a sudden early pa.ssive contraction of the bladder, occurring when very little fluid has entered the bladder ; and again, if the contraction brought about by the injection of the fluid is active and total, i. e. involves the whole bladder, the reflux cannot occur.

The only conclusion therefore is that this precocious contraction must be a partial one in which the muscular fibres which surround the ureters in the bladder-wall have not taken part. The ureters are probably asleep with their mouths open, according to Guyon, and "once awalsened the bladder cannot be again surprised."

When we consider that Guyon only succeeded in obtaining the reflux 5 times in 38 cases, and that then it was often only on one side; that the narcosis might have been responsible for the "drowsy condition" of the bladder-muscle and ureteral sphincters; that it occurred every time in the thin bladders of rabbits, only 5 times in 38 in the thicker bladders of dogs, and that the human bladder is considerably thicker than that of dogs ; thatin the numerous cases of cystitis which have been treated by irrigations we have never seen any symptoms of renal pain or infection, we are led to believe that the aforesaid experiments are inconclusive, and that the ureteral reflux does not occur in man, or even in dogs, except under peculiar and exceptional circumstances. We even wonder how Guyon and Courtade could distinguish a " passive " partial contraction of the bladder which did not involve the ureteral sphincters from an "active total contraction." The operation of dividing the sphincter of the ureter, situated as it is behind the bladder, without weakening the bladder-muscle or injuring the mucous membrane of the ureter, is probably the most delicate operation ever performed.

We can justify our practice of forced dilatation by the assertion of Lewin and Goldschmidt that when the bladder of the rabbit, even, is over-distended, it is impossible for fluids to get into the ureters. According to all these investigators, then, a small amount of fluid injected slowly may bring about ureteral reflux with fatal kidney infection, while a large amount rapidly forced in cannot enter the ureter. Accepting these assumptions, then our method of flushing bladders with copious irrigations is much less dangerous than Guyon's favorite instillations of small amounts.

When we consider, then, the great uncertainty of the existence of a ureteral reflux in man, and the very satisfactory results we have had with forced dilatation in cases of contracture of the bladder, we are constrained to think that their use is not contraindicated.


force fluid into the bladder through strictures of very small calibre.

In one case — a man convalescing from an operation for cranial abscess — the stricture of fifteen years' duration would not admit the passage of the finest bougie. Urination was extremely difficult, so much so that patient was obliged to squat on the floor and to strain so severely that a hemorrhoidal mass as large as the fist would be forced out.

His bladder was easily irrigated with an elevation of about ten feet, and after this had been done several times daily for two weeks he could void his urine while lying on his back in bed without an extrusion of the piles. The stream of urine became considerably larger.

Another case of moderately tight stricture showed decided evidence of dilatation after a week's treatment. I do not mean to advise this in preference to urethrotomy, but in cases of stricture complicated by severe cystitis, where operation is often followed by absorjjtion of septic materials, chill, fever, and occasionally fatal pysemia, preparatory lavage of the bladder in this manner is certainly indicated.

When a patient is discharged after dilatation of a stricture the daily use of this method would probably tend to prevent the recurrence of a stricture, and be of benefit to any bladder infection which might coexist.

After perineal section, where it is desirable, on account of cystitis, to continue bladder irrigations, I have found it very easy to force the fluid into the bladder by simply closing the perineal wound with the fingers, or if the ojieniug is small, by the pressure of a sponge covered with rubber protective.

In cases of enlarged prostate, fluid may be easily forced into the bladder without a catheter, but the same trouble is encountered in evacuating it as with the urine. After suprapubic operation, however, it is a very valuable procedure and the most thorough method of cleaning the bladder and combating infection. By closing the suprapubic sinus with a plug or the finger the bladder may be dilated, thus curing or averting one of the most undesirable effects of suprapubic drainage, viz. contracture of the bladder.

Vesical Calculus. In several cases of stone in which the bladder was small we have employed forced dilatation with very gratifying results. In a case now in the wards, who on admission had a severe acid cystitis with a staphylococcus pyogenes albus infection and a bladder which when fully distended held only about 140 cc, we were able in a week to increase the capacity to 400 cc. This was followed by a marked improvement in the cystitis and greatly decreased frequency of micturition. The bladder was then easily reached by suprapubic operation, and the bladder infection so much bettered that it was thought advisable to suture the bladder after removal of the calculus. We consider such preliminary treatment very valuable where infection or contracture is present.

Atony of the Bladder. The possibility of benefiting an atonic bladder by alternate distension and evacuation, a form of massage, so to speak, for the weakened muscle, is shown in the following case (VII).

An old man, paralytic, constantly requiring catheterization from paralysis of bladder, after a time began to regain use of


May, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


107


limbs, but the power of expelling urine did uot return, probably from atrophy and lessened tonicity of the bladder muscle.

Systematic forcible distension of bladder with iluid was begun and given twice daily. At first it seemed that the catheter would be required to withdraw fluid, but its use was deferred, and after a few minutes, to our satisfaction, the fluid was expelled. After a few weeks of treatment the tonicity of the bladder was practically restored and the patieQt required no further catheterization. The following case also shows the marked benefit obtained.

Case VIII. — Syphilis of cord, paraplegia, paralysis of bladder, catheterization, cystitis. Cure of paraplegia under iodides, but contracture of bladder with incontinence persisting. Capacity of bladder 65 CO. Urination every 20 minutes. Under forced dilatation capacity increased to 500 cc. and interval to 4 hours. Almost complete restoration of muscular power of bladder.

R. 0., age 4G. Cigarmaker. Admitted Sept. 17, 1897.

Complaint. Frequent micturition, every fifteen minutes.

Past History. Gonorrhoea twice, but no bladder trouble with it. Syphilis 15 years ago. Positive history of secondaries and tertiaries. Took K. I. very irregularly for three years, after which cutaneous lesions disappeared. In 1891 pains and sores returned, and again he took treatment irregularly.

In 1895 had a stroke of paralysis. Girdle sensation around body at level of navel, left leg completely paralyzed, right only partially. Retention of urine, incontinence of fseces. After being catheterized for 2 months began to h ave incontinence of urine. Urine became very


foul. Patient took heavy doses of K. I. and in two months power of limbs began to improve, and in 4 months he could walk fairly well. Bladder trouble did not improve, but urine continued to be voided involuntarily in small amounts, and patient has worn a rubber urinal to catch urine.

Status Prmsens. Voids urine every 10-15 minutes. No pain or dysuria. Wears urinal by day. Catbeterizes himself three times at night, as by so doing he does not void so frequently. After catheterization can hold urine for half an hour.

Rectum. Has fairly good control of bowel, except when faeces are very liquid.

Examination. Knee jerks increased activity, muscular power of left leg weaker than right. Prepuce, glans and skin of penis excoriated from use of urinal. Meatus small. Searcher passed easily into bladder. No stricture. No prostatic enlargement. Record shows that 40 cc. is largest amount of urine voided, and generally 20 cc. Bladder small, capacity 40 cc, walls rough, manipulation of searcher causes hemorrhage. Urine withdrawn acid and very purulent.

When forcibly distended until painful bladder holds 65 cc; on second trial 70 cc. forced in; Distension causes hemorrhage. Two days later 120 cc. could be forced in with considerable pressure. The bladder in this case is more easily dilatable than others. Bladder is forcibly distended with fluid four times daily without catheter by hydraulic pressure. K. I., which patient has been taking regularly before entrance, is continued.

Note. — Following this treatment the improvement of bladder was marked, capacity and interval rapidly increased, and with it the patient regained more and more control over micturition.

The following table shows the rapidity of improvement :


Day of Treatment.


Capacity of Bladder.

Largest amount

held on forced

distension.


Urine.

Largest amount

voided at one

time.


Interval.

Average time

between

urinations.


Remarks. — Case VIII.


Sept. 18.


130 200 370 330 340 435


40 100 100 100 140 175


Paralysis 2 years ago. Retention of urine. Catheterization. Cystitis. Incontinence of urine. Gradually increasing contracture of bladder. Urine now voided involuntarily every twenty minutes. Forcible irrigations begun, four times daily. Thompson's fluid.

Much improved.

Power of voluntary control returning.

Voids urine more frequently at night than during the day.

Condition markedly improved. Can now hold urine often for three hours and void at pleasure. Has given up use of urinal. No more dribbling. Has not fully regained expulsive power of bladder. Has 130 cc. residual, but muscular tonus is improving daily. Patient became insubordinate and was discharged.


Feb. 3, 1898. Patient returns to genito-urinary dispensary asking to be treated. Has not been under treatment since he left hospital (several months ago). Bladder has retained its size, patient voids urine at will, no dribbling, but still has a moderate residual. Still uses catheter from habit. Urine acid, pus moderate in amount. Prostate not enlarged.

Feb. 26. Condition as in last note. Irrigation bag prescribed to irrigate bladder without catheter three times a day with boric acid solution. Instructed to discontinue catheter habit.

Feb. 28. Has discontinued catheter and finds that he can hold his urine 4 hours during day. Bladder holds about 500 cc.

Mar. 29. Patient has irrigated bladder with boric solution twice daily. Bladder holds 580 cc. During day urine is voided every 3^ hours in amounts varying from 70 to 130 cc. After voiding a residual of 100 cc. is present. Expulsive power of bladder still


defective. Still walks with a limp, rectal control not perfect, still taking iodides.

Remarks. — Tlie results obtained in this unpromising case are very satisfactory and show the improvement of muscular tonus and continence obtainable by the exercise of the muscle. The gain in capacity of bladder was also marked.

Technique of Irrigating the Bladder withotd Catheter. Articles Necessary. — An ordinary fountain syringe with tube about eight feet long, a conical nozzle which will fit tightly into the meatus but not injure the urethral mucous membrane, and a pole or other apparatus by which the irrigating bac may be elevated or lowered as desired. (A nail in the wall will answer the purpose.)


108


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 86.


The patient should lie on his back on a bed or couch which is covered by an oilcloth, with a basin between his legs. The operator stands on the right side, takes the penis between thumb and finger of his left hand, the sterile nozzle in his right. The foreskin is retracted, and with the bag elevated three or four feet, the fluid is allowed to play upon glans penis and meatus. The urethra is alternately distended with fluid and emptied to clean the anterior urethra, and the nozzle is then crowded tightly into the meatus, the bag raised to an eleviition of about seven feet, the penis being held just back of the corona so as not to compress the urethra, as shown in Fig. 4. Valentine's complicated nozzle and stopcock are unnecessary.

The urethra will soon become ballooned out and for a time the fluid will be seen to stop flowing through the nozzle, but very soon the sphincters will give way and a " purling " sensation be conveyed to the hand by the fluid flowing into the bladder. After the sphincters are overcome very little pressure is required to force fluid into the bladder, and it is best to lower to a height of four and a half or five feet, as too much pressure may produce spasm of the bladder and prevent dilatation.

As the fluid flows gently into bladder the patient will soon experience a sense of fulness and tiien of gradually increasing pain.

In cases of contracture where systematic dilatation is to be adopted, the distension must be continued until pain is very considerable and the patient tells you he cannot " stand any more." The tube is then squeezed to cut off the flow, the nozzle withdrawn, and the fluid, which is ejected with considerable force, caught in a half -litre glass or other receptacle.

The operation is repeated until the quart of fluid has been used.

The procedure is so simple that patients soon learn to conduct their own treatment. They always become intensely interested in the progress of the dilatation and vie with each other as to the amount of fluid and urine held.*

Solutions Used. — Very bland fluids are the most satisfactory in most cases. Best of all is Thompson's fluid, which is composed of borax, glycerine, sodium chloride and water. It is the most soothing preparation for any inflamed mucous membrane that we know of. Boric acid in 2 per cent, solution is excellent.

A very good plan is to use occasionally a stronger antiseptic fluid, such as silver nitrate gr. J to gi, or bichloride of mercury 1 to 150,000 solution, up to 1 to 50,000.

When four or five irrigations are given daily it is well to use one of these once daily, followed by a weaker solution.

Silver nitrate is especially effective where an ulcerative condition of the mucous membrane exists.


Up to a few months ago there was scarcely anything on the possibility of irrigating the bladder without catheter in American literature, but since the popularization of the so-called Janet method of treating gonorrbcea, it has been very widely employed. Janet deserves credit for the energetic way in which hehaslauded the virtues of copious irrigations of dilute antiseptics, but the only originality is in the substitution of permanganate for bichloride in Dr. Halsted's method.


Very little internal treatment is of value. Boric acid or salol

in gr. v-x doses may be' given if the urine is alkaline, and citrate of potassium when hyperacidity causes much burning.

The reaction of the urine in cystitis depends almost entirely on the character of bacterium present, and it is irrational to attempt to change its reaction by internal drugs.

As shown in these cases, the urine becomes acid as the fjladder inflammation begins to subside.

Contracture of the Bladder. JIoiv ]wodured. — As in inflammation elsewhere, there is at first a proliferation and infiltration of round cells, which as time goes on become more and more spindle-shaped and finally form fibrous tissue. Ulcerative areas in the mucous membrane also lead to the production of scar tissue, with its inherent tendency to contract. The inflamed mucous membrane, irritated fjy the presence of urine,, expels it frequently; the bladder is therefore never fully distended and offers no resistance to the contraction of the scar tissue, and contracture results. In this process the blood supply of mucosa is greatly interfered with, and the mucous membrane is thrown into folds and pockets which retain the purulent exudate, thus adding to the inflammation.

The effect of forced dilatation with fluids is probably as follows:

Irritating secretions are washed away.

The individual bundles of fibrous tissue are separated or loosened, allowing increased vascularity.

Folds and pockets of mucous membrane are smoothed out. Ulcers are stretched and cracked, allowing new blood-vessels to grow out, in precisely the same way that leg ulcers are cured by scariflcation. The bladder muscle is exercised and the tone is improved. The mixcous membrane cleaned, stretched, and with increased vascularity, is given a chance to throw ofl: the inflammation.

In a normal empty bladder the epithelium is several layers thick, but when fully distended is said to be only one layer thick. Dilatation of an inflamed bladder therefore gives the antiseptic fluids a better chance to reach the disease.

Conclusions.

Cases II, V, VI, and VIII may be taken as examples of what can be accomplished toward dilating a contracted bladder and restoring the normal frequency and power of urination. The improvement in case V is really wonderful.

A review of these cases shows :

That it is possible to restore the capacity of a bladder contracted by chronic inflammation of the worst character, by systematic distension by hydraulic pressure.

That such dilatation has a most beneficial effect on the vesical inflammation and muscular tonicity.

That the number of urinations daily may thus be greatly diminished.

That no ill effects are produced by considerable hydraulic pressure, and there is no danger of infecting the kidney.

One of the most striking features of the treatment is the rapidity with which patients improve. Pain present for years may disappear in a few days, pus and mucus diminish markedly, and strongly ammouiacal urine become acid in a short time.


May, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


109



EQUIPMENT FOR IRRIfJATIOX.S AT TIIK (4ENIT0-URINART DISPENSARY OF THE JOHNS HOPKINS HOSPITAL.

1. Bottles containing stock solutions of Bichloride of Mercury, Silver Nitrate, Boric Acid and Thompson's Fluid. 3. Copper reservoir of sterile water kept at proper temperature by a Bunsen burner.

3. Printed formula' for making up various irrigations.

4. Irrigators suspended from pulleys, 13 feet above the tloor, the right hand for anterior urethral and the left hand for intravesical irrigations .5. Halsted's table for Geuito-Urinary work.



METIIon OF HOLDINfi PENIS AND NOZZLE FOR BLADDER IRRIGATIONS.

The tube passes between thumb and fori-liny-cr so the flow cnn be regulated at will. The nozzle is held firmly with the other lingers.


110


JOHNS HOPKINS HOSPITAL BULLETIN.


[\o. 86.


And yet a late text-book on geni to-urinary diseases says as follows :

" The theory that the capacity of an inflamed bladder can be increased by dilatation is contrary to physiology and anatomy. To attempt by forced injections to relieve frequent micturition cannot be too strongly condemned."

Discussion.

Dr. CuLLEN. — I have been much gratified with Dr. Young's method, and it is certainly destined to be of great service not only in the male but also in the treatment of cystitis in women. Last summer we had quite a number of cases showing varying degrees of vesical inflammation, and I had the opportunity of testing the efficacy of the treatment as outlined by Dr. Young. In all, with the exception of one case, much improvement followed, and subsequent examination proved that this patient was suffering from tuberculosis of the bladder, as demonstrated by sections of the bladder wall. One marked case is especially worthy of mention.

A patient (Gynecological No. 5351) was admitted to the Johns Hopkins Hospital on June 25th, 1897, complaining of frequent and painful micturition. Eight years ago she gave indefinite signs of renal colic, and the urine contained blood for two months, since which time the urine has been bloodtinged on an average every three months for 3 or 4 days, and during the'greater part of the eight years micturition has been frequent and painful.

On admission the patient micturates very frequently, at times every few minutes, and has to rise eight or more times during the night, often so frequently that she no sooner gets to sleep than the desire to micturate wakes her up. The pain is most severe after the bladder is empty, and she feels as if the viscus contains a stone.

Examination wonder ether, June 26th. The urethra easily admits a No. 11 cystoscope. The base and the anterior surface of the bladder are red, injected and covered by whitish yellow patches which on removal are found to be composed of mucus and calcareous particles. On examining more closely these areas are found to be covered with ulcerations, and the calcareous particles occupy the centres of the excavations. The lateral bladder walls are normal, and bimanual palpation fails to reveal any calculus.

The patient was treated by irrigations with HCl, to dissolve the calcareous pai-ticles, and the hydrochloric acid was removed by washing out with boracic acid solution, and after the bladder was emptied, by the application of 10 per cent, ichthyol.

Jujie 29/!/*. Patient being in knee-chest position, the bladder was irrigated with 1-1000 HCl, followed by boracic acid solution and then 10 per cent, ichthyol, to ensure the widespread application of which Clark's vesical balloon was introduced. The distension caused by the rubber balloon gave great pain.

June SOth. Topical application of ichthyol to the bladder after irrigation with HCl and boracic acid solution was made.

July 2nd. Irrigation with HCl and boracic acid was repeated. The treatment is very painful, but the patient says that she ah'eady feels improvement. Frequent irrigations were


employed, and on July 10th the following note was made: "All the calcareous particles have disappeared, and the mucosa, while still red and injected, has materially improved. The solution of HCl was now discontinued, and the bladder was washed out three times a week with the boracic solution, and then 10 per cent, ichthyol applied with or without the balloon."

July 16th. The posterior and anterior surfaces of the bladder are much imjiroved, but on examination of the base just within the inner orifice of the urethra several white calcareous patches are seen. With the patient in the kneechest posture the HCl had evidently not come in contact with those areas. After several irrigations with the patient in the dorsal position these disajipeared.

July 'dlst. The bladder has not been treated for eight days and a marked improvement is seen. The areas of ulceration at the trigonum are still covered by pus, which can, however, be easily removed by the applicator.

As the bladder mucosa did not assume its normal ajipearauce as rapidly as we had hoped, dilatation of the bladder was commenced, with forced irrigations of boracic acid. The following amounts were injected each day :


ugust Ith,


160 cc.


A


ugu


t 13th,


250 cc


5th,


170



"


I4th,


260


" 6th,


180



"


15th,


270


7th,


190



"


18th,


180


8th,


200



« 


20th,


200


9th,


210



((


21st,


210


10th,


220



a


22ud,


200


11th,


230



a


23rd,


250


12th,


240






It will be seen that the dilatation was progressive up to the 15th, and then after a cessation of three days the bladder did not contain as much, but that in a very short time the maximum amount was again nearly reached. In this patient the amelioration of the symptoms was most marked. Micturition became less and less frequent, and the urine could be held from two to four hours. The pain likewise ceased, and she rose once or twice only at night.

On leaving the hospital on September Sth the patient felt comparatively well and had practically no trouble with the urine. I received a letter from her three months afterward and learned that she was doing her home-work and was feeling well. (See charts of cases appended).


THE JOHNS HOPKINS HOSPITAL BULLETIN.

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 of 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.

Volume IX is now in progress.

The subscription price is $1.00 ppr year.

( omplete set (Vols. I-VIII), bound in cloth, for $13.00.


Mat, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


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Mat, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


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114


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 86.


A CASE OF CARCINOMA METASTASES IN BONE FROM A PRIMARY TUMOR OF THE PROSTATE.

By Stdney M. Cone, M. D., Assistant in Surgical Pathology, The Johns HojjMns University.


Von Eecklinghausen' writes of osteoplastic changes in bone accompanying metastases from primary carcinoma of the prostate. He compares the changes with fibrous ostitis and osteomalacia of bone, and makes many valuable additions to our knowledge of the gross and mici'oscopic structure of bone in disease. He records five cases of his own and refers to one case of cai'cinoma of the prostate with subsequent metastases in the vertebrae — that of Sir Henry Thompson.^ This case is reported in full in the Transactions of the Pathological Society of London, in 1854, Vol. V, p. 204, with a pathological report by J. Hutchinson. Saase' has recently reported a similar case and gives a comprehensive view of the work of Von Eecklinghausen in this report.

The case I am going to report does not differ in any essentials from those previously reported, but is interesting as confirming several very important points in the pathology of bone, and discrediting the existence of primary carcinoma of the osseous system.

The patient, W. B. M., aged 75, white, was admitted to Dr. Halsted's wards in the Johns Hopkins Hospital, in September, 1895, suffering with cystitis, and was discharged October 10th, improved. He returned December 26, 1896, complaining of a painful swelling over his right tibia : he also had symptoms of cystitis with incontinence of urine. Notes made at this time by Dr. Young refer to the great enlargement of the prostate and probable existence of a tumor. Careful examination excluded the existence of tumor of any other organs. On January 5, 1897, Dr. Halsted amputated the leg and the patient made an uninterrupted recovery, returning to his home in February.

The gross appearance of the tumor of the tibia suggested to the operator carcinoma. Sections were made at once after boiling and immediate decalcification in concentrated hydrochloric acid. The appearance of these sections suggested endothelioma. Even the later results of microscopic examination showed the pictures illustrating Marckwald's* article on " Jlultiple intravascular endotheliomas in the whole bony skeleton."

Not being sure of a primary carcinoma existing in the prostate, and disbelieving the existence of primary carcinoma in bone, Marckwald's explanation seemed to be a good one. He refers, however, to the ease with which his endothelioma might he mistaken for carcinoma. Von Recklinghausen likewise mentions how readily one might mistake one of his cases for endothelioma.

When seen at his home in July the patient was very much emaciated, having lost about 30 pounds in weight. He complained of pain in his back, chest and right hip. His urinary symptoms had improved under treatment. The patient died September 12, 1897.

Autopsy. A man of large frame, very much emaciated. The stump of the right leg is covered by a pad of dense scar tissue, otherwise the leg is normal. There are no external marks to indicate tumor formation, except a few dark moles over his back and abdomen (these existed foryears, according to the history). Onfirm palpation a nodule is felt at the right iliac crest within the pelvis. Another spindle-shaped mass can be felt over the second rib on the right side.

Examination of the abdominal viscera reveals no abnormalities except in the pelvis.where the prostate is found very much enlarged and adherent posteriorly to surrounding structures ; elsewhere it is sharply circumscribed. The prostate measures 6x5x5 cm. The


lateral lobes are symmetrically enlarged and measure 3 cm. in diameter. The middle lobe measures 3x1.5 cm. and seems continuous with surrounding structures.

Section of the lateral lobes shows a firm surface variable in appearance. There are bulging, gray, translucent areas and yellow, soft, expressible dots between the firmer, opaque stroma which makes up the greater mass of the gland. The middle lobe presents quite a different picture. It varies in different parts. The greater portion is soft, with a varying cut surface — yellow, soft, pus-like material being enclosed by a thin, opaque, fibrous stroma. The greater portion of this soft pulpy tissue is posterior, away from the urethra, and infiltrates the surrounding structures. The tissues about the middle lobe cannot be differentiated from one another, and no distinct pelvic lymphatic glands are to be seen, all being matted in a firm fibrous mass. The glands along the vertebrse are firm but do not show metastases. The prostatic and hemorrhoidal veins are plugged with phleboliths. The seminal vesicles are enclosed in a dense fibrous tissue.

The bones which show greatest evidence of disease are the second, third and fourth lumbar vertebra;, the second rib and the ilium. The vertebrie bulge laterally and anteriorly and can be easily penetrated by a knife blade. The rib presents a symmetrical spindle-shaped enlargement, bulging for the most part into the pleural cavity. It is covered by periosteum and pleura. The pleurae are adherent at this point. The bone is rough beneath the periosteum and can be easily penetrated. It measures at its greatest diameter 4 cm.

Section through the rib shows a stalactitic growth of bone into the pleural cavity, the plates appearing smooth and asbestos-like. The remaining bone is granular and presents no symmetry in its arrangement. Between the plates of bone is seen a soft white material in dots and fixed in a smooth, shining lining wall. There are cysts between the plates of bone just beneath the periosteum and in the granular bone. The lining wall of these cysts shows a thin, shining, smooth surface 1 to 2 mm. in thickness. About these cysts the bone in th e granular areas is denser than elsewhere. The appearance of the granular bone varies in color from a reddish to a dark brown and it contains lighter white dots. The bone is very friable. The stalactitic growths seem to be directly continuous with the granular central bone and push the periosteum ahead. There is no evidence of periosteal new-bone formation in the ribs.

The node on the ilium projects 1.5 cm. and has a diameter of 2 cm. It is covered by thickened periosteum. There is a central white, softer, fibrous mass surrounded by granular bone like that in the rib. The rim of the nodule is made up of plates of bone, asbestos-like in appearance ; these seem to grow from the periosteum. In this bone is seen the white tissue described in the rib.

The vertebrse show none of the flat plates of bone, but present the same granular new growth of bone seen in the rib and the ilium. There is no spongy bone with branching cancelli in any of the new growths of bone described.

An enlarged gland alongside the trachea is for the most part firm and darkly pigmented. It contains a well-circumscribed area, white in color (this proved to be carcinoma). There is a cystic dilatation at one end of the gland filled with a dark reddish fluid (this is microscopically a cyst lined by epithelial cells such as were found in the bone and prostate). One of the abdominal lymph glands attached to the vertebra is firm, whitish-gray in color and homogeneous on section.

Description of the Tmnor in the Tibia. — Six cm. from the internal malleolus and on the.anterior aspect of the tibia, lying under the


May, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


115


periosteum, is a bulging tumor measuring 4 cm. in diameter. The shaftof the bone beneath the bulging mass is eroded, and the tumor seems continuous with a mass filling the medullary cavity. This medullary mass is an irregular mixture of bony spicules, hemorrhagic soft tissue, dark brown, soft, friable tissue with a sprinkling of gray, pin-head-sized areas throughout. This tissue fades inlo a more homogeneous, gelatinous, gray substance with intervening cancelli of bone, as it approaches the periosteum. The cortex is destroyed and the new growth spreads itself beneath the thickened periosteum, between itandthe dense cortical bone, aboveand below the place where it has found its way out. This bone is irregularly eroded where the tumor growth appears. Perpendicular to the shaft and situated between the light soft masses are bone lamellse, formed from the periosteum and intimately associated with it. Sections of this tissue fixed in boiling water and decalcified at once in concentrated muriatic acid, show epithelial cells forming a mosaic between the cancelli of new bone which are directly continuous with bands of connective tissue of the periosteum.

The microscopical examination of the prostate gland shows a great hyperplasia of the muscular elements in the lateral lobes and a proliferation of the glandular element. Some of the gland tubules are filled with loose masses of epithelial cells and alveoli of cells. Others are lined by one and two layers of cuboidal cells with a deeply stained round nucleus at the base. There is a clear refractive space or several retractile globules next the lumen. In the middle lobe all of the spaces are filled with cells in various stages of degeneration. Very few normal tubules are to be seen. Some few spaces are paved as if by a mosaic. There are few real tubules — it resembles more a mesh work of fibrous structure in which the tissue has condensed about large polygonal fenestras, most of which are full of cells, loose and in tubular arrangement. These spaces are uniform in size, being about the size of an air vesicle of the lung ; they are bounded by a condensation of the fibrous and muscular tissue of the prostate. Some of the spaces communicate with one another and give the appearance of a breaking-down of tissue by masses of cells which seem to invade the tissues at these parts.

In describing the microscopic appearance of the tumor as it appears in the prostate, bones and bronchial lymph gland, there are so many points in common that one description will suffice. Two appearances are presented by the tumor — first, a tubular adenomatous growth, cystic in places ; second, a conglomerate mass of cells which have lost theirarrangement in tubules. This latter gives the impression of round cell infiltration or lymphoid nodules — the cells having lost their cylindrical or cuboidal shape and the nuclei staining quite deeply and appearing homogeneous. At the outskirts of these masses there may be seen the type of cell lining the alveoli and cysts. The tubular form of the tumor is best demonstrated in the bones and the bronchial lymph gland, but can also be seen in the blood-vessels of the prostatic plexus and in the primary tumor. There is very little stroma between the tubules; the lumina are seldom seen patulous, for the cells project into them, cylindrical in shape, meeting one another in the middle line. The nuclei are situated at the base of the cells and are perfectly round, deeply staining and homogeneous in character. It is this situation of the nuclei which aids one in distinguishing the lumen from the delicate stroma which may be wanting. The character of the cells is that of the cell lining the prostate gland tubules, only they vary in shape as already stated. Another characteristic is the vacuolization and division of the clear zone situated toward the lumen into small clear spherical globules. These are sometimes so uniform in size as to give the appearance of "shadows" of red blood corpuscles filling dilated alveoli. It maybe stated here that some of the alveoli are seen filled with red blood cells, causing a close resemblance to endothelioma.

As to the individual sections it maybe stated that the bladder wall shows evidence of chronic inflammation, its walls being infil


trated with round cells and showing connective tissue increase; there is no carcinoma in its walls. In the tissue posterior to the prostate is a tumor filling the blood-vessels and invading the structures surrounding them. The lymph glands show connective tissue growth, but no tumor in them. One of the largest vessels filled with the cells shows a peripheral mass of cells in tubular arrangement lining the vessel wall ; toward the central lumen and surrounding a blood clot are numerous cells, massed in such numbers as to give the appearance of round cell infiltration. In none of these sections are polymorphonuclears present. A gland attached to the vertebra shows a marked proliferation of its endothelium and formation of fibrous tissue along the lymph spaces ; there is no evidence of metastases here. The gland next the bifurcation of the trachea shows a branching network of tubules, lined by cuboidal and cylindrical cells, through a blood clot. Blood pigment is situated in the dense connective tissue about tlie gland. A cyst has formed at one end of the gland and is lined by cylindrical epithelium one layer deep ; it resembles the cysts in the bones.

For histological study the new-formed bone about the cysts in the rib is most interesting. The lining is of cylindrical cells on a thin fibrous tissue in which are scattered little areas of cells arranged in alveoli. The alveoli are more or less dilated in various stages of cyst formation. This same appearance is presented among the cancelli of new bone branching about the outer wall of the cyst. In fact, wherever there are new bone cancelli one sees tumor formation. The cells in these tubules come in contact with the bone — in places grooving the same. Commonly there is a fibrous tissue intervening between tubules and bone cancelli, and osteoclasts fill the grooves in the bone. The spaces between the cancelli, when not containing epithelial masses, are filled with a vascular connective tissue. The nodule in the ilium, besides showing the appearances of a tumor in the bone just described, presents a cartilaginous nodule in the midst of denser new bone formation. Even the dense bone contains tumor cells. In the cysts of tliis section is seen a homogeneous substance deeply stained with eosin and resembling colloid. The usual contents of the dilated tubules are granular with des-quamated cells.

The section of the vertebra presents dense new bone, poorly staining granular bone and free trabeculse in the midst of tubules of epithelial cells. Microscopic examination of the bone removed at the first operation shows a new growth of bone from the periosteum ; in the medulla there is evidence of necrosis of the old trabecular of the tibia, fragments lying free in the midst of the tumor and refusing to stain. Tubules of epithelial cells lie between the periosteal new-formed trabeculse.

Some of the observations of Von Recklinghausen which we were able to note in our case are of great interest. lie mentions the order in which carcinoma metastases occur in bonea as: vertebrse, femora and pelvis, ribs and sternum, humerus, flat bones of the skull, fibula, tibia, radius and ulna. Many interesting observations are made in the different cases described by him which make it seem valuable to mention his individual cases.

Case 1. The first case was in a man aged 75, who entered the hospital because of a large hard tumor of the right forehead ; it projected 15 mm. from the bone, and was not adherent to the skin.

The operation consisted in shelling out the tumor, which was easily done, even though it extended to the dura mater. The tissue of the tumor was reddish-white, and was typically alveolar, being made up of hollow tubules and cysts lined by cubical or low cylindrical epithelium.

"A marked vascular connective tissue with alveoli of the


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size and form found in the thyroid gland led to the diagnosis carcinoma and to suggest the primary lesion in the thyroid, like in a case described by Gohnheim." The ribs and bones of the skull at their points of thickening were no more easily injured than other boues, yet on the interior of them were found white prominences which proved to be carcinoma. At the trigone of the bladder was seen a flat elevation, made up of separate white pea-sized elevations covered by mucous membrane. The prostate was three times its normal size and surrounded by a bean-shaped connective tissue mass filled with carcinoma nodules.

New bone cancelli of finished or unfinished bone were found not only in the osteophytes outside the bone but also within the medullary spaces of the diploii and spougiosa. Some of these were old decalcified bone, others were new formed. (His methods for determining these points are contained in the same article.) The microscope shows the spicules in the frontal bone tumor to be a new formation and not old decalcified bone. There was great spindle-cell hyiierplasia in the spaces of the new bone. Sharply bound cell-nests were held iu real alveoli of the poorly fibrous and feebly cellular marrow tissue.

"The new bone formed plates about scattered carcinoma areas, not only as an evidence of reactive irritation at its border, like chains of outposts (guards) formed by the old tissue in the manner of an inflammatory proliferation against an invading enemy, but also as an integral part of the bone tumor even though it was a carcinoma."

In spite of the great ossification and absence of degeneration it was a case of multiple bone carcinoma arising from the prostate as the primary seat of the tumor. The reason for this was that all the tumors contained the type of epithelial cell found in the prostate, and especially because the lymph gland metastases followed the route which the " materia peccans " took from the prostate. It was carried by the blood to the bones alone. There would have been no examination of the other bones had it not been for the peculiarity of the tumor in the frontal bone.

Case 3. A man aged 77 years.

There were small nodules at the neck of the bladder. The prostate was hard. The lymph glands in the lumbar region were hard and contained a milky sap. Those about the jugular vein acted likewise. A cheesy gland was found at the base of the tongue. A string of lymph glands was on the left side of the prostate. A milky juice (carcinomatous) was expressed from the left lobe of the prostate, otherwise there was no degeneration or discoloration. Microscopically it resembled the first case. It was generalized in bone, but not iu the soft parts. " On palpating the smooth surface of the tumors in bone one got the sensation of rubbing a file covered by a cloth." Most of the tumors were covered by periosteum. A strong needle pierced the tumor but could not penetrate the surrounding bone. The impression was made that the tumor sprung from the medulla and became secondarily subperiosteal. The axial portions of the spongy bones were the parts mostly involved. The external tumors preferred the rough places on the bones, i. e. " where largest vessels came to the surface." One could have thought


of osteoma were it not for the microscopic examination. In all spaces, even in the densest bone, were strings and alveoli of cells iu mosaic arrangement as in Case 1.

In connection with this case the following points were noted: There were not two distinct diseases growing side by side, but the carcinoma caused the secondary hyperplastic ostitis by the active congestion awakened by its presence. Bone formatiou was evidenced by these facts :

1. Nuclei of spongy bone with the beginning tumor formation were present; 2. sclerosis and eburnation of the axial spongiosa existed; 3. the ribs and vertebra showed thickening within the affected areas ; 4. the cancelli took up new arrangements, forming stars and appearing as radii in the callus; 5. the osteophytic growths like those seen in spina ventosa.

Case 3. A man, aged 73. Primary carcinoma in the prostate, secondary to the glands along the vertebral column, lungs and bones.

There were white areas in both lobes of the prostate and infiltration of the walls of the seminal vesicles. The areas iu the bones appeared white and yellowish-white, and owing to the ill-defined boundaries gave the impression of an " infiltrating growth." Osteosclerosis and osteoporosis went hand in hand. Besides the femora, humeri, iliac bones and vertebra?, the spine of the scapula was also involved. The microscopic appearances were the same as iu the other cases. In the lymph glands it was not easy to show alveolar and tubular arrangement of the cells on account of the poor connective tissue framework ; one might have diagnosed sarcoma from these sections. " The lung metastases were due to reti"ograde transport from the bronchial glands."

Case 4. A man, aged 76. Carcinoma of the prostate with metastases to the pelvis, vertebras, ribs and femora, and doubtful carcinoma of the abdominal lymph glands. The prostate tumor measured 55x30 mm. and resembled a venous angioma.

Case 5. A man, aged 74. Carcinoma of the prostate with regionary metastases to the ureter, bladder and glands; miliary carcinoma of the serous membranes ; osteoplastic carcinosis. There was considerable infiltration of the tissues of the pelvis. The prostate was atrophic, measuring 35x20 mm., was hard and white and smooth on section. The glands in the axilla were involved.

Case 6. A skeleton preserved iu the museum and described by Lobstein. The conclusion is drawn that it was a case of carcinomatous ostitis probably arising from a primary tumor in the prostate. The conclusion was made from the appearance and location of the osteophytes and endosteal bone formation, together with certain points made by Lobstein from the fresh specimen.

Some of the points peculiar to bone carcinomas obtained from the above cases were summarized under four heads :

1. These were infiltrating in character and because of this resembled inflammatory changes. Because of the diffuse growth the term carcinomatous ostitis was justified.

3. The new boue formation was prominent, the destructive character of the tumor was in the background.

3. The exostoses were seen at the exit of the vessels, while in osteomalacia the ligaments and muscle attachments were preferred.


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4. The begiuuiug of the carcinoma was within the bone and broke through from the medulla.

Comparing the changes in this series of cases with those in metastases following carcinoma of the breast, the author mentioned that the contour of the metastases in the latter is usually sharp, but when they become infiltrating, osteoplastic changes occur. Prostatic carcinoma will probably be found to be the cause of general bone carcinosis as often in man as is the mammary carcinoma its origin in women.

It is hard to make out carcinoma in the prostate with the naked eye; the tissue does not degenerate much.

Sir Henry Thompson's case was a man aged 60. The prostate gland was involved in a growth about the size of an orange; some of the adjacent glands were also infiltrated. There were " encephaloid " growths along the lower dorsal vertebrje.

Hutchinson's report on the case is quite full. He refers to the soft creamy material infiltrating the prostatic tissue. A lymph gland on the posterior surface of the bladder presented on section the same creamy material which showed microscopically the same appearance as that from the prostate. In the spinal canal attached to the lamina of a lumbar vertebra was a mass the size of a filbert enclosed in a dense fibrous envelope. This tumor presented the same appearance as the lymph gland except that "it was less succulent." The involvement of the bones seems to differ from the cases described by Von Kecklinghausen in not being infiltrating in character. Saase before giving his case discusses the origin of carcinoma in bone ; he quotes V^ou Recklinghausen's work at some length. The case reported was a man aged 61 years. The diagnosis was not made during his life. The prostate was twice its normal size; pressure expressed a grayish white sap from its cut surface. One of the lymph glands of the pelvis showed metastases ; these were located in the hilus, none were in the cortex. The vertebrae cut with ease; the femora were sclerosed in part and were spongy and friable in the lower half. The microscope showed between cancelli of bone cylindrical cells pressed together. No stroma was visible, it being substituted by cancelli and plates of new bone. He differs with Von Recklinghausen,' who thinks the origin of the bone tumors to be only from the marrow. The route of the metastases suggested a vascular origin of the tumor, i. e. that it was an endothelioma or that the primary tumor was sarcoma.

Von Recklinghausen points out the fact that the tumors of the prostate very readily get into the blood-vessels and spread in this way. Cohuheim' made similar observations on tumors of the thyroid ( Virch. Arch., No. 08), and two years later (1878) Winiwarter made the statement, " the breaking of carcinomas directly into the veins is more common in thyroid carcinomas than any others. Very often a general infection occurs without intermediate lymph gland involvement. It reminds one more of a general development of sarcoma." Middledorpf," in writing of the bone metastases from thyroid carcinomas, refers to Von Eiselsberg's work and corroborates Cohuheim's view that the tumor grows directly into the veins of the thyroid.

• Those who believe in endothelioma in bone have no difficulty in explaining the fact that the bones are involved with


out a necessary involvement of the lymph glands. Some go so far as to oppose the diagnosis of carcinoma in cases set down as such long ago by such men as Von Recklinghausen. Ruuge's' case, reported in Virch. Arch., No. 66, is a notable example of this fact. It involved the atlas and axis of the spinal column and was diagnosed by Von Recklinghausen as carcinoma. Driessen" (Ziegler's Beitrage, Vol. XII, 1893) calls this an endothelioma. He gives a fair expose of both sides of the subject and reports a number of adenomatous-looking growths of the bones which are endothelial in origin.

The case reported by MarckwakV as multii^le endothelioma in many of the bones shows numerous points of resemblance to the carcinomas described. The nodules are soft, brown, splierical and seem to originate in the medullary canal and ])ierce the bone, pushing the periosteum ahead. New bone cancelli are formed in the outgrowths. There is also a dense new bone formation in the medulla and periosteum. There are regular rows of cells, rich in protoplasm and with a large round nucleus. There is little stroma and the whole suggests carcinoma. Red blood corpuscles fill spaces between the epithelium, and these spaces widen greatly in places. Some of the cells are cylindrical and show a broad protoplasmic border next to the lumen. There is no degeneration to be seen. The greatest involvement is in the vertebrae, sternum, ribs and pelvic bones; the skull is also involved. Marchand" reports a case of cylindroma of the antrum of Highmore. In this case the lymph glands too were involved. The tumor resembled " the so-called bone carcinomas."

Against the endothelioma idea may be stated the fact that frequently small non-suspected primary foci of carcinoma have been found where least suspected. See for instance Cohuheim's case of goitre giving metastases, and Von Recklinghausen's remarks on the small size of the tumors of the prostate which can give metastases. Geissler' cites a case of carcinoma of the scapula excised for a primary bone sarcoma, whereas the autojisy revealed a carcinoma of the bladder, the primary growth.

If one were to depend on the shape of the cell and character of its nucleus in differentiating an endothelial growth from one of epithelial origin it is easily conceivable that he could readily err. Hansemann" states that the endothelium in ordinary proliferation looks like epithelium. It becomes cubical and cylindrical and may not have intercellular substance. He can well understand the difficulty Volkmann might have in convincing those not disposed to believe his views about endothelioma, yet he agrees with him. One need only see the diagrams of the capillaries of the uterus of the bat pictured in Bohm and Davidoff's histology to see how confusing this distinction between endothelium and epithelium may become. Orth in his Pathologisch-Anatomisclie Diagnostik states that by increase in size a hyaline swelling of the endothelium of the greatly multiplied vessels may thei-e appear gland-like canals. These appear in sections as if cut in various positions, causing it to resemble gland very closely.

The literature on the subject of endothelioma is too extensive to bring into the bounds of this paper. The work on the tumors of the parotid promises the best field for clearing up this subject.


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This case and those referred to lead us to make the following conclusions:

1. Tumors like carcinoma in bone, without an evident primary focus, must lead one to suspect prostate or thyroid.

2. Endothelioma and carcinoma are not readily distinguished from one another.

3. Statical and traumatic influences are potent in locating the metastases.

4. The new hone formation and location of the metastases are significant of carcinoma of the prostate.

5. The metastases occur by the veins.

6. The organs are rarely the seat of metastases.

7. The pelvic lymph glands may not be involved.

8. Very small nodules of carcinoma may give rise to extensive metastases.

9. There is an extensive new bone formation (osteoplastic carcinosis).

It is due to the kindness of Dr. Branham that we were enabled to get an autopsy and thus prove the origin of the disease. I wish to thank Dr. Liviugood for performing the autopsy at the patient's home.

Bibliography.

1. Von Eeckliughausen : Festschrift zu Rudolf Virchow, 1891.

2. Thompson : Transactions of the Path. Soc. Lond., Vol.V, p. 204.

3. Saase: Arch, fiir klin. Chir., No. 48, p. 593.


4. Marckwald: Virch. Arch., No. 141.

5. Runge: Virch. Arch., No. 06.

6. Driessen: Ziegler's Beitriige, Vol. XII, 1893.

7. Geissler: Arch, fiir klin. Chir., Vol. XLV, p. 704.

8. Cohnheim: Virch. Arch., Vol. 68.

9. Hansemaun: Die mik. Diag. der bosartigen Geschwiilste. Berlin, 1897.

10. Middledorpf : Arch, fiir klin. Chir., Vol. XLVIII, p. 501, 1894.

11. Marchand: Ziegler's Beitriige, Vol. XIII.

Description of the Diagrams.

I. Periosteal new bone with thickened periosteum and tumor.

a, thickened periosteum.

h, carcinoma in the periosteum.

c, new formed bone caucelli of periosteal origin.

d, carcinoma between new formed bone cancelli.

e, degenerated carcinomatous area. /, a blood-vessel.

II. From the medullary cavity of bone.

«, red blood corpuscles filling a dilated alveolus. h, new formed bone.

c, tumor showing cuboidal and cylindrical cells and cystic dilatation of alveoli.

d, degenerated centre of a carcinomatous area.

e, fibrous tissue between the bone caucelli.


GLOSSITIS IN TYPHOID FEVER, WITH REPORT OF A CASE.

By Thomas McCrae, M. B., Assistant Resident Physician, The Johns Hopkins Hospital.


ITie cases of the occurrence of this complication iu typhoid fever reported iu the literature appear to be very few, the condition itself being a comparatively rare one. In over 700 cases of typhoid fever treated in the Johns Hopkins Hospital this is the first time that this condition has been found. In the case to be reported it is of especial interest, iu that it occurred during convalescence from the original attack and ushered in a relapse.

There are numerous references by the older writers to the association of glossitis with the eruptive fevers. Thus, Kerr, writing on glossitis in a Cyclopedia of Practical Medicine published in London in 1833, speaks of "tumefied states of the tongue which occur in typhoid and various fevers attended with an atonic condition of the system." There are numerous references to glossitis coming on during the course of or in convalescence from acute febrile diseases. Clark in his work on the tongue says, "Indeed, slight attacks of intercurrent glossitis are not infrequent in the course of erujitive fevers." But neither he nor Butlin in his " Diseases of the Tongue " refers to any instance in which it occurred with typhoid fever. No reference to the association of the two was to be found in any of the text-books of medicine. Hoffmann in his book on the pathological conditions in typhoid fever does not speak of


it. Sorel' in his statistics of 871 cases does not report its occurrence, nor Freundlich in a statistical report of cases in Freiburg. Eenou' and (lallety-Bosviel,' in special articles on the tongue and mouth iu typhoid fever, do not mention glossitis. The reports of Berg,' Jenner' and Studer," embracing the reports of the examinations of 1984 cases, do not speak of it. Ilolscher," in the statistics of 2000 cases, speaks of "purulent infiltration " of the tongue iu three cases, while Dopfer' in 927 cases found the same condition in two cases.

Nichols' has reported a case of " septic infection in typhoid fever" in which two days before death swelling of the right half of the tongue was noted. The case came to autopsy and the tongue was found red, swollen and glazed in its right half. On section it showed haemorrhages and small abscesses. Cultures yielded streptococci, staphylococci und the colon bacillus. This may perhaps be the same condition as Ilolscher aud Dopfer have spoken of as "purulent infiltration" of the tongue.

The case reported is from Dr. Osier's clinic iu the Johns Hopkins Hospital :

W'. U., aged 27, white, dredger. Admitted on November 27, 1897, with a mild attack of typhoid fever. The previous history was unimportant. The attack was quite characteris


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tic — fever, rose spots, enlarged spleen and the Widal reaction all being present. The temperature fell to normal on the IGth day and he made an uninterrupted recovery. He was discharged on December 31, 1897, on the 37th day of his disease, and after 22 days of normal temperature. He seemed perfectly well on discharge.

On January 3, 1898, the fourth day after leaving the hospital, he was re-admitted, comjilaining of pain in the throat with soreness and swelling of the tongue. He gave a history of having felt well until January 2ud, when he had a chill, soon followed by pain in the head and throat. Swelling of the tongue and behind the jaw accompanied by pain on swallowing also came on. There was no history of the taking of mercury or the application of any irritant. His condition rapidly grew worse until his admission.

On admission — temperature 104.2°, pulse 100, face flushed, the neck full and swollen at the angles of the jaws. The mouth presented a striking picture. The tongue was much swollen, protruding between the teeth and preventing the closing of the mouth. There was a profuse constant flow of saliva. The tongue was red, inflamed, symmetrically enlarged, markedly tender and somewhat indurated as far back as could be felt. No spot of softening could be found. The throat could not be seen. Swallowing was difficult. Cultures were taken from the left half of the tongue by Dr. Gwyn. Bleeding followed the punctures. On the following day the swelling was less and the left half was rather smaller than the right, due probably to the bleeding following the punctures. Two days later there was less swelling, less pain and the mouth could be closed. Three days later the tongue was practically normal.

The temperature, which on admission was 101.2°, fell to


normal on the day after admission and then rose gradually each day until it reached 101° on January 7tb. With this he had a typical relapse, with continued fever, rose spots and enlarged spleen. This lasted for about two weeks and was mild throughout. The temperature fell to normal on the 16th day of the relapse and he was discharged well on January 26th. The cultures from the tongue were negative.

In this case after 31 days of normal temperature the glossitis seemed to be the first symptom of the relapse. The relapse itself was mild save for the severe onset, and as soon as the swelling subsided the patient had no further trouble in swallowing or distress of any kind. The diminution of the swelling in the left half of the tongue after the blood removed in taking the cultures supports the value of the treatment advised in severe cases, namely, free incisions into the substance of the tongue.

References.

1. Sorel : Bull, et mem. soc. med. d'hOp. de Paris, 1889, 3. s., 224-246.

2. Eenou : Bull. Soc. denied, d' Angers, 1875-76, n. s. 89-90, pp. 103-109.

3. Gallety-Bosviel: Oontrib. a I'etude des alterations de la bouche dans la fievre typhoTde. Paris, 1889, No. 233.

4. Berg: Deut. Archiv f. klin. Med., Bd. LIV, Heft 2 and 3, 1895, p. 161.

5. Jenner: Edin. Month. Jour.of Med., 1850, Vol. X, p. 311. G. Studer: Deut. Archiv f. klin. Med., Bd. XLIX, Heft 2

and 3.

7. Holscher: Miinch. Med. Wochen., 1891, pp. 44 and 62.

8. Dopfer: Miinch. Med. Wochen., 1888, p. 621.

9. Nichols : Montreal Medical Journal, 1896, p. 104.


PROCEEDINGS OF SOCIETIES,


THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY.

Meeting of February 21, 1898.

The meeting was called to order by the President, Dr. Barker.

The Bacteriology of Yellow Fever. — Dr. Gko. M. Sternberg, of Wasliington. [Dr. Sternberg gave an interesting review of his bacteriological studies in yellow fever and illustrated his remarks by many excellent lantern slides. As the address was unwritten we regret that it cannot be reproduced. — Editor.]

Discussion.

Dr. Welch. — Dr. Sternberg has presented to us in a most interesting way the history and present status of the bacteriology of yellow fever. Incidentally he spoke of his observation that organs taken fresh from the body and at once wrapped in cloths soaked with sublimate solution frequently show within forty-eight hours development of bacteria in their interior. This is in accordance with our experience. Several years ago Dr. C 0. Miller in my laboratory removed


with antiseptic precautions from recently killed animals the liver, spleen, kidneys and other organs and threw them entire into solutions of sublimate as strong as 1 to 500. Often bacteria developed in the interior of these organs, especially often in the liver.

Dr. Sternberg's bacteriological studies of yellow fever are generally recognized as most trustworthy. He successfully disjiroved the claims of the numerous alleged discoverers of the specific organism of this disease. Dr. Sternberg's attitude of caution as to the acceptance of Sanarelli's bacillus icteroides as the causative agent of yellow fever seems to me entirely warranted in the present state of the evidence. It may be demonstrated that this bacillus is the cause of the disease, but the matter is still open to debate. Weak jioints in the evidence thus far are the small number of cases of yellow fever examined by Sanarelliand the failure to demonstrate his bacillus in nearly half of his cases. His explanation of this failure does not seem to me entirely satisfactory. The results of inoculation of animals by this bacillus are regarded by Sanarelli as a main support of his conclusions, but suggestive and striking as these results are they do not suffice to warrant the statement that yellow fever has been produced exjierimentally by


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inoculation of Sanarelli's bacillus. The remarkable necroses of the liver, of wbich Dr. Sternberg lias shown photographs, may be caused by inoculation with many kinds of bacteria as well as by various toxins.

Probably the strongest argument at present in support of Sanarelli's bacillus as the cause of yellow fever is its agglutination by the blood of yellow fever patients, but here also further observations are needed.

Dr. Booker. — ^The interesting review Dr. Sternberg has given us of his work on yellow fever is a pleasant reminder to me of the time we worked together, in the pathological laboratory of this institution, upon our respective investigations on yellow fever and the summer diarrhceas of infants. Some of the illustrations Dr. Sternberg has exhibited to-night are familiar objects in my work, and it is interesting to note the points of resemblance of some of the toxic lesions and the bacteria found in the two diseases. His picture of the kidney might well be used to represent the condition of this organ in fatal cases of summer diarrha3a. Degeneration of tubular epithelium occurred in nearly all of my cases, and hyaline tube casts were found in the tubules in many cases. The form of degeneration he has represented for the liver in yellow fever I have not seen, but other kinds of degeneration of the liver are often found in fatal cases of summer diarrhoja. We frequently made comparison of the bacteria isolated from our cases, and among other bacteria which showed resemblance was a strongly pathogenic bacillus isolated by Dr. Sternberg from yellow fever patients in Decatur, and, at first, thought to be of considerable importance, which proved to be identical with bacillus a of my series. It is a liquefying bacillus, and causes diarrhcea convulsions, and death when injected subcutaneously in rabbits. When the identity of the two organisms was established Dr. Sternberg abandoned its study, and soon afterwards became interested in bacillus x, which he has just described to us, and which did not resemble any of the bacteria found in my cases.

Although Dr. Sternberg removed from the laboratory before the study of this organism was completed, I remember that he was greatly impressed with its importance, and considered it, even then, to be highly promising.

The rosette colony which he described as a rare growth for the colon bacillus isolated from his yellow fever cases was frequently seen in the cultures of the colon bacillus isolated from the feces of infants affected with summer diarrhoea, especially when the cultures were made in old gelatine.


NOTES ON NEW BOOKS.


Diseases of the Stomach. By John C. Hemmetke, M. B., M. D., Ph. D. (P. Blakialon, Sons & Co., Philadelphia, 1897.)

This large volume of 788 pages is prefaced by an introductory chapter in which Prof. Da Costa is quoted as having said that "books attract books, and, as a rule, any new work in any particular class has a striking familiar resemblance to those already published." The author, in justification of the publication of this work, remarks that "if this new contribution to the pathology and treatment of organic diseases of the stomach does not conform to Da Costa's generalization, it is not because of any premeditated


plan to make it different from other works on the same subject, but because a number of entirely new methods of diagnosis have entered into it, and because an attempt has been made to do justice to the work of American clinicians in this department." Attention is drawn to the extensive contributions made to our knowledge of the normal and diseased stomach and its functions by the clinicians, surgeons, pathologists, anatomists and physiologists of America.

The work of the pultlishers has been well executed, the paper and printing being excellent, while the figures and plates, which are quite numerous, have been well reproduced.

The subject-matter is divided into three parts, all of which are more or less closely related. In each division the various subjects are dealt with in detail.

Part I, which is subdivided into nineteen chapters, deals with the " Anatomy and Physiology of the Digestive Organs — Methods and Technics of Diagnosis." In the chapter on the " Histology of the Stomach " extensive quotations are made from the valuable contributions of Mall and of Bensley on this subject, and two beautiful colored plates devised by Mall on the block system for showing the vascular and lymphatic supply of the various coats of the stomach are reproduced.

The originality of the author is more amply illustrated in this than in any other part of the work. Among others, reference may be made to his method of intubating the duodenum to obtain the intestinal contents ; to his device for determining the capacity of the stomach by the use of a dilatable intragastric rubber bag having the general form of the stomach, the capacity being indicated by the amount of air required to distend the bag sufficiently to just fill the stomach ; and finally to his method of testing the activity and character of gastric peristalsis (also by the use of an intragastric dilatable rubber bag), in which the peristaltic waves are recorded on a kymograph. Whereas these methods may, with further use, yield valuable information, they cannot be expected to come into general use and must necessarily be largely confined to ward and laboratory use.

The chapters on the chemistry of the gastric juice are concise and to the point. Whereas German text-books on diseases of the stomach usually give a greater variety of methods, here only those that have been found of most practical value are described.

In this section we find some inconsistencies in spelling, which cannot altogether be attributed to typographical errors. Thus, on page 6G and in one or two other places we find "von Mehring" instead of " von Mering," which is the usual spelling where this author's name is quoted. Another inconsistency is the manner of spelling the plural of apparatus ; in some places "apparati" and in others "apparatuses" are found.

Part II, comprising nine chapters, is devoted to the " Therapy and Materia Medica of Stomach Diseases." The principles of the dietetic treatment of gastric diseases are dealt with at considerable length. A valuable chapter is devoted to the diet kitchen, and to the preparation of various articles of diet, which cannot help but be of great value to the practitioner in the dietetic treatment of gastric diseases. The therapeutic uses of electricity, mineral waters and various medicinal substances are discussed. Chapters are devoted to the various surgical operations used for the relief of the organic diseases of the stomach, and to the urine and blood in gastric affections.

Part III, subdivided into thirteen chapters, comprises a little more than one-half of the volume. It includes a very thorough consideration of the etiology, symptomatology, pathology and treatment of the various diseases to which the stomach is subject. The different forms of gastritis are described at considerable length.

The chapters on gastric ulcer, malignant growths, gnstroptosis and dilatations, and gastric neuroses are deserving of special mention. In considering the diagnosis of carcinoma ventriculi considerable stress is laid on the diagnostic value of the presence of the Oppler-Boas bacillus in the stomach contents.


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In some chapters the work is less systematic than is desirable. On page 530 the author proceeds to give a resume of the diagnostic factors in carcinoma ventriculi. He divides the tumors under three headings as regards their position, viz. (1) Carcinoma of the cardia ; (2) Carcinoma of the body of stomach, i. e. the curvatures and the fundus and walls ; (3) Of the pylorus. The first two divisions are discussed at length, but one looks in vain for a separate discussion of the last division, the most important, and finds to his disappointment that it has been included under division 2.

Altogether the volume is a very creditable American production. We think that it might, with advantage, have been curtailed at certain points, and certain unnecessary repetitions might have been avoided.

The author shows that he has kept abreast with the current medical literature. The bibliography on all the subjects is very extensive, thus increasing the value of the volume as a book of reference.

Constipation inAdultsand Children. By H. Illoway, M. D. {The Macmillan Company, New York, 1897.)

This work is divided into two parts ; the first consisting of 400 pages dealing with the causes and treatment of constipation in adults ; the second with the same conditions in infants. Under the heading treatment, most attention is given to massage and Swedish movements, illustrated by numerous cheap cuts. The work has many pictures, but most of them are poorly reproduced and do not add essentially to its value. Much space is taken up with long histories of cases of constipation, quoted from other authors, which had better have been omitted or at least abbreviated.

The tendency throughout the work is to magnify the importance of constipation, which, after all is said, is notadiseasebutasymptom.

The author evidently has a "bee in his bonnet" and does not weigh fairly the diiference between cause and effect. He seems to us to be continually putting the cart before the horse and thus injuring his plea. The book should be condensed to be really valuable. It is a mistake and a work of supererogation to devote so much attention to a symptom. One might with equal fairness write a book on headache or stomach-ache.

We do not intend to discuss the author's views, but diflEer essentially with him on many points. We cannot agree in thinking that appendicitis is frequently a result of constipation, or that torpidity of the liver results from it ; after both conditions exist a vicious circle may be set up, but we believe constipation in both these instances rather the result than the cause. As to its effects on the nature and consistency of the chyme there is only doubt, nothing is actually known on this point. The author does not believe that auto-intoxication is the result of constipation, except when the latter is associated with a certain degree of diarrhoea. The question of auto-intoxication is a most obscure one as yet, but we think many of the symptoms so often associated with chronic constipation are the results of this condition and the patient may be said to suffer from autointoxication.

The book will prove helpful to many if they are willing to wade through it, although there is nothing new in it; but constipation is frequently a difficult condition to manage satisfactorily, and the detail of treatment herein described will be appreciated by those who have been troubled by these trying cases.

The Bulletin of the Ohio Hospital for Epileptics. (Puhliahed by the Hospital, Oallipolis, Ohio, January, 189S.)

The first number of this bulletin contains a report of more than ordinary interest and suggestiveness by Ohlmacher, the director of the pathological laboratory. Although divided into two parts it is practically but one paper ; the first half givingthe clinical histories ami pathological findings of six cases of epilepsy which came to autopsy, and the second half being "Upon the resemblance of


the foregoing cases of epilepsy to certain diseases associated with ' thymic hyperplasia."

These six cases all occurred in adults, and all but one suffered from grand mal ; " in Case VI," as the author says, " the unsatisfactory evidences of the existence of epilepsy seem to be verified by the results of the autopsy." In three cases the thymus was found persistent and enlarged, in two others remnants of this gland were found, and in one only that body known as "fatty thymus," which shows no traces microscopically of a true thymus gland. In but one instance did death apparently occur suddenly. To quote again : " While the presence of a persistent or enlarged thymus gland in three of these cases must naturally be regarded as an important matter, itshould be distinctly noted that the presence of the thymus gland makes but a portion of a series of anatomical findings relating to a peculiar hyperplastic condition of the lymphatic structures in the body." In four of the cases other glands such as tonsils, bronchial and mesenteric were found enlarged, in another there was carcinoma, and in that case where only the "fatty thymus" was found no enlargement of lymph glands could be demonstrated.

The importance of this paper rests on the very careful microscopical work done by the pathologist, and the attention he has drawn to the concurrent existence of epilepsy and persistent thymus. In his introduction to the second paper he says : " A study of the literature bearing upon the persistence and enlargement of the thymus gland in human adults, which was suggested by the discovery of a persistent or enlarged thymus in three out of five cases of genuine epilepsy, results in centering attention upon at least two morbid states, one of which has long been suspected to have a clinical aSinity with epilepsy. In these two conditions a third disease may be added on account of the possibility of its morbid anatomical analogy with what we have found in our cases. These three conditions are: 1. Thymic asthma; 2. Sudden death in adults with persistent thymus; and 3. Exophthalmic goitre."

Whatever deductions we may feel inclined to draw from the result of this study of Ohlmacher's, we are grateful for the appearance of such a thorough piece of work and one which is a most valuable contribution to the literature on these conditions. We are still in profound darkness as to the purport of the thymus gland in the human system, or of the whole system of lymph glands, and also as to the causes of epilepsy and exophthalmic goitre. We know that the thymus usually is quite atrophied at the end of the second year of life, but that it does frequently persist and remain active, and that many cases of sudden death have occurred in adults where the only pathological (?) findings were an enlarged, active thymus, with hyperplasia of other lymph glands. The action of its secretion is not yet understood, but it is not hard to believe it possible that in adults its hyper-secretion, or hyposecretion, or perhaps some modified secretion, may give rise to epilepsy. If such a syndrome of toxic symptoms is caused by modifications of the thyroid gland secretion as wesee in exophthalmic goitre, why is it not easy to conceive of epilepsy and even sudden death occurring from changes in the secretion of the thymus? It is more difficult to explain the co-existent lymphatic hyperplasia, but enlargement of the lymph glands is frequently found as a result of toxic influences, and the constant secretion of the thymus gland in adults might readily lead to hyperplasia of the smaller lymph glands. However, it is not worth while to enter into vague speculation as to these conditions. We desire merely to draw attention to this most admirable contribution to our knowledge of the thymus, which has appeared at a most opportune time, when much more attention than formerly is devoted to the study of all the glands, and especially to the large ductless ones of the human system. There are pathologists at other epileptic and insane asylums who have abundant opportunity to investigate these points, and we hope it will not be long before we have further illumina


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[No. 8fi.


tion on these obscure diseases. There are three first-rate illustrations in this article.

The ho.spital board of governors is to be much congratulated on having obtained the services of such an excellent pathologist as Ohlmacher, and the future bulletins of this institution will be awaited with much interest. The remaining papers in this bulletin are of lesser import, but as a first number from a but little known institution we have only words of praise for it and believe that it deserves most hearty recognition from all interested in the science of medicine.

A Text-Book of the Diseases of Women. By Henry J. GAEniouES, A. M., M. D., Professor of Gynecology and Obstetrics in the New York School of Clinical Medicine. Containing three hundred and thirty-five engravings and colored plates. 728 pp. Second edition. {Philadelphia : W. B. Sminders, 1897.)

This neatly bound and well-printed book contains a large amount of information upon diseases of women. The writer has treated the subject in a systematic manner, and his style is clear and for the most part concise. The illustrations are, as a rule, old ones, and mostof the photographs among the new ones are indistinct and show little. The book was written to meet the demands of the medical student and the general practitioner of medicine. One feature of the book which will be of particular value to the medical student is the large number of methods for the surgical treatment of the different gynecological diseases. To meet the demands of the general practitioners of medicine, general treatment is dwelt upon at some length. The chapter upon Anatomy is full, while the paragraphs upon Pathology leave much to be desired. Taken as a whole the work is one of the most complete which we have seen printed in English and will, no doubt, have a large number of readers. G. B. M.

Elements of Latin. For Students of Medicine and Pharmacy. By George D. Ckothers, A. M., M. D., Teacher of Latin and Greek in the St. Joseph (Mo.) High School, and Hiram H. Bice, A. M., Instructor in Latin and Greek in the Boys' High School of New York City, xii-242 pp. (The F. A. Davis Co., Publishers, Philadelphia, New York City, and Chicago, III.)

This is an excellent little book for those who wish to know enough of Latin to write or to read prescriptions and to understand anatomical terms. The method employed is simple and sensible, the vocabularies are carefully selected and the arrangement of the book is good. The "Notes" seem rather far-fetched and are of doubtful utility. They are cumbered with extracts from the U. S. Dispensatory which seem to have little connection with the study of Latin and are of little utility to the student of medicine.


BOOKS RECEIVED.


The American Tear-Book of Medicine and Surgery. Collected and arranged with critical editorial comments. By S. W. Abbott, M. D.,«(! al. Under the general editorial charge of George M. Gould, M. D. 1898. 4to. 1077 pages. W. B. Saunders, Philadelphia.

Orthopedic Surgery. By James E. Moore, M. D. 1898. 8vo. 354 pages. AV. B. Saunders, Philadelphia.

Therapy of the Clinics of the Royal and Imperial Hospital of Vienna, Austria. Translated and revised with notes from the last two compilations of Earnest Landesmann, M. D. By John H. Metzerott, M. D. 1897. 12mo. 765 pages. Fergus Printing Co., Chicago.

The Diseases of Infancy and Childhood. By L. Emmett Holt, A. M., M. D. 1898. 8vo. 1117 pages. D. Appleton & Co., New York.


Prize Essays on Leprosy. Thompson. Cantlie. 1897. 8vo. 413 pages. The New Sydenham Society.

A Guide to the Clinical Examination of the Blood for Diagnostic Purposes. By Richard C. Cabot, M. D. 1897. Svo. 405 pages. William Wood & Co., New York.

The Medical Annual and Practitioner's Index. 1898. Sixteenth year. 12mo. 847 pages. John Wright & Co., Stone Bridge, Bristol.

Transactions of the College of Physicians of Philadelphia. Third series. Vol.19. 1897. 8vo. 256 pages. Printed for the College, Phila.

Diseases of the Stomach. In three parts. By John C. Hemmeter, M. B., M.D., Ph.D. 1897. Svo. 788 pages. P. Blakiston, Son& Co., Phila.

Atlas of Methods of Clinical Investigation, with an Epitome of Clinical Diagnosis and of Special Pathology and Treatment of Internal Diseases. By Dr. Christfried Jakob. Authorized translation from the German. Edited by A. A. Eshner, M. D. 1898. 12mo. 259 pages. W. B. Saunders, Phila.

The Surgical Complicationsand Sequels of Typhoid Fever. By William W. Keen, M.D., LL. D. Based upon tables of 1700 cases. Compiled by the author and by Thompson S. Westcott, M. D. With a chapter on the Ocular Complications of Typhoid Fever. By G.

E. de Schweinitz, A. M., M. D. And as an appendix the Toner Lecture, No. V. 1898. Syo. 386 pages. W. B. Saunders, Phila.

A Compendium of Insanity. By John B. Chapin. 1898. 12mo. 234 pages. W. B. Saunders, Phila.

Doctor and Patient : Hints to Both. By Dr. Robert Gersuny. Translated by A. S. Levetus. With a preface by D. J. Leech, M. D.,

F. R.C. P., etc. 1898. 12mo. 79 pages. John Wright & Co., Bristol.

Annual and Analytical Cyclopccdia of Practical Medicine. By Charles E. de M. Sajous, M. D., and one hundred associate editors, assisted by corresponding editors, collaborators and correspondents. Vol. I. 1898. 4to. 601 pages. The F. A. Davis Co., Publishers. Philadelphia, New York, Chicago.

A Modern Pathological and Therapeutical Study of Rheumatism, Oout, Rheumatoid Arthritis and Allied Affections. By Edmund L. Gros, M.D., of the Faculty of Paris. {Translated from the French.) 1897. 16mo. 47 pages.

The Anatomy and Functions of the Muscles of the Hand and of the Extensor Tendons of the Thinnb. By J. Francis Walsh, M. D. Essay awarded the "Boylston" prize for 1897, Department of Anatomy and Physiology, by the Boylston Medical Committee. Boston, Mass. 1897. 8vo. 51 pages. Charles H. Walsh, Philadelphia.

An American Text-Book of Oenito-Urinary Diseases, Sy2>hilis and Diseases of the Skin. Edited by L. Bolton Bangs, M. D., and W. A. Hardaway, A. M., M. D. 1898. 4to. 1229 pages. W. B. Saunders, Philadelphia.

Medical and Surgical Reports of the Boston City Hospital. Ninth Series. Edited by C. F.Folsom, M. D., AV.T. Councilmaii, M. D., and Herbert L. Burrell, M. D. 1898. Svo. 276 pages. Published by the Trustees, Boston.

DESCRIPTION OF THE JOHNS HOPKINS HOSPITAL.

By John S. Billinos, M. D., LL. D.

Containing 56 large quarto plates, phototypes, and lithographs, with views, plans and detail drawings of all buildings, and their interior arrangements — also woodcuts of apparatus and lixtures ; 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.


May, 1898.J


JOHNS HOPKINS HOSPITAL BULLETIN.


123


PUBLICATIONS OF THE JOHNS HOPKINS HOSPITAL.


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

Report in Pathologry.

The Vessels and Walls o( the Dog's Stomach; A Study of the Intestinal Contraction: Healing of Intestinal Sutures; Reversal of the Intestine; The Contraction of the Vena Portae and its Influence upon the Circulation. By F. P. &fALL, 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 Dermatolof^y.

Two Cases of Protozoan (Coccidioidal) Infection of the Skin and other Organs. By T. C. Gilchrist, M. D., and Emmet Rixford. M. D.

A Case of Blastomycetic Dermatitis in Man; Comparisons of the Two Varieties of Protozoa, and the Blastomyces found in the preceding Cases, with the so-called Parasites found in Various Lesions of the Sliin, etc. ; Two Cases of Molluscum Fibrosum; The Pathology of a Case of Dermatitis Herpetiformis (Duhring). By T. 0. Gilchrist, M. D.

Report in Patlioloery.

An Experimental Study of the Thyroid Gland of Dogs, with especial consideration of Hypertrophy of this Gland. By W. S. Halsted, M. D.


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

Report in Meiliclne.

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

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

Report in Medicine.

Tubercular Peritonitis. By William Osler, M. D.

A Case of Raynaud's Disease. By H. M. Thomas, M. D.

Acute Nephritis in Typhoid Fever. By William Osler, M. D.

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

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

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

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

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

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

A. 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 Neurologry* I.

A Case of Chorea Insaniens. By Henry J. Berkley, M. D. Acute Angio-Neurotic Oedema. By Charles E. Simon, M. D. Haematomyelia. By August Hoch, M. D.

A Case of Cerebro-Spinal Syphilis, with an unusual Lesion in the Spinal Cord. By Henry M. Thomas, M. D.

Report in Patliologry, I.

Amoebic Dysentery. By William T. Cooncilman, M. D., and Hinri A. Latleub, M. D.


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

Report in Pattiologry.

Papillomatous Tumors of the Ovary. By J. Whitridoe Williams, M. D. Tuberculosis of the Female Generative Organs. By J. Whitridoe Williams, M. D.

Report in Patlioloey.

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

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

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

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

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

Report in Gynecology.

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

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

Intestinal Worms as a (jompUcatioo in Abdominal Surgery. By A. L. Stavily, M. D.


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

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

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

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

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

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

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

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

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

Record of Deaths occurring in the Gynecological Department from June 6, 1890, to May 4, 1S92.


Volume IV. 504 pages, 33 charts and illustrations.


Report on Typlioid Fever.


Report in Nenrolosry.

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 Subma.\illary Gland of Miis mitsculus; The Intrinsic Nerves of the Thvroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Henry J. Berkley,

Report in Surgery.

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

Report in Gynecology.

Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis; Tuberculosis of the Endometrium. By T. S. Cullen, M. B.

Report in Pathology.

Deciduoma Malignum. By J. Whitridoe Williams, M. D.


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

CONTENTS

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

Stndles 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 Nob. 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 (Ethvl Alcohol). 2. Experimental Lesions produced by Acute Alcoholic Poisoning (Ethyl Alcohol) ; Part II.— Serum Poisoning. — Experimental Lesions induced by the Action of the Dog's Serum on the Cortical Nerve Cell; Part 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 Patliology.

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

Cullen, M. B. Pregnancy in a Rudimentary Uterine Horn. Rupture, Death, Probable Migration of

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

William D. Booker, M. D. The Pathology of Toxalbumin Intoxications. By Simon Flexner, M. D. T7ie pricp of n Di-t hound in cloth [Tols. T-TI] of the Hospital Jtrports in

$30.00. roll. I, II and III are not sold separately. The price of

Vols, ir, r and ri is $5.00 each.


Monographs.

The following papers are reprinted from Vols. I, IV, V and VI of the Keports. for those who desire to purchase in this form : STUDIES IN DERMATOLOGY. By T. C. Gilchrist, M. D., and Emmet Rixpord,

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 Lewei.lyb F. Barker, M. B. 1 volume of 280 pages. Price, in paper, $2.75. STUDIES IN TYPHOID FEVER. By William Osler, M. D., and others. Extracted

from Vols. IV and V of the Johns Hopkins Hospital Reports. 1 volume of 481

pages. Price, bound in paper, $3.00. THE PATHOLOGY OF TOXALRTTMIN INTOXICATIONS. Bv .=lnion Flexner, M. D.

volume of 1.10 pages with I full-page llthogniphs. i rice, bound in paper, J'i.OO. Subscriptions for the above publications may be sent to

The Johns Hofkins Press, Baivumou, Ho.


124


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 86.


THE JOHNS HOPKINS MEDICAL SCHOOL. SESSION 1897-1


FACULTY.


Dahiel O. Oilman, LL. D., President.

William H. Welch, M. D., LL. D., Dean and Professor of Pathology.

Ira Remsen, M. D., Ph. D., LL. D., Professor of Chemistry.

WiLLiAU OsLER, M. D., LL. D., F. R. C. P., Professor of the Principles and Practice

of Medicine. Henry M. Hdrd, M. D., LL. D., Professor of Psychiatry. WiLLiAU S. Halsted, M. D., Professor of Surgery. Howard A. Kelly, M. D., Professor of Gynecology and Obstetrics. Franklin P. Mall, M. D., Professor of Anatomy. John J. Abel, M. D., Professor of Pharmacology. William H. Howell, Ph. D., M. D., Professor of Physiology.

William K. Brooks, Ph. D., LL. D., Professor of Comparative Anatomy and Zoology. John S. Billings, M. D., LL. D., Lecturer on the History and Literature of Medicine. Alexander C. Abbott, M. D., Lecturer on Hygiene. Charles Wardell Stiles, Ph. D., M. S., Lecturer on Medical Zoology. Robert Fletchlr, M. D., M. R. C. S., Eng., Lecturer on Forensic Medicine. William D. Booker, M. D., Clinical Professor of Diseases of Children. John N. Mackenzie, M. D., Clinical Professor of Laryngology and Rhinology. Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology. Henrt M. I'homas, M. D., Clinical Professor of Diseases of the Nervous System. Simon Flexner, M. D., Associate Professor of Pathology. J. Whitridge Williams, M. D., Associate Professor of Obstetrics. Lewellys F. Barker, M. B., Associate Professor of Anatomy. William S. Thayer, M. D., Associate Professor of Medicine. John M. T. Finney, M. D., Associate Professor of Surgery.


Georob p. Dreter, Ph. 0., Associate in Physiology.

William W. Russell, M. D., Associate in Gynecology,

Henry J. Berkley, M. D., Associate in Neuro- Pathology.

.1. Williams Lord, M. D., Associate in Dermatology and Instructor in Anatomy.

T. Caspar Gilchrist, M. R. C. S., Associate in Dermatology.

Robert L. Randolph, M. D., Associate in Ophthalmology and Otology.

Thomas B. Aldrich, Ph. D., Associate in Physiological Chemistry.

Thomas B. Futcher, M. B., Associate in Medicine.

Joseph C. Bloodgood, M. D., Associate in Surgery.

Thomas S, Cullen, M. B., Associate in Gynecology.

Ross G. Harrison, Ph. D., Associate in Anatomy.

Frank R. Smith, M. D., Instructor in Medicine.

George W. Dobbin, M. D., Assistant in Obstetrics.

Walter Jones, Ph. D., Assistant in Physiological Chemistry.

Adolph G. Hoen, M. D., Instructor in Photo-Micrography.

Sydney M. Cone, M. D., Assistant in Surgical Pathology.

Louis E. LiviNGOOD, M. D., Assistant in Pathology.

Henry Barton Jacobs, M. D,, Instructor in Medicine.

Charles R. Bardeen, M. D., Assistant in Anatomy.

Stewart Paton. M. D., Assistant in Nervous Diseases.

Norman McL. Harris, M. B., Assistant in Pathology.

Harvey W. Ccshing, M. D., Assistant in Surgery.

J. M. Lazear, M. D., Assistant in Clinical Microscopy.

J. L. Walz, Ph. O., Assistant in Pharmacy.


GENERAL STATEMENT.

The Medical Department of the Johns Hopkins University was opened for the instruction of students October, 1893. This School of Medicine is an integral and coordinate part of the Johns Hopkins University, and it also derives great advantages from its close affiliation with the Johns Hopkins Hospital.

The required period of study for the degree of Doctor of Medicine is four years. The academic year begins on the first of October and ends the middle of June, with short recesses at Christmas and Easter.

Men and women are admitted upon the same terms.

In the methods of instruction especial emphasis is laid upon practical work in the Laboratories and in the Dispensary and Wards of the Hospital. While the aim of the School is primarily to train practitioners of medicine and surgery, it is recognized that the medical art should rest upon a suitable preliminary education and upon thorough training in the medical sciences. 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.

REQUIREMENTS FOR ADMISSION.

As candidates for the degree of Doctor of Medicine the school feceives :

1. Those who have satisfactorily completed the Chemical-Biological course which leads to the A. B. degree in this university.

3. Graduates of approved colleges or scientific schools who can furnish evidence ; (a)'That they have acquaintance with Latin and a good reading knowledge of French and German ; (6) That they have such knowledge of physics, chemistry, and biology as is imparted by the regular minor courses given in these subjects in this university.

The phrase "a minor course," as here employed, means a course that requires a year for its completion. In physics, four class-room exercises and three hours a week in the laboratory are required; in chemistry and biology, four class-room exercises and five hours a week in the laboratory in each subject.

S. Those who give evidence by examination that they possess the general education implied by a degree in arts or in science from an approved college or scientific school, and the knowledge of French, German, Latin, physics, chemistry, and biology above indicated.

Applicants for admission will receive blanks to be filled out relating to their previous courses of study.

They are required to furnish certificates from officers of the colleges or scientific schools where they have studied, as to the courses pursued in physics, chemistry, and biology. If such certificates are satisfactory, no examination in these subjects will be required from those who possess a degree in arts or science from an approved college or scientific school.

Candidates who have not received a degree in arts or in science from an approved college or scientific school, will be required (1) to pass, at the beginning of the session in October, the matriculation examination for admission to the collegiate department of the Johns Hopkins University, (2) then to pass examinations equivalent to those taken by students completing the Chemical-Biological course which leads to the A. B. degree in this University, and (3) to furnish satisfactory certificates that they have had tlie requisite laboratory training as specified above. It is expected that only in very rare instances will applicants who do not possess a degree in arts or science be able to meet these requirements for admission.

Hearers and special workers, not candidates for a degree, will be received at the discretion of the Faculty.

ADMISSION TO ADVANCED STANDING. Applicants t<iradmlssirm to advanced standlug must furnish evidence (1) that tho foregoing terms of admission as regards prelliniuary training have been tulfllled, (2) that courses equivalent in lilud and amount to those given here, preceding that year of the course for admission to which application is made, have been satlstactorliy completed, and (3i must pass examinations at the beginning of the session In October In all the subjects that have been already pursued by the class to which admission is sought. Certifloates of standlug elsewhere caunot be accepted in jilace of these examinations.

SPECIAL COURSES FOR GRADUATES IN MEDICINE.

Since the opening of the Johns Hopkins Hospital in 1889, courses of instruction have been offered to graduates in medicine. The attendance upon these courses has steadily increased with each succeeding year and indicates gratifying appreciation of the special advantages here afforded. With the completed organization of the Medical School, it was found necessary to give the courses intended especially for physicians at a later period of the academic year than that hitherto selected. It is, however, believed that the period now chosen for this purpose is more convenient for the majority of those desiring to take the courses than the former one. The special courses of instruction for graduates in medicine are now given annually during the 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-Ui-inary 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, bedside 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 tliat they are prepared to profit by the opportunities here ofi'ered. The number of students who can be accommodated in some of the practical courses is necessarily limited. For these the places are assigued according to the date of application.

The Annual Announcement and Catalogue will be sent upon application. Inquiries should be addressed to the

REGISTRAR OF THE JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE.


The Johns Hopkins Hospital Bulletins are issued montMy. They are printed by THE FRIEDENWALD CO., Baltimore. Single copies may be promred from Messrs. CUSHINO & CO. and the BALTIMORE NEWS COMPANY, Baltimore. Subscriptions, $1.00 a year, maybe addressed to the publisliers, THE JOHNS HOPKINS PRESS, BALTIMORE ; single copies will be sent by mail for fifteen cents each.


BULLETIN


OF


THE JOHNS HOPKINS HOSPITAL.


Vol. IX.- No. 87.]


BALTIMORE, JUNE, 1898.




coisTTDEJisrars.


PAGE.

A Microscopical Study of the Spinal Cord in Two Cases of Pott's Disease. By William G. Spiller, M.D., ----- 125

Note on the Osteoid Tissue found in the Tubercular Exudate in the Thoracic Region of the Cord. [Dr. Flexner], - -133

A Case of Osteitis Deformans. By AVm. T. Watson, M. D., - 133

The Rise of the Theory of Electrolytic Dissociation, and a few of its Applications in Chemistry, Physics, and Biology. By Harry C. Jones, Ph. D.,

Localized Scleroses of the Aorta of Probable Syphilitic Origin. Clinical Report and Necropsy in two Cases. By Clement A. Penrose, M. D., .--.- -...


136


140


Further Remarks on Adeno-Myoma of the Round Ligament. By Thomas S. CuLLBN, M.B., - - - •- 142

Proceedings of Societies :

Hospital Medical Society, - . - - 144

Regeneration of the Dorsal Root of the Second Cervical Nerve within the Spinal Cord [Messrs. Baer, Dawson and Marshall] ; — Hydraulic Pressure in Genito-Urinary Practice [Dr. H. H. Young] ; — Forty-six Intubated Cases of Diphtheria treated with Antitoxine [W. T. Watson, M. D.].

Notes on New Books, _.___- 147

Books Received, ---------- 148


A MICROSCOPICAL STUDY OF THE SPINAL CORD IN TWO CASES OF POTT'S DISEASE.*

By William G. Spillee, M. D., Professor of Diseases of the Nervous Si/s^em in the PhiladelpMa Polyclinic; Associ(de in the William Pepper Laboratory of Clinical Medicine, Univerdty of Pennsylvania.

[From the William Pepper Labofatory of Clinical Medicine.]


We have learned much about spinal caries since Percival Pottf wrote his work on this disease so many years ago, but we have not exhausted the subject, and it is still one of much interest.

The two cases which I have the honor to present for your consideration represent two forms of the affection, an early and a late; one in which the cord has not been comjjressed by displaced vertebraj, and one — and rather a rare variety — in which the cord has been almost severed as the result of such displacement in connection with an extradural tuberculous


The cause of the compression is only mentioned in thirtynine of the fifty-two cases of paralysis from spondylitis which Schmaus collected from the literature;! in thirty-three of these a caseous pachymeningitis was noted; in six the com


Read by invitation before the Johns Hopkins Hospital, January 17th, 1898.

fPott, Remarks on that kind of palsy of the lower limbs which is frequently found to accompany a curvature of the spine, etc. The Chirurgical Works of Percival Pott, F. R. S., Vol. III.

t Die Compression-Myelitis bei Caries der Wirbelsiiule. Wiesbaden, 1890. J. F. Bergmann. Quoted by Kraske.


pression was caused by dislocation of the vertebra^ and in five of these six the odontoid process of the axis was dislocated. Therefore only in one of thirty-nine cases the compression was due to kyphotic displacement. Kraske* adds to this number and shows that only in one case out of fifty-two was the compression of the cord due to deviation of the vertebn« alone (omitting the five cases above mentioned). He tells us that only in about two per cent, of the cases the paralysis from spondylitis is caused by kyphosis alone; in all the rest it is due to compression from a peripuchymeningitic exudate.

The case B. H. is, therefore, one of considerable interest, for the compression was chiefly due to displaced vertebrae, though there was also a peripachymeningitis.

The first case — for which I am indebted to Dr. Willard and Dr. Lloyd — was in a boy of about twelve years of age. Dr. Lloyd, who frequently saw the patient during his lifetime, told me that the boy had complained of great pain in the region of a cervico-thoracic kyphosis. He was not paralyzed. Before death dyspncea became intense, and Dr. Lloyd believed


Kraske, Archiv fiir klin. Chirurgie, Vol. XLI.


126


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[No. 87.


that death was due to paralysis of the respiratory muscles. This was possibly the result of intense round cell infiltration of the cord in the mid-cervical region where the phrenic nerve has its origin.

The report of the necropsy is as follows: The hody was that of a much emaciated boy. Kyphosis was present without scoliosis, and the prominence was at the fifth, sixth, seventh cervical and first thoracic vertebra;, and was greatest at the junction of the seventh cervical with the first thoracic. Much pus was found within the cervical portion of the vertebral canal, external to the dura. The dura was adherent by its anterior surface to the bodies of the seventh cervical and first thoracic vertebra, and a cheesy, fibrous mass was observed on its ventral and external surface. The bodies of the lower cervical and first thoracic vertebra; were carious and yielded to slight pressure from a blunt instmment. No tuberculous lesions were found elsewhere.

The spinal cord was not compressed and secondary degeneration was not noted. The chief interest of this case lies in the fact that it shows the earlier stages of Pott's disease — whereas the following case shows the late— and presents a very intense round cell infiltration of the meninges and cord, without specific signs of a tuberculous process interior to the dura. Such signs are, however, very abundant in the mass external to the dura. The dura has acted to some degree as a barrier, but it also shows some round cell infiltration. Along the periphery of the lateral columns in the upper thoracic region spaces are found from which the nerve fibres have disappeared, and in some sections a few swollen axis cylinders are seen. There is very distinct perivascular infiltration of round cells within the cord ; this is well marked at the mid-cervical region and involves the vessels of all parts of the transverse area, and is noticed also within the anterior horns. The perivascular infiltration is especially noticeable at this level, about the vessels of the anterior fissure and posterior septum. In the posterior columns of the mid-cervical region necrotic areas are seen, which stain faintly with Weigert's hajmatoxyliu solution and show a diminution in the number of nerve fibres. When the carmine and Delafield's hematoxylin are used, moderate round cell infiltration, some proliferation of neuroglia, and some slight swelling of the axis cylinders are noticed in these areas. This necrosis is probably dependent on the vascular condition. No other necrotic areas have been noticed within the cord. The motor cells of the mid-cervical region do not appear greatly altered, but unfortunately the method of Nissl could not be used. In the first and second cervical segments the infiltration is much less in intensity, but it is very distinct in the lumbar region, where the vessels are also much dilated.

The anterior roots in the upper thoracic region are greatly degenerated, but the posterior have partially escaped. The motor cells in this portion of the cord are distinctly altered. The Marchi stain does not reveal degenerated fibres.

In the mass external to the dura many giant cells, large collections of round and epithelioid cells, and caseous areas are found.

The second case, for which I am indebted to Dr. Willard, is as follows: The child, B. H., came of a tuberculous family and suffered from bronchitis every winter. The evidences of


Pott's disease first appeared when the patient was three years of age. She complained of pain in the back, and kyphosis was soon afterward noticed. About four months after the first evidences of the disease were detected the child was found to be liable to fall without sufficient cause. A year later the tendons of both heels were operated on, a fact which shows that the disease progressed rapidly. At eight years of age prominence of the first, second and third thoracic vertebra?, atrophy of the legs with paralysis, contracture of the hamstring tendons, and large sores over the hip-joints were noticed. The child died when eight years old; the process, therefore, lasted five years. It is stated that she had had no power of motion in the legs and no control of the bladder, although rectal disturbance had not been noted.

When the vertebral column was examined at the necropsy the body of the seventh cervical vertebra was found almost at a right angle with that of the first thoracic. The latter was carious and yielded to slight pressure from a blunt instrument. Permission was not obtained to remove any of the bony part of the spinal column, and more careful examination of the vertebrse could not be made. The cord was very small in the region corresponding to the prominence made by the first thoracic with the seventh cervical vertebra, and had evidently very little space for growth. The unusual degree of compression was possibly the result of the development of the Pott's disease at the early age of three years. Segments an inch above or below the seat of compression were much larger. The compressed portion was soft and was removed with difficulty. A cheesy fibrous mass was found adherent to the external and right side of the dura, extending downward about an inch, and upward about half an inch from the compressed region, and together with the displaced vertebrae had caused the signs of compression. The dura was not adherent to the cord, and no evidence of internal meningitis was present.

Dr. Sailer examined the thoracic and abdominal viscera and found areas of pneumonic infiltration in the stage of red hepatization in the middle lobe of the right lung and in the lower part of the upper lobe of the left.

After the spinal cord had been hardened it was examined microscopically. In the region of greatest compression, at the cervico-thoracic junction of the vertebrse, the cord contains very few medullated fibres, and even those present are most irregularly arranged. It is impossible to make any distinction between gray and white matter. The vessels within the cord are sclerosed. Numerous nuclei, both round and elongated, are found in all parts of the sections, and some of a these probably represent a round cell infiltration. No nerve ^ cells are observed. The pia is much thickened and contains altered blood pigment. Both anterior and posterior roots external to the cord are in a fairly good state of preservation. The vessels within the cord stand out prominently from the surrounding tissue as faintly stained pink patches when the carmine is used, and as pale yellow ones with Weigert's hamiatoxylin. The central canal is closed at this portion of the cord.

Sections two to three root segments above the area of greatest compression show the central canal quite widely open. There is little round cell inliltration. The columns of Goll,


JCJNE, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


127


with the esceptiou of a few fibres along their jieriphery, are greatly degeuenited. These few normal fibres have probably escaped destruction at the area of compression. A few scattered normal fibres are found also in other parts of these columns. Kormal fibres from the posterior commissure are distinctly seen passing into the degenerated columns of Goll. Burdach's columns also are not free from degeneration. The direct cerebellar tracts and columns of Gowers are much degenerated, but just below the motor decussation many medullated fibres may be seen within the former; it would seem, therefore, that these tracts are partly formed by nerve fibres whose cells are situated above the lower cervical region, or that — and this is more probable — fibres of the crossed pyramidal tracts are more intimately mingled with those of the direct cerebellar tracts at this level. Very distinct ascending degeneration of the lateral columns in the area of the crossed pyramidal tracts is noted, and this extends through several root segments and gradually disappears above the mid-cervical region. The direct pyramidal tracts show an ascending degeneration of less intensity.

Below the compressed area the horns of the cord gradually assume their normal form, and medullatecl fibres first appear nearest the gray matter and gradually increase in extent toward the periphery. The crossed pyramidal, Gowers', and the direct cerebellar tracts are greatly degenerated, and the direct pyramidal is also involved. Very few medullated fibres are found in the area of the lateral motor tracts below and near the region of compression, and though the number of these increases as lower levels of the cord are examined, they are never as abundant as one might expect. There are, therefore, associative fibres within the crossed pyramidal tracts, but their number is limited.

In the lateral columns the degeneration extends considerably in advance of that marked out as the area of the lateral motor columns by secondary degeneration from cerebral lesions. Degeneration of the peripheral part of the anterior columns near the anterior fissure may be ti'aced well into the mid-lumbar region.

The central canal is enlarged both above and below the cervico-thoracic junction, and in the lumbar region is surrounded by so much gliar tissue that it almost resembles the condition frequently seen in syringomyelia. Very distinct degeneration is seen in the posterior columns below the area of compression, not limited to Schultze's comma zones, and involving most of the transverse area of the posterior columns, except at their periphery, where the long neurones from the lumbo-sacral cord are found. This degeneration may be traced fully three and a half to four centimetres below the compressed portion of the cord.

The cells of the anterior horns in the lumbar cord appear to be normal both in shape and number, but Clarke's columns are entirely deprived of cells throughout their extent in the thoracic region, and in the upper part of the lumbar cord, where they contain normally very many cells, they present the usual form but are without cells. The fibres within these columns from the posterior roots are normal in number. Careful seai-ch may possibly reveal here and there an atrophied cell in these columns.


This is evidently a case in which compression has played the chief role, but there is some round cell infiltration about the vessels of the pia and certain of those of the cord as far as the lower thoracic region.

The Marchi stain reveals degenerated fibres scattered all over the transverse area of the cord below the compression, but these are most numerous in the anterior columns.

The ascending degeneration in the pyramidal tracts, both crossed and direct, observed in the case B. H., is worthy of mention. In the crossed pyramidal tract this is more distinct than in the direct, and extends through several cervical segments. This retrograde degeneration has formed the subject of study in a number of cases, and in 1896, in the American Journal of the Medical Sciences, Dercum and Spiller gave the literature on the subject so far as they were able to obtain it. It has been explained by some writers, and especially by Sottas, as an upward degeneration in motor fibres which, of course, conduct impulses downward ; by others it has been thought to be an involvement of associative fibres — of fibres which arise within the spinal cinerea, pass out into the lateral column and terminate within the cinerea at higher levels. In favor of the first view is the fact that it is found usually in processes of long duration, for I am unaware that it has been described as occurring in any acute process, which we should expect would be the case if it is merely a cellulifugal degeneration. Then again, when the remaining part of the lateral column and the crossed pyramidal tract are degenerated the process often does not extend so far upward in the former as in the latter. Thus Hoche* mentions degeneration of fibres in the lateral column, not belonging to any known system, extending through three segments above the focal lesion, and of the crossed pyramidal tract extending through seven segments. It is not easy to explain this on the assumption that longer associative fibres are found in the crossed pyramidal tract than in the remaining part of the lateral column. " The law of the excentric position of the long tracts in the spinal cord " (Flatau, Zeitschrift f. klin. Med., Vol. XXXIII, Nos. 1 and 2), which simply means that the long fibres take a peripheral and posterior location, might possibly be used as an argument. Eggerf explains the retrograde degeneration of the crossed pyramidal tracts, observed in his case, by the theory that it represented short fibres, and that sclerosis occurred when these fibres were degenerated, and that this in turn caused degeneration of the long pyramidal fibres. I have several times observed this retrograde degeneration of the motor tracts and am convinced that it is more common than is usually supposed. In my case B. H. the normal fibres in the crossed pyramidal tract below and near the focal lesion are not numerous. Below the transverse lesion these ascending associative fibres, having their origin in the sjiinal cinerea, should not be affected, and they should be in normal number, if retrograde degeneration is to be discarded. If we grant that retrograde degeneration may occur in associative fibres, we should be at a loss to explain why the pyramidal fibres are not subject to the same laws, and we must


Hoche, Archiv fiir Psychiatrie, Vol. XXVIII, 189G. f Egger, Archiv fiir Psychiatrie, Vol. XXVII.


128


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[No. 87.


grant the possibility of this form of degeneration in order to exphiin the degeneration of the direct cerebellar tracts below the transverse lesion in this case.

lu the direct pyramidal tracts the degeneration possibly is confined to Marie's* sulco-marginal zones, but does not extend very far upward. 1 know of no way in which the question as to whether it involves associative fibres here, or fibres of the direct motor tracts, may be settled. These areas may degenerate upward for a long distance. Iloche (1. c), for instance, has traced this degeneration from a lesion in the mid-thoracic region into the motor decussation, and Dercum and Sjiiller (/. c.) traced it from the upjier thoracic region to the same point.

The degeneration of Gowers' tract below the lesion, which is observed in the case B. H., has been found also in other cases, and it seems to be generally held that this tract contains fibres which conduct impulses in both directions. Hoche (/. 6".) in a case with a lesion of the mid-thoracic region found this bundle degenerated below the lesion as far as the lower lumbar cord. This is where many neuropathologists believe the bundle arises, — at a lower level than the direct cerebellar tract. Daxenbergert and others speak of descending degeneration of Gowers' tract.

The fact that fibres of the antero-lateral column not belonging to any known system degenerate only a few segments either above or below a transverse lesion of the cord has been observed in many cases. This may be well seen in the case B. H. The restoration of fibres in the antero-lateral column begins always nearest the cinerea, for these in this portion are short associative fibres, and the Grenzschicht of Flechsig is never degenerated through any great extent of the spinal cord. This is in conformity with "the law of the excentric position of the long tracts in the spinal cord." (Flatau, I. c.)

As a rule the comma zonesof the posterior columns can only be traced a short distance by Weigert's stain, two, three or four segments, but when the Marchi method has been employed they have been followed much further. In the case B. H. they are not sharply separated from the degenerated fibres in the rest of the posterior columns, though the area occupied by them is possibly slightly paler by Weigert's stain. This generalized degeneration of the posterior columns seems to me well worthy of note, for it can be followed four centimetres below the focal lesion, through several segments, in portions of the cord in which the gray matter is apparently normal. It seems to be more extensive than that we are accustomed to speak of as the traumatic zone, for according to Schiefferdecker the traumatic degeneration extends above or below a focal lesion only about J to 1 cm. (quoted by Worotynski, Neurologisches Centralblatt, No. 23, 1897). I am inclined to regard this descending degeneration in the posterior columns as retrograde, if we have the right to use such a term for a process which is more one of atrophy than degeneration. It may be that the development of the compression at the early age of


Marie, Lerons sur les maladies de la moelle. Paris, 1892. fDaxenberger, De itsche Zeitschrift fiir Nervenheilkunde, Vol


IV.


three years explains this condition, for we have been taught that the pyramidal fibres are not fully developed until the fourth year of extra-utei'ine life. We know that the fibres of the posterior columns receive their medullary sheaths quite early, but it is possible that at the third year of extra-uterine life— if we can believe that the compression of the cord in the case B. H. was already well developed at that period — these fibres are less resistant than they are later.

Similar diffuse descending degeneration in the posterior columns below the area of compression has been noticed in a case of Pott's disease by Fiirstner. In his case the compression was at the level of the ninth thoracic vertebra. He describes the lesion as follows : " There is a degeneration in the posterior columns which is not very intense, but which may be traced into the lumbar region, and occupies almost the entire width of the posterior columns, with the exception of the peripheral })ortion of these columns and of the well known band of fibres which has its course parallel to the posterior horns." This degeneration of the posterior columns Fiirstner* regarded as wider than that we not infrequently see in Schultze's comma zones.

Cellulipetal degeneration of sensory fibres has been considered a rare occurrence, and indeed I have seen the statement (Nageottef) that retrograde intramedullary degeneration of posterior root fibres has never been observed. It would be difficult to explain the descending degeneration of the posterior columns as an involvement of the associative fibres, for V. LenhossekJ tells us that positively there are only a few cells in the posterior horns which send their axis cylinders into the posterior columns.

The descending degeneration of the direct cerebellar tracts has not been frequently mentioned, and the completeness of it in the case B. H. is possibly due to the early age of the patient at the time the destruction began. Striimpell,§ Daxenberger,|| and BischofTTf have spoken of it, and Bischoff thinks it is possible that the destruction of the direct cerebellar tract in his case may have had a connection with the descending cerebellar fibres described by Biedl.** In his case the cells of Clarke's column were normal. Thomas,ftin lesions experimentally produced on the cerebellum in the dog, found atrophy of these cells. In Daxenberger's (I. c.) case also these cells were not normal in number and size, nor were they normal in Striimpell's {I. c.) case. I have, therefore, searched carefully for cells in Clarke's column in the case B. H. and have been unable to find them, even in the lumbo-thoracic segments, where normally they are most abundant. A very few atrophied cells may be found by diligent search. The fibres within Clarke's columns are normal in appearance, as we should expect them to be, inasmuch as most of them come


Fiirstner, Archiv fiir Psycliiatrie, Vol. XXVII. f Nageotte, Revue Neurologique, 1 895.

I v. Lenhosst'k, Der feinere Bau des Nervensystems. Second edition, p. 355. »

§Striimpell, Archiv fiir Psychiatric, Vol. X.

I Daxenberger, Deutsche Zeitschrift f. Nervenheilkunde, Vol. IV.

1[ Bischoff, Wiener klin. Wochenschrift, No. 37, lS9fi.

Biedl, Neurologisches Centralbl., 1895, p. 434. ft Thomas, Le Cervelet. G. Steiuheil, Paris, 1897.


June, 1898.]


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from the jjosterior roots. This retrograde degeneration of sensory fibres — for we hiive every reason to believe that the direct cerebellar tract is sensory — extending even to the origin of the fibres within the cells of Clarke's colnmn, is of considerable importance and has rarely been described. It is probably due to the fact that the destruction began when the jiatient was very young, for such complete cellular atrophy is far more common in the young, as many experimental lesions have shown. It is also possible that the cells of Clarke's column were altered by the "reaction at distance" before the fibres of the direct cerebellar tracts were entirely degenerated.

In the case B. H. the area of degeneration, representing the fibres of the crossed pyramidal tract, in its downward course passes toward the periphery of the cord, and in the lumbothoracic region occupies the external and posterior part of the lateral column. Normal fibres are found in the crossed pyramidal tract below the area of compression, but they are not nearly as numerous as I have been led to expect from similar lesions of this tract reported in the literature, though in my case B. H. the normal fibres within this tract are more numerous at low than at high levels of the thoracic cord. It has been frequently stated that degeneration of the crossed pyramidal tract, resulting from a cerebral lesion, is less extensive than that following a spinal lesion. It may be that fibres of cerebellar origin — Van Gehuchten's* cortico-ponto-cerebellospinal tract — are added to the cortico-spinal tract, or that a system of fibres forming the anterior part of the crossed pyramidal tract arises in the thalamus, as v. Bechterewf has concluded from the investigations of Boyce and Sakowitsch and from a study of the greater area of the lateral motor tract as represented during its myelination, compared with the area as represented by degeneration from cerebral lesions.

It is unquestionably true that the degenerated area of the crossed motor tract in the case B. II. is greater than that we find after cerebral lesions, but this is also partly due to the fact that many associative fibres are destroyed. It is probable that some associative fibres are contained within the lateral motor tract, but I cannot believe, from the case B. H., that fibres which arise below the lower cervical segments and pass downward are very numerous within this tract.

There is no atro23hy of the motor cells of the anterior horns in the lumbar region, although we should expect to find it in this case, if in any, on account of the early age at which the transverse lesion occurred. I have never been able to observe this atrophy of the cell body of the peripheral neurone resulting from a lesion of the central neurone, and confess that I have always been most skeptical regarding statements concerning its existence. Recently, however, SchafferJ has published some noteworthy observations of tertiary degeneration. It may be mentioned that Egger {I. c.) says that in his case the cells were less numerous in one anterior horn in the lumbar region. I am not questioning Egger's statement, but from repeated observation we know how likely one is to be misled


in an investigation of this kind, for often in normal cords the cells in the two anterior horns are not equally numerous, and we have no standard of what constitutes a normal number of cells.

Bruns* found the crossed pyramidal tracts, esjiecially the right, wonderfully well preserved below and near a transverse lesion, though they were not entirely normal ; and the explanation he suggests is that the degeneration began in the peripheral end of these tracts and had not extended to the traumatic area within the space of about four months. In my case B. H., which had lasted five years, this difference in the degree of degeneration in the distal and more proximal portions of the pyramidal tracts is not observable.

The degeneration in the antero-lateral columns in Bruns' case was believed by the author to represent the fibres of the direct pyramidal tract, descending fibres of Glowers' column, fibres of the systeme descendant du zone sulco-marginale (Marie) or faisceau marginal (Lowenthal), fibres of the faisceau intermediaire du cordon lateral (Lowenthal), and the descending cerebellar tract of Marchi. The latter has never been demonstrated in man (Thomas). These areas are degenerated in the case B. H., and they have been found altered by Westphal, Schnltze, Tooth, Schmauss, Daxenberger (quoted by Bruns) and others in cases observed by them.

Bechterewt has recently shown that there is still another system in the inner portion of the anterior column of the cord, and that this system arises in the anterior part of the corpora quadrigemina. He gives no name to this or to his system anterior to the crossed pyramidal tract, and we may, perhaps, speak of them as the quadrigemiuo-spinal and the thalamo-spinal tracts.

Dr. Young states that the patellar reflex in the case B. II. was diminished. So much has been written on the loss of the reflexes in total transverse lesions situated high in the cord that I may simply refer to the excellent papers by Bastian,! Bruns,§ Egger,|| Hoche,][ Habel** and others. Bruns' case was the first in which the reflexes were lost, and the entire spinal cord, the roots of the Cauda equina, and a number of nerves and muscles of the lower extremities were examined microscopically. The changes in the nerves and muscles were not of great importance and could not be used to explain the absence of the patellar reflex and the flaccidity of the paralysis.

The posterior roots in Bruns' (I. c.) case in the area of total traumatic degeneration were remarkably well preserved, but the anterior were totally degenerated. He gives no satisfactory explanation for this. In the first case reported in this


Van Gehuchten, Journal de Neurologieet d'Hypnologie, 1897. t V. Bechterew, Neurologisclies Centralblatt, No. 23, 1897. JSchaffer, Jlonatsschrift fiir Psychiatrieund Neurologie, Vol.11, No. 1.


Bruns, Archiv fiir Psychiatrie, Vol. XXV, 1893. f Bechterew, Neurolog. Centralbl. No. 23, 1897.

IBastian, A Dictionary of Medicine, edited by Richard Quain, M. D., F. R. S., p. 1481. Medico-Chirurgical Transactions, published by the Royal Medical and Chirurgical Society of London, Vol. 73, p. 151.

§ Bruns, Archiv fiir Psychiatrie, XXV.

II Egger, Archiv fiir Psychiatrie, XXVII.

II Hoche, Archiv fiir Psychiatrie, XXVIII.

Habel, Archiv fiir Psychiatrie, XXIX.


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paper the postorior roots were less affected. This is probably due to the fact that the anterior roots were most exposed to pressure and the invasion of the tuberculous process, and shielded to some degree the posterior roots placed behind them.

Bischoff (7. c ) concluded from his examination of a case of Pott's disease that the root fibres which enter below the second thoracic segment do not form all of Goll's columns, inasmuch as the ventral and lateral portions of these columns in the cervical region are formed by fibres from higher segments and IJrobably not by those from the thoracic region.

If this view of Bischoff, viz. that the ventral and lateral parts of Goll's column are formed by fibres of the cervical roots, is correct, we are not surprised that these are the portions which the cervical fibres occupy. We know that the higher the degeneration of the posterior roots extends, the greater is the degeneration of the ventral and lateral portions of the postero-median columns in the cervical region. Reference may be made to the two cases pictured in the author's digest on the pathology of tabes,* or to many other cases, in illustration of this point. But there is considerable evidence to show that above the sixth thoracic roots the column of Goll in man is fully formed. In Pfeiffer'st case in which the first and second thoracic roots, in Nageotte'sJ case in which certain fibres of the second and third posterior thoracic roots, in Marguli6s'§ case in which the right sixth posterior thoracic root, and in Dejerine and Thomas'|| case in which the eighth cervical and first thoracic roots were affected, the columns of Goll in the cervical region were not degenerated. Bischoff employed the method of Marchi, and his results were possibly more accurate than those of the above-mentioned cases in which the hisematoxylin of Weigert was used.

The case B. H. bears on this subject. The transverse lesion is situated in the lower cervical and upjier thoracic cord, and at the mid-cervical region the columns of Goll are degenerated as far as the posterior commissure and spread out against the commissure in the well known flask-like form. The columns of Burdach also show distinct degeneration, but just below the motor decussation (first to second cervical segments) the degeneration is almost entirely confined to the columns of Goll, and only along their lateral borders is a slight degeneration of the columns of Burdach. At this level the columns of Goll do not extend to the posterior commissure. The columns of Goll, as they are represented by the degenerated area in the sections from the case B. H., do not receive cervical fibres except from the lowest cervical roots, if they receive them from these.

In a paper read at the last meeting of the American Medical Association IT[ attempted to show that there is considerable evidence for the theory that tuberculosis of the cord and its


Spiller, International Med. Map. 1897. •fPfeiffer, Deutsche Zeitschrift fiir Nervenheilkunde, Vol. I.

X Nageotte, Revue Neurologique, 1895.

gMargulies, Neurologisches Centralblatt, 1896, p. 347.

II Dejerine and Thomas, Comptes rendiis de la Societe de Biologie, 1896, p. 679.

II Spiller, The Journal of the American Medical Association, April 9, 1S98.


membranes may appear in the form of simple meningomyelitis, without the presence of giant cells, miliary tubercles, or even detectable bacilli, especially if Miiller's fluid has been used for hardening. I was led to this conclusion after the examination of a case of meningomyelitis, apparently due neither to syphilis nor tuberculosis, as far as specific lesions were concerned, in a person who had died from generalized tuberculosis.

When the idea that spinal tuberculosis might appear as simple meningomyelitis first presented itself to my mind I was not aware of the attention which this subject had received, and was therefore somewhat surprised by the results of my examination of the literature. I found that a number of writers hold that both syphilis and tuberculosis may appear as simple meningomyelitis. Oppenheim, for instance, says: "We observe in syphilitic and tuberculous persons a form of myelitis which neither clinically nor anatomically can be considered specific, and yet it must stand in some relation to the infectious process."*

In the examination of these two cases of Pott's disease I have not noticed any lesions interior to the dura which might be called specific. It hardly seems probable that any one would hesitate to call these two cases tuberculous, unless the question of the rare manifestation of syphilis in this form might arise. The caries of the vertebras, the external pachymeningiti?, the giant cells, the necrosis of tissue within the tubercles, the epithelioid cells, render the diagnosis of a tuberculous process very probable. Within the dura, especially in the first case, the meninges are infiltrated with round cells, some of the vessels show a distinct endarteritis, round cell infiltration may be found about certain vessels within the cord, and in the first case several foci of degeneration may be noticed in the posterior columns at a considerable distance above the point of compression. A nuclear stain shows that these foci are the seat of a slight round cell infiltration. Within the dura, therefore, at least in one of these two cases of tuberculous spondylitis, only the signs of an ordinary meningomyelitis are present, even at some little distance from the seat of compression. Indeed in this first case the compression was so slight that it did not produce ascending or descending degeneration. The action of bacterial products on the cord need cause no surprise. We have had numerous experiments on this subject, and in this country Welchf and FlexnerJ have done much to enlighten us.

It is' not clearly proven that the tuberculous process, external to the dura in my first case, has been the cause of the meningomyelitis, but it seems probable. If now a simple meningoijiyelitis may be produced by a process probably tuberculous external to the dura, what is there objectionable in the theory that it may also be produced by a tuberculous process external to the vertebrse ?

Boettiger§ has attempted to show that the tuberculous and


Oppenheim, Lehrbuch der Nervenkrankheiten, p. 224. I Welch and Flexner, The Johns Hopkins Hospital Bulletin, II, 107, 1891 ; III, 17, 1892. ) Flexner, The Johns Hopkins Hospital Reports, VI, 1897. § Boettiger, Archiv fiir Psychiatrie, Vol. XXVI, 1894,


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the syj^bilitic meuingomyelitis are the same in their histological appearances, and Raymond says that " the syphilitic meningomyelitis at its commencement has nothing specific but its cause ; it has nothing specific so far as relates to the appearances under the microscope."* It therefore follows from this and other papers that the tuberculous meningomyelitis has nothing specific histologically at its commencement except the bacillus.

Virchowt teaches, if I understand him rightly, that in contusion and similar conditions with extravasation of blood, chemical products are formed which act as irritants with or without the presence of bacteria, and he compares these products with those formed by the micro-organisms. If this is true it may have some relation to the meningomyelitis in my first case.

I have been much interested in trying to find the nature of this round cell proliferation observed in these and other cases of meuingomyelitis, and its final destiny. Raymond {1. f.) speaks in very positive terms, and Virchow (I. c.) in his paper on inflammation says that even yet the expression "small cell infiltration" is commonly used. I have been frequently struck by the expression "leucocytic infiltration," and have sought to find some authority for its use. It seems to be the opinion of some writers that unless we find multinuclear cells or cells with multilobular nuclei we have no right to speak of "leucocytic infiltration," and that we should regard the cells containing little protoplasm and large single and round nuclei as proliferations of connective tissue or its analogon, the neuroglia. But surely there are such cells as these within the blood.

Raymond (J. c), in speaking more especially of syphilis, tells us that these round cells may undergo a retrograde change and disappear, or that they may form larger or smaller masses and undergo a gummatous change, or that they may form connective tissue and give rise to sclerosis.

StriimpellJ takes a very decided stand in regard to the presence of meuingomyelitis in Pott's disease. He says that all the changes in the spinal cord in spinal caries are only the necessary consequences of purely mechanical pressure. "At all events," he continues, " as we must state after numerous examinations made by us, in opposition to the prevailing view, no one has the slightest right to explain the paralysis occurring from sjjondylitis as the result of secondary myelitis." If preparations are made from the spinal cord, there are, according to Striimpell, no vascular changes to be found, no hypersemia, no accumulations of cells about the vessels, and only occasionally small traumatic haemorrhages. Frequently thei'e are foci of degenerating nerve fibres, groups of swollen axis cylinders with partial or complete loss of their medullary sheaths, and in places spaces from which the nerve fibres have disappeared. In later stages there is proliferation of the neuroglia.

We can hardly be in doubt from this as to what Striimpell considers evidences of inflammation, for our views on this subject do not always harmonize.

Striimpell finds a supporter in Kraske {I. c), who also says


•Raymond, Le(;on sur les maladies du Bysteme nerveux, deuxieme serie, p. 491.

f Virchow, Virchow's Archiv, Band 149, Folge XIV, Band IX, 1897.

t Striimpell, Lehrbuch der spec. Path. u. Ther,, Vol. III.


that the paralysis cannot be attributed to secondary inflammatory changes in the cord, and that this is equally true of the rare cases in which the cord is involved in the tuberculous inflammation, for this involvement occurs after the paralysis and toward the end of life. He acknowledges that the views regarding the relation of the paralysis to the tuberculous inflammation are still contradictory to one another.

Dinkier* reports a case in which two lesions were present in the spinal cord, one at the second and third thoracic segments, and one at the sixth, seventh and eighth thoracic segments. The lower lesion was evidently the older and showed proliferation of the glia, round cell infiltration, distension of vessels, etc. The upper lesion Dinkier regarded as the result of a dural tuberculosis, and he states that it was a typical compression lesion such as was described by Schmaus. Dinkier mentions, however, that at this upper level he noticed round cell infiltration in the pia and arachnoid. It seems to me, therefore, that both these lesions must be regarded as iuflalnmatory. Dinkier states that tuberculosis of the lungs and vertebrae of ten causes mixed infection, and bethinks the lower lesion was possibly a metastatic process which had its origin in the pulmonai-y tuberculosis. It is difficult to see why the lower lesion should not be regarded as tuberculous, but be that as it may, it is evident that meningomyelitis may be caused either directly or indirectly by the tubercle bacillus, and even before paralysis appears, as in my first case.

Furstnerl observed intense round cell infiltration of the membranes and cord in a case of Pott's disease. He had operated on his patient, but there is no reason to think the cord was infected at the time of operation. It would not be difficult to quote other cases of Pott's disease in which meningomyelitis was observed.

In one of my cases there are large accumulations of round cells within the cord about the vessels, vascular dilatation and some swollen axis cylinders. These are distinct signs of inflammation, and indeed it seems to me after reading Virchow's recent address in Moscow that we should regard the swelling of the axis cylinders as a sign of parenchymatous inflammation. If we do so, we shall have difficulty in separating degeneration of nerve tissue from inflammation. These are Virchow's words : " I chose the name of parenchymatous inflammation for that process which, in the first place, produces swelling of the specific portions."

It is not easy, according to Bruns,J to determine the truly inflammatory nature of myelitis, and anatomically it is possible with certainty only in the very rare cases in which the producers of the inflammation (Eutziindungserregern) have been shown to be present in the cord. By this I suppose he means the bacteria. All other histological findings which are regarded as chai'acteristic of inflammation are found in cases of tumor and compression, cases which cannot truly be regarded as inflammatory. They are present also in thrombotic softening.


Dinkier, Deutsche Zeitschrift fiir Nervenheilkiinde, Vol. XI, Nos. 3 and 4. f Furstner, Archiv fur Psychiatric, XXVII. |Bruns, Allgemeine Zeitschrift liirPsychiatrie, Vol. LIII, p. 614.


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In contradiction to the statements of Striimpell, Noble Smith* informs us that the nerve symptoms in spinal caries are much more frequently the result of the inflammatory process extending to the cord or nerves than they are of pressure. This, however, does not seem tobe the generally accepted view. I cannot follow Smith when he says that recovery occurring after symptoms of paralysis may indicate regeneration of pyramidal fibres. While regeneration frequently occurs in the peripheral nerves, and theoretically there is no reason why it should not occur within the cord, as a matter of fact the evidence of the latter is not satisfactory, as Leyden and Goldschcider state.

I shall merely touch upon the subject of operation in Pott's disease, as it hardly comes within the scope of this paper. Paralysis so frequently exists without degeneration of fibres that we can hardly be too cautious in suggesting surgical interference, at least by any of the older methods. It is not uncommon to find that the paralysis disappears even when it has existed for some time. It seems to be in these cases merely the expression of a functional change. Oppenheimt reports a case in which the paralysis disappeared after a duration of five or six years. Recently Calot's method has received great attention, although one writer states that its principle is as old as Hippocrates. This statement, however, can hardly detract from the honor due Calot. The time has been too short to judge fully of the eiHcacy of the method. The chief fear seems to be that the forcible reduction may arouse a quiescent process. In the first of my two cases there is a possibility that it might have increased the meningomyelitis, and in the second case it could have done little or no good, but in this case Calot would not have advised it.

Occasionally we hear of cases in which the method has not been sue 3ssful and the patient has died of tuberculous meningitis after a few months. We cannot forget the hopes that were at one time raised by the suggestions of operation on the spinal vertebraj in Pott's disease, but the papers of Kraske {I. c), F".stnerJ and ])inkler§ are not encouraging, and Willard,|| at a meeting of the New York Neurological Society, voiced the general opinion of those present when he spoke of the disappointment which has followed surgical interference in these cases by the older methods.

Discussion. Dr. Barker. — There are many points in Dr. Spiller's report in common with a case which has recently been studied in the anatomical laboratory by J. Rosenheim. The latter has cut sections from many segments of the spinal cord of a case of Pott's disease, and although the results of the study have not yet been published, they are soon to appear. The pressurelesion in Mr. Rosenheim's case was situated between the 8th cervical and the 4th thoracic nerves, some three segmeats of the spinal cord being extensively involved. Above the lesion


Smith, Spinal Caries, second edition. tOppenheim, Berliner klin. Wochenschrift, No. 47, 1896. X Furstner, Archiv fiir Psychiatrie, XXVII.

§ Dinkier, Deutsche Zeitschrift fiir Nervenheilkunde, Vol. XI, Nos. 3 and 4. 1 WillarJ, Journal of Nervous and Mental Disease, April, 1897.


there was marked degeneration of Gowers' tract and of the direct cerebellar tract as well as of the dorsal funiculi. Below the lesions there were the typical degenerations in the pyramidal tracts.

Dr. Spiller has been able to trace a degeneration in the comma tract for a distance of 4 cm. below the lesion ; in Mr. Rosenheim's case it was possible to follow it through some three segments. We know now from the studies of Hoche, Mann and others that this tract is really a long tract extending throughout the whole thoracic region of the spinal cord. I did not understand from Dr. Spiller's paper whether or not he had found degenerations in the oval field of Flechsig in the lower portion of the cord. Mr. Rosenheim has been able to demonstrate degeneration in this area in his case, and there can be but little doubt from his findings and those in similar cases by Hoche that in some way or another certain fibres from the upper part of the cord are continuous with the oval field of Flechsig. It seems probable from Hoche's studies and from the researches of Bruce and Muir that there are two distinct descending endogenous tracts in the dorsal funiculi, one more ventrally placed corresponding to the " comma " tract and the "cornu-commissural fibres" of Marie; the other more dorsally placed and corresponding to somewhat scattered fibres in the upj^er portions of the cord, iu the lower portions to more compact bundles, the septo-marginal tract of Bruce and Muir, the oval field of Flechsig, and further down the triangle median of Gombault and Philippe. In order to bring these endogenous fibres of the dorsal funiculi into accord with corresponding fibres in the ventral and lateral funiculi I would suggest that we speak of the two ti-acts together under the name of the fasciculus dorsalis jn-oprius, distinguishing & jmts ventralis from a. pars dorsalis.

I am glad that Dr. Spiller has referred to the views of von Bechterew and others regarding descending fibres in the region of the pyramidal tracts, which probably have their origin in centres below the pallium. There is much evidence in favor of the view that very numerous nerve fibres come down from the region of the inter-brain and the mid-brain to the medulla and to the spinal cord, fibres which throw the lower motor neurones under the influence of higher centres. Without such fibres it would be difficult to explain many of the facts of comparative anatomy and of ontogeny. The studies of Dr. Melius show the importance of the substantia nigra as a waystation between the pallium and lower centres.

The changes referred to iu the nucleus dorsalis of Clarke are of especial interest, and Dr. Spiller has brought further confirmation of the view now universally held that the fibres of the direct cerebellar tract represent the medullated axones of the cells in the nucleus dorsalis. Thus far no one, unless it be Laura, has actually demonstrated the connection of Clarke's nucleus with the fibres of the fasciculus cerebello spinalis. The embryological studies of Flechsig, however, and the results of experimental degeneration as investigated by Mott, taken together with evidence which has been afforded by the study of changes in the nucleus secondary to lesions of the tract (as in cerebrosijjnal meningitis), make it almost certain that the axones of the tract and the cells of the nucleus both represent constituent portions of the same set of neurones.



Fig. 1.

Section just below tlie pyramidal decussation. The columns of Goll are entirely degenerated, with the exception of a few fibres along their periphery, and do not extend to the posterior commissure. The columns of Burdach are slightly degenerated adjoining the columns of Goll. Normal fibres are found in the area of the direct cerebellar tracts (tin).



Fig. o.

Section from the region of greatest compression, at the cervico-thoracic junction of the spinal column. The normal arrangement of the white and trray matter is entirely altered, and only a few normal fibres are present witliin the cord.




Fig. S.

Section from the niid-ccrvical region. The direct cerebellar tracts (pp) and columns of Gowers are greatly degenerated. The crossed and direct pyramidal tracts are also much degenerated. The columns of Goll extend to the posterior commissure. The columns of Burdach are not entirely free from degeneration.




Fig. 4.

Section from the lower part of the compressed area. The anterior horns uu are indistinctly marked out by normal fibres in the adjoining columns. The greater portion of the section is entirely dcircnerated.



1 m »3 J,



Fig. 5.

Section 3}^ em. below Fig. 3. The antero-lateral columns, includini^ the direct cerebellar and Gowers' tracts (lyy) and the periphery of the anterior columns, are greatly degenerated. The ventral portion of the posterior columns is also distinctly degenerated.



^ Section from the mid-cervical region in Case I, showing intense cellular infiltration in the posterior septum (»;) near the posterior commissure. U Right and left columns of Goll.



Fig. 6.

Section fiom the mid-lumbar retrion. The direct (//•) and crossed pyramidal tracts are degenerated.

Figures 1 to 6 inclusive are from Case II.




.7--'^5H'




Osteoid masses contained within the tuberculous e.\udate in the tlioracic region (Case I). The majority of them are present in the outer zone of the exudate near the bony canal and only slightly removed from the intervertebral discs which show irregularities and are becoming clarified.


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Dr. Flexner. — Dr. Spillers pajier is an embarrassment of riches. There are two or three points only which the limited time will permit me to refer to. The first concerns the relation of degeneration in the nerve-raets and peripheral spinal nerves to changes in the motor cells of the anterior horns. I was surprised at the slight changes observed in the cells notwithstanding the extensive degenerations of the nerves. It is, of course, unnecessary to remind Dr. Spiller, or this audience, of the experimental and other work of Von Gudden, Friedlander, Grigoriew and Nissl, which has shown that the nerve cells suffer severely following injury to and removal of the peripheral nerves.

Dr. Spiller's remarks on this topic have raised the question of what characters stamp an inflammation as specific, that is, in this instance, as tuberculous. We have come to recognize in the micro-organisms of the specific diseases a capacity to produce definite histological structures which can be at once recognized as due to that cause — so, for example, the miliary tubercle — and at the same time, to give rise to other changes of a simple and non-specific inflammatory type. The thickening of the framework in the lung in tuberculosis is one example of such an action, and many other fibroid and degenerative processes in the body have the same origin. An intermediate sort of lesion is found in the diffuse tuberculous tissue in which even giant cells may be wanting and bloodvessels present, and whose specific characters are given through the presence of tubercle bacilli and the degenerations which it tends to undergo. The crucial test, of course, is the finding of the tubercle bacillus, and in many chronic conditions this is a laborious undertaking.

It is interesting to have Dr. Spiller bring up again the Virchow conception of parenchymatous inflammation. Since the days of Cohnheim, jjathologists have demanded something more than a mere degenerative lesion before stamping the process "inflammation," and they have attemjjted, although it must be confessed not always with success, to mark off more sharply simple degenerative from actual inflammatory changes.

Dr. Spiller. — It is well known, as Dr. Flexner states, that the cells of the anterior horns of the spinal cord are affected by degenerative changes in the anterior roots. It is much to be regretted that the spinal cord in my first case was hardened in Miiller's fluid and that the application of the Nissl stain was impossible. In the thoracic region the motor cells were


distinctly altered. Could the Nissl stain have been employed, the cells of the mid-cervical region might also have been found degenerated. I have not intended to deny the existence of cellular lesions in the latter portion of the cord visible by Nissl's method, but I place very little value on studies of cells stained by carmine alone, unless the changes are of an intense degree.

I have been unable to stain the tubercle bacillus in this tissue hardened in Miiller's fluid, but Dr. Abbott and Dr. Flexner tell me that they know the bacillus has been found under similar conditions. As Dr. Flexner puts it, "it is a labor of love."

It is impossible to assert that the myelitis in my first case has been caused by the tubercle bacillus, though I have found no other cause. It is, however, a very important fact that myelitis of considerable intensity, withpolynuclear and mononuclear cellular infiltration, may occur in Pott's disease, and it is possible that some of the symptoms of this disease may at times be due to the myelitis and not entirely to the compression.

I should like to emphasize the statement that the degeneration of the posterior columns in my second case was not confined to Schultze's comma zones, but was much more extensive. This diffuse form of descending degeneration in the posterior columns of the cord has rarely been reported, and is entirely diflferent from the degeneration frequently observed in Schultze's comma zones, inasmuch as it is not systemic.

Note ou the osteoid tissue found iu the tubercular exudate iu the thoracic region of the cord. — Dr. Flexner. There is contained amid the typical tuberculous exudate, outside the dura, scattered masses of osteoid tissue. These are of irregular form and shape. They consist of a ground substance which is homogeneous or faintly granular or fibrillated, and contain irregular nuclei resembling, in part, bone corpuscles. For the most part the masses are non-calcified. But now and then calcification can be seen to be going on, and in such cases the masses take a blue hajmatoxylin stain. The majority of the flakes are in the outer zone of the exudatenearest the bony canal; and the cartilage of the intervertebral discs (0 shows slight irregularity, and in places is undergoing calcification. It is therefore not improbable that serial sections might have shown the osteoid masses to have originated from the intervertebral cartilages.


A CASE OF OSTEITIS DEFORMANS.


By Wm. T. Watson, M. IX, of Baltimore.


In 1876 Sir .James Paget reported to the Medical and Chirurgical Society of London, five cases of a previously undescribed disease to which he gave the name " Osteitis Deformans." He described one case in great detail and gave reports of both microscopical and chemical examinations of the bone.


Read before the Johns Hopkins Hospital Jledical Society, February 7, 1898.


Although a good many cases have since been reported, about sixty in all, nothing very material has been added to the description of the disease as first given by Paget. He gave as the chief characteristics of the disease the following :

It begins in middle age, or later ; is very slow in progress ; may continue for many years without influence on the general health, and may give no other troubles than those which are due to the changes of shape, size and direction of the diseased bone. Even


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when the skull is hugely thickened and all its bones exceedingly altered in structure the mind remains unaffected.

The disease affects most frequently the long bones of the lower extremities and the skull, and is usually symmetrical. The bones enlarge and soften, and those bearing weight yield and become unnaturally curved and misshapen. The spine, whether by yielding to the weight of the overgrown skull, or by change in its own structures, may sink and seem to shorten, with greatly increased dorsal and lumbar curves ; the pelvis may become wide ; the necks of the femora may become nearly horizontal, but the limbs, however misshapen, remain strong and fit to support tlie trunk.

In its earlier periods, and sometimes through all its course, the disease is attended with pains in the affected bones, pains widely various in severity and variously described as rheumatic, gouty or neuralgic, not especially nocturnal or periodical. It is not attended with fever. No characteristic conditions of urine or feces have been found in it. It is not associated with syphilis or any other known constitutional disease, unless it be cancer.

The bones examined after death show the consequences of an inflammation affecting, in the skull the whole thickness, in the long bones chiefly the compact structure of their walls, and not only the walls of their shafts, but, in a very characteristic manner, those of their articular surfaces.

In 1890, fourteen years later, after Paget bad seen 33 cases of the disease, he made the following statement :

1. The preponderance of males among the patients affected with this disease is confirmed.

2. The most frequent ages at which the disease was flrstobserved were between 40 and 50.

3. The frequency of cancer or sarcoma occurring in those affected with osteitis is confirmed. Of eight cases traced to the end, five died with cancer or sarcoma. This fact, confirmed as I believe it is by the observations of others, is decisive as to an intimate relation between osteitis and the formation of malignant tumors. I do not venture to guess what that relation is.

4. It may be only by chance coincidence, but it seems worth mentioning that in 23 cases, 4, after long continuance of the osteitis, became blind — 1 with choroiditis, 3 with retinal ha;morrhages.

5. I have tried in vain to trace any inherited tendencies to the disease. Many have had gouty ancestors, but I do not think more than any other equal number of persons in the same rank in life.

6. The most frequent seats of the osteitis are the tibise, femora, clavicles, spine, and vault of the skull. The posterior and regularly median curvature of the spine is always well marked, the pelvis often broad. I have never seen any evidence of the disease in the bones of the face, hands or feet. In this respect the contrast with the acromegaly of Marie has seemed complete.

The morbid anatomy, as given by Paget, is as follows :

Periosteum not visibly changed. The outer surface of the walls of the bones irregularly and finely nodular, as with external deposits or outgrowths of bone, deeply grooved with channels for the periosteal blood-vessels, finely but visibly perforated in every part for the transmission of the enlarged small blood-vessels. Everything seemed to indicate a greatly increased quantity of blood in the vessels of the bone.

The medullary structures appeared to the naked eye as little changed as the periosteum. . . . The medullary spaces were not encroached upon.

The compact substance of the bones was in every part increased in thickness. ... In the greater part of the walls of the shafts of the bones the whole construction of the bone was altered into a hard, porous or finely reticulate substance like very fine coral. In some places there were small, ill-defined patches of pale, dense and hard bone, looking as solid as a brick.

lu the compact covering of the articular ends of the long bones


. . . the increase of thickness was due to encroachment on the cancellous texture, as if by filling its spaces with compact porous new-formed bone.

The microscopical appearance as given by Mr. Butlin is as follows:

The number of Haversian systems and canals in any given section would seem to be much diminished. The space between the Haversian canals was occupied by ordinary bone substance, containing numerous lacunae and canaliculi. The Haversian canals were enormously widened, many of them were confluent, and thus the appearance of a number of communicating medullary spaces was obtained ; an appearance that was rendered still more striking by the presence in the canals of a large quantity of ill-developed tissue in addition to the blood-vessels.

The contents of the Haversian canals were seen to consist generally of a homogeneous or granular basis, containing cells of round or oval form, about the size and having much the appearance of leucocytes. Larger nucleated cells were also present, and fibres or fibro-cells sometimes in considerable quantity. Myeloid cells were occasionally observed, but they were not plentiful. Fat also existed in many of the larger spaces, especially in the skull. The vessels were unusually small compared with the channels in which they ran ; indeed, they did not seem to be larger than those of normal bones.

The walls of some of the canals were lined by a single layer of osteoblasts — a condition precisely similar to that observed in a normal ossification of the bone in membrane.

The presence of new bone was most evident in the periosteum of the tibia, external to the ordinary compact layer of the shaft. This external layer was of course but thin, and was much softer and less developed than the cortex of the bone from which it sprung. It evidently was not nearly sufficient to account for the great increase in the diameter of the tibia. There was no similar recent formation of bone on the outskirts of the medullary canal.

The number of lamellse surrounding the Haversian canals was no larger than in normal bone, whilst tne arrangement of the intervening space was most complex and totally different from that of healthy bone. Lacunse and canaliculi throughout the sections did not strikingly differ from those of ordinary bone.

As to the nature of the disease, Paget, Butliu, Clutton, Eve, Silcock and others believe it to be a chronic inflammation of bone, but Goodhart, Lunn and others do not deem that its inflammatory nature has been proven.

Lunn, who reported 4 cases in 1885, while admitting that chronic inflammation might have some share in the process, thought that it would not altogether account for the changes found after death. His conclusions were that osteitis deformans consists of —

1. A constitutional disease, producing atrophy and absorption of a large part of the osseous system.

2. Consequent weakening of the bones so that they yield when exposed to strain.

3. Compensatory strengthening by the growth of what may be looked upon as a variety of callous.

4. The occasional formation of definite tumors.

5. A fatal cachexia.

Commenting upon these views, Silcock, in 1885, said : It is difficult to imagine how a process can primarily be one of atrophy and absorption when the first recognizable sign of the disease is the thickening and enlargement of the bone. Nor can the superadded bone in this case be regarded in the light of "compensatory strengthening " of the curves, or of a buttress-like forma


Fici. 1. Skiagraph ol' left Uunu juint. Tibia sieatly eiiiargx'd. Fibula aiipaiontly iioi'mal.



Side view, sljowiug bowing of liaeli ami lower extremities.



Fid. :,.

Head view, sliowing enlariremeiit of cranium, the face bones remaining normal.



Slviasrraph of left tibia, showing marked anterior curvature, and srreat thickening. Dark and light areas probably eorrcspcind to areas of condensation and rarefaction.


June, 1898.


JOHNS HOPKINS HOSPITAL BULLETIN.


135


tion, since the mass of it is deposited on tlie convexity of tlie curve and not in tlie concavity. As^ain, the external thickening of the bones of tlie cranium is wholly inexplicable on the theory enunciated. As held by Paget and Butlin, the essential features of the osseous lesions of the disease are indistinguishable from, if not highly characteristic of, inflammation.

Concerning the etiology of osteitis deformans absolutely nothing is known.

It is more frequently seen in England than elsewhere, and is more common in London than in other parts of England. This fact led Johnathan Hutchinson to conclude that the malady was probably connected with gout, but this view has not been accepted by others.

Diagnosis: The diseases with which it might possibly be confounded are rickets and osteomalacia. In rickets the bones are too short and not too long, too small, not too large; and their curvatures are not like those of osteitis.

In osteomalacia the walls of the bones become exceedingly thin, and when they yield it is not with regular curving, but with angular bending or breaking.

The course of the disease is very chronic. When death ensues it is from some coincident disease which has been aggravated by the condition of the bones only in so far as they may have diminished the range of breathing and the general muscular activity.

Sis cases of this disease have been reported in America, the first by McPhedran in Toronto in 1885, the second by Gibney in New York in 1890, the third by Mackensie in Toronto in 1891, the fourth and fifth cases by Taylor in New York, 1892, and the sixth by Herwisch in Philadelphia in 1896.

The present case is then the seventh to be reported in America and is more typical than any of the others.

I had hoped to be able to bring the case before you to-night, but have been disappointed. I have, however, some photographs which will in some measure make up for his absence.

R., aged 63. Family history unusually good. His father was a French Canadian, born near Montreal, who "never had a day's sickness," and died of congestion of the brain at the age of 79. His father's brother, at the age of 100, was killed while walking on a railroad track. His mother was born in New Jersey and died on her 90th birthday of old age. He has two brothers living at the ages of 73 and 75. No relative ever died of cancer.

Personal histori/. He was never in bed a day from any illness. A slight attack of measles in childhood and a carbuncle ten years ago were his only ailments. He has always led a very active life. He conducted a successful business from 1860 until 1886, and did not then retire on account of physical or mental disability. Every year since he was a boy he has indulged in fishing, duck shooting, sailing and outdoor sports. Up to the age of 43 he was strong and active, " as straight as an arrow," and five feet eleven and three quarter inches in height.

The present malady began about 35 years ago, when the skin over the anterior portion of the upper half of the left leg became inflamed, the inflammation gradually spreading to the ankle. Later on an inflammation appeared on the correspond


ing portion of the right leg. This lasted four or five months and then subsided, leaving behind some large pigmented areas.

About twenty years ago he began to have pains in the bones and calves of his legs. The calf muscle would be drawn into bunches. These pains have persisted more or less ever since, usually worse at night. At the onset of these pains he noticed for the first time that his legs were bending and his height was diminishing. This bending of the legs has steadily advanced and is still progressing.

About fifteen years ago the increased size of his head began to attract attention. This increase, the patient is confident, began 35 years ago, when at the age of 37 he had to increase the size of his hat from a No. 7 to a 7 J. At intervals of four to five years he has had to take a hat a size larger, until now he wears a No. 8. This indicates a total change in circumference of 3y^y inches. There has been no evident increase in the size of the head for three or four years past. He has never had pain or discomfort of any kind in his head.

Ten years ago his back commenced to bow and the shape of his chest to change, becoming flatter in front. These changes are still progressing. His height was formerly five feet eleven and three quarter inches. In July, 1897, it was five feet three inches. At the present time it is five feet two and one-half inches. Total loss in height nine and one quarter inches. This loss of height, due to bowing of the back and lower extremities, is rapidly progressing.

The general health of the patient has continued very good. While his gait is awkward it is steady, and his only complaint is of the pains in his legs and thighs, which are not so annoying as formerly. His intellect is unimpaired.

In the fall of 1896 he went on a hunting trip. When attempting to take aim he found to his surprise that he could not see with his right eye.

Present: condition. In July, 1897, I took R. to Dr. Osier, who made the diagnosis and dictated the following note:

" Head fairly symmetrical, looks large ; the most marked prominences are just over the temporal muscle at the squamoparietal junction. Above this there is a distinct groove like flattening, and then a marked prominence on either side of the parietal suture. The j^osterior parts of the parietal bone and the occipital bone are uniform and symmetrical.

No apparent enlarging of the bones of the face; no enlargino- of the jaws or of the zygoma ; in fact the face looks small in proportion to the size of the head. Teeth are bad ; nearly all gone. No enlargement of maxillary process.

Body: No enlargement of cervical vertebra. A most remarkable bowing of the dorsal spine. The lordosis is of the most extreme grade. There is no special prominence of any of the vertebra;. The ribs do not appear to be enlarged. The chest, from the front, is singularly box-shaped, a perfectly quadrilateral thorax. There is a little scoliosis, the curve being towards the left.

No enlargement of the clavicle or shoulder-blades. No enlaro-ement of the bones of the arm or of the hand. No clubbing of the fingers. Dupuytren's contraction in both hands.

The pelvis is not enlarged, crests of the ilia feel normal.

Legs are remarkably bowed. With the heels together, from


136


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 87.


the inner side of one knee-pan to the other is 23 cm. From the crest of one tibia to the other is 26 cm. The thigh bones do not seem enlarged. The tibiae present the most remarkable deformity. They are both extremely curved anteriorly, enormonsly enlarged ; a condition of diffuse hyperostosis. The left leg is larger than the right. Measurement of the most prominent part of the calf: left, 37 cm.; right, 35.5 cm. The bones are smooth and uniform, except on the anterior margin, where both are a little rough. The fibulfe feel a little enlarged at the upper end, but do not seem to be involved to the same extent. On the anterior surface of both legs and over the outer maleoli there are old pigmented changes in the skin, which is rough and hard. Both inner condyles of the femur look enlarged. Measurements over the knee joint: right, 39.5 cm. ; left, 38 cm. Height five feet three inches."

Dr. Reik has recently examined his eyes and reports as follows :

Mr. R. has a high grade of myopia, with large posterior staphyloma and extensive choroidial changes in each eye. In the right eye there is in addition a central lens opacity and consequently vision is practically nil. Vision in the left eye is ^f with a — 12 Ds.; with a —8 Ds. he can read Jaeger No. 1.

Discussion. Dr. Cone. — It is interesting in the bibliography of this case to bring in the work of V'on Recklinghausen. He mentions cases of osteitis deformans in which there was a development of fibroma and of sarcoma, and mentions also that cysts frequently form in these cases, and he describes them very fully. The walls are fibrous, contain a spongy network of bone, and


outside of this is fatty marrow. He mentions that the seat of these changes is the spots where the bone is under most statical pressure. As to the inflammatory origin of the disease, there is one case cited by Gruber in which, following erysipelas, there was this hyperostosis and a condition resembling elephantiasis.

Dr. Watson. — In reply to Dr. Osier I would say that in Paget's experience the cranial bones were frequently aifected. In four of the six American cases there was enlargement of the head. In Mackensie's case, aside from some spinal curvature, a very much enlarged cranium was the sole lesion. In Herwisch's case, in addition to an enlarged cranium there was some thickening and curving of the femora and left tibia and some thickening of the crests of the ilia. In the case of Dr. Gibney the head was increased in size and the legs very much bowed.

In one of Dr. Taylor's eases there was a very large head, considerable bowing of the spine, some enlargement of the pelvis and enlargement and bowing of the right femur. In his second case there was no head enlargement, the sole lesions consisting of enlargement and bowing of the right femur and some lateral spinal curvature. In McPhedrau's case the only bones involved were the right tibia and femur.

The case reported to-night corresponds more closely to Paget's description than any of the American cases, although one of Dr. Taylor's cases is almost as typical.

The statement made by Paget that there is a preponderance of males among the patients affected with this disease seems to be contradicted by later statistics, for of 43 cases analyzed by Thieberge in 1890, 21 were men and 22 were women.


THE RISE OF THE THEORY OF ELECTROLYTIC DISSOCIATION, AND A FEW OF ITS APPLICATIONS IN CHEMISTRY, PHYSICS, AND BIOLOGY.*

By Harry C. Jones, Ph. D., Instructor in Physical Chemistry, Johns Hopkins University.


It is doubtless unusual for this Society to be confronted with a subject which is apparently so widely removed from medicine as that of physical chemistry. But since certain comparatively recent developments have made it probable that the latter is destined to exert some influence upon the former, I have been kindly asked by your President to discuss that side of physical chemistry which has already been brought in touch with certain biological problems. I shall therefore give a very brief account of the origin and development of the theory of electrolytic dissociation, which is one of the keystones to the whole science of physical chemistry.

The botanist, Pfeffei', carried out a quantitative investigation of the osmotic pressure which solutions of both non-electrolytes and electrolytes exert against the pure solvent. His work is so well known that a mere reference to it is nearly sufficient. The artificial membranes which he devised, by depositing some finely divided precipitate, such as copper ferro


Read before the Johns Hopkins Hospital MeJical Society, March 7, 1898.


cyanide, in the walls of fine-grained jiorcelain, were seraipermeable, i. e. they allowed the solvent to pass through them, but prevented the dissolved substance from doing so. With such membranes he was enabled, for the first time, to make a careful quantitative study of the amount of osmotic pressure which different substances exert.

The results of Pfeffer were examined by Van't Hoff, who pointed out that they led to the following interesting and important generalizations :

I. The osmotic pressure of solutions of non-electrolytes is proportional to the concentration.

II. The temperature coefficient of osmotic pressure is very nearly yi-j of the osmotic pressure, for every degree Centigrade.

III. The osmotic pressure of a solution is exactly equal to the gas pressure which the dissolved substance would exert, if it were present as a gas, in a space equal to that occupied by the solution. A molecule exerts the same osmotic pressure as it would exert gas pressure under the same conditions of temperature.


June, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


137


These three laws of osmotic pressure will be recognized, at once, to be strictly analogous to the three laws of gases — that of Boyle, that of Gay-Lussac, and. that of Avogadro.

Van't Hoff further pointed out that the electrolytes — strong acids, and bases, and the salts — present exceptions, and exercise a greater osmotic pressure, for equivalent concentration, than the non-electrolytes.

The explanation of this difEerence was offered by Arrhenius. He studied the depression of the freezing-point of water produced by both electrolytes and non-electrolytes, and found that the former was always greater than the latter. He took into account, also, the property of solutions of electrolytes to conduct the current, and pointed out a quantitative relation between the conductivity of such solutions and the depression of the freezing-point of the solvent produced by the dissolved electrolyte. He showed, thus, that solutions of those substances which give abnormally large osmotic pressure, give abnormally great depression of the freezing-point of the solvent, and conduct the current.

It had already been shown by Raoult, that the depression of the freezing-point of a solvent by any dissolved substance, depended upon the relation between the number of parts of the dissolved substance and of the solvent. It seemed, then, that in the case of electrolytes there were more parts of the electrolyte present than could be accounted for on the assumption that the substance was present in the solution in the simplest molecular condition. To account for such facts as these, Arrhenius proposed the theory which has become so well known as the theory of electrolytic dissociation. When an electrolyte is dissolved in a solvent like water, the molecules break down, not into atoms, but into ions, which are atoms, or groups of atoms, charged with electricity. The amount of such dissociation is dependent upon the concentration of the solution. The more dilute the solution, the greater the dissociation of the molecules into ions, and at about one one-thousandth normal, the dissociation of all the strong acids, and bases, and most of the salts, is complete. This means that there are no molecules of the electrolyte present, but only the ions into which the molecules have dissociated.

This suggestion, it must be said, is not entirely new with Arrhenius, it is closely related to certain views held by Grotthuss, Williamson and Clausius. But the broad application of the theory to these newly discovered facts, together with quantitative methods for measuring the amount of the dissociation in a given case, we owe to Arrhenius.

Given the theory, the all-important question remains, is it true ? The time at my disposal will not permit me to discuss many of the lines of evidence which bear upon the theory of electrolytic dissociation. It is so far-reaching in its significance, so fundamental in its bearing, that any physical or chemical property of solutions can reasonably be summoned to furnish evidence as to its validity. I will refer very briefly to a few points which bear directly upon the theory in hand. If dilute aqueous solutions of electrolytes contain only ions, and no molecules, then it is clear that all the properties of such solutions must be the properties of ions, and notof molecules, since there are no molecules present. But since a


molecule always dissociates into at least two ions — a cation, which is charged positively, and an anion, which is charged negatively — the properties of completely dissociated solutions must be a function of two constants, the one depending upon the cation and the other upon the anion. If we study the physical properties of such solutions, such as their specific gravity, power to refract light, power to rotate the plane of polarization of light, color, etc., we find that they are the sum of a constant for the cation and a constant for the anion.

If we turn to the property of completely dissociated solutions to conduct the current, we find here again the same additive condition. The conductivity of these solutions is the sum of two constants, which is the well known law of Kohlrausch, usually expressed as the law of the independent migration velocities of the ions.

A quantitative test of the theory may be made by a study of the osmotic pressure of solutions of electrolytes. It will be remembered that the generalizations of Van't Hoff were reached through a study of Pfeffer's measurements of the absolute osmotic pressure exerted by non-electrolytes. Pfeffer found also that electrolytes exert a greater osmotic pressure than non-electrolytes. De Vries, using the plasmolytic, or living cell method, which gives only relative osmotic pressures, found, also, that electrolytes exert a greater osmotic pressure than non-electrolytes. This excess in the osmotic pressure of non-electrolytes is, in terms of the theory, due to a dissociation of the molecules into ions. De Vries showed that solutions of undissociated substances, containing the same number of molecules in a given volume, exerted the same osmotic pressure. Such solutions were terms isohydric. The same applies to solutions of electrolytes, with this difference, that at moderate dilutions we have to deal with the sum of the molecules and the ions present. De Vries was able by his method to determine the concentrations of solutions of electrolytes which are isohydric with one another. When these concentrations were represented in molecular quantities their reciprocal values were termed isotonic coefficients.

The dissociation of electrolytes can be calculated from the measurements of the osmotic pressure of solutions made by De Vries, and also from the measurements of the conductivity of the same solutions, and these two sets of values should agree with one another, if the theory of electrolytic dissociation is true. Below are given the amounts of the dissociation of a few substances, calculated for a given dilution, from osmotic pressure and from conductivity :


Substance.


Dissociation

from

Osmotic Pressure.


Dissociation

from

Conductivit}'


KNO3 NaNOa


69^ 69


80^ 73


KCl


(i9


84


NaCl


71


• 82


(COOK)^

K,SO,


61 60


66 67


( 'onsidering the large error involved in the osmotic pressure method, the agreement is probably within the error of experiment.


138


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 87.


It was early found that the power of electrolytes to lower the vapor-tension, or to lower the freeziug-poiut of the solvent in which they are dissolved, is greater than that of non-electrolytes. Either of these properties of solutions of electrolytes can be used to measure their dissociation. Since the method of measuring the freezing-points of solvents and solutions has been worked out far more accurately than the method of determining their boiling-points, the former is to be preferred as a method for measuring dissociation. I will give some results of the dissociation of electrolytes as calculated from my own measurements of the freezing-point depression of solvents, produced by them, and compare these with the dissociation of the same dilutions of the same electrolytes as calculated from Kohlrausch's conductivity work.


Substance.


Concentration.

Gram-molecular

normal.


Dissociation

from Conductivity.


Dissociation from

Freeziug-point

Lowering:.


NaCl


n.ooi


9S.0%


98.4^


"


11.111


93. 5


90.7


"


0.1


84.1


83.5


KCl


O.Odl


98.0


101.0


"


0.01


94.2


90.7


"


0.1


86.0


83.4


H.,SO,


0.003


89.8


86.0


"


0.00.5


85.4


83.8


"


0.0.5


62.3


60.7


HCl


0.002


100.0


98.4


"


0.01


98.9


95.8


"


0.1


93.9


88.6


HNO3


0.003


100.0


98.4



0.01


98.5


96.8



0.1


93.5


87.8


KOH


0.002


100.0


98.4


"


0.01


99.2


93.7


"


0.1


92.8


83.1


These are but a few results taken from a large number, involving all classes of electrolytes — acids, bases, and salts. The agreement is so striking that comment is superfluous.

Another line of evidence is to be sought in the study of mixtures of salt solutions. In terms of our theory, a dilute solution of potassium chloride contains only potassium ions and chlorine ions, and, similarly, a dilute solution of sodium bromide contains only sodium ions and bromine ions. These facts would be e.xpressed thus :

KC1 = K-|-C1

NaBr = Na-|-Br

A mixture of these solutions would contain, then, potassium, sodium, chlorine, and bromine ions; and all the properties of this mixture would be a function of the properties of these four ions, there being no molecules present. If, on the other hand, we started with potassium bromide and sodium chloride, and mix their dilute solutions, we would have exactly the same ions present, and the properties of the second mixture should be, for the same concentration, exactly the same as the first, and such is the case.

But if we should mix solutions of substances which are undissociated, such as methyl chloride and ethyl bromide, we ought to obtain a mixture with properties which arc different from a mixture of methyl bromide and ethyl chlo


ride, because we have here to deal only with molecules, which would be different in the two cases. And here again the facts agree perfectly with the theory. A mixture of methyl chloride and ethyl bromide has properties which are different from a mixture of methyl bromide and ethyl chloride.

Would that time permitted to take up an adequate number of the many lines of evidence which point to the theory of electrolytic dissociation in solution in water, and, to a less extent in many other solvents, but it does not.

I believe that when all the evidence at hand is taken into account, it points so conclusively to the general truth of the theory of electrolytic dissociation that we can accept it with the same degree of confidence as we do the law of Avogadro or many of the so-called laws of nature. And it may be said that the theory is now generally accepted by those who have impartially examined the evidence which is available.

If the theory be true, the question which next arises is, what is its scientific value? Has it been helpful in correlating facts which have hitherto appeared to be unconnected ? If so, its value is apparent. Or does it suggest, or point out new lines of experimental investigation ? If it does, its value is unquestioned. If it should assist in both of these directions, so much the greater is its worth. I can take up only a few examples. Take the well known reaction of the neutralization of acids and bases. In terms of the theory of electrolytic dissociation, a dilute aqueous solution of a strongly dissociated electrolyte contains no molecules, only ions. A solution of a base contains the hydroxyl anion, and a cation whose nature depends upon the base used. A solution of an acid contains the hydrogen cation, and an anion whose nature depends upon the acid chosen. Similarly, a solution of a salt is but a solution of anions and cations. To take as a concrete example, hydrochloric acid and sodium hydroxide, the reaction would be represented thus :

CI + H + oil + Na = 01 + Na -I- H.O, or in general :

A-|-H + OH + C = A-f6-|-H=0.

The anion of the acid and the cation of the base remain unchanged in the process of neutralization, which consists only in the formation of water. If this is true, then the process of neutralization of a given acid by a given base, is the same as the neutralization of any other acid by any other base.

This can be tested directly by experiment. The heat liberated in the neutralization of an equivalent of a completely dissociated acid by an equivalent of a completely dissociated Ijuse, being always the heat of formation of the same amount of water from the ions H and OH, must be a constant, independent of the nature of the acid or of the nature of the base. The following results show that this is true:



HCl. H Br.


Ht.


HNOj.


CHjCOOH.


HCOOH.


XaOTI


13.7 C


al.


13.7 Cal.


13.3 Cal.


13.4 Cal


KOH


13.7



13.8


13.3


13.4


.5Ca(0Il).j


14.0



13.9


13.4


13.5


.,Bii(Oll),


13. S



13.9


13.4


13.5


.\t<r(OII)„


14.1



13.9


13.3


13.5


June, 1898.]


JOHNS HOPKINS HOSPITAL BULLETIN.


139


The agreement between the heats of neutralization is striking, in consideration of the necessary errors involved in thermo-chemical measurements.

The theory of electrolytic dissociation thus brings together all the processes of neutralization of acids by bases, and refers them to a common cause, the union of the hydrogen and hydroxyl ions to form water.

It may be stated that it has been shown by no less than a half-dozen sejiarate pieces of work, that hydrogen and hydroxyl ions cannot exist in the presence of one another, in any appreciable quantity, uncombined; or, in a word, water is un dissociated.

Another example may be taken from chemistry.

If the properties of solutions of electrolytes are properties of the ions, then what relation exists between the chemical activity of solutions and their dissociation ? The dissociation of substances must be determined, .and also their power to effect chemical reaction, and the results of these two measurements must tlien be compared. A few of the many results available will suffice to bring out the relation. In column I are given the dissociations of acids referred to hydrochloric acid as 100; in II, the velocities with which they effect the catalysis of methyl acetate; in III, the velocities with which they invert cane sugar.


HCl


ion


100


100


n,so,


65.1


73.


73.3


HCOOH


1.68


1.31


1..53


CIT.COOH


0.43


0.34


0.40


CII^CICOOII


4.90


4.30


4. 84


CIICUCOOH


25.3


33.0


37.1


CC13COOH


63.3


68.3


75.4


(COOII)^


19.7


17.0


18.0


CII,(COOII),


3.1


3.87


3.08


c,H.(COon),


0.58


0.50


0.55


The agreement is as satisfactory as the conditions would allow us to expect.

The strength of acids is thus directly proportional to their dissociation.

We then naturally look for a common cause of that property which we describe as (wid,iii compounds such as those

given in the last table, and this is easily found. All of these

+ compounds dissociate into a hydrogen cation (H) and an

anion, whose nature depends upon the compound in question,

varying with every acid. Wherever we have hydrogen ions

we have the acid property, and the strength of any acid

depends only upon the number of hydrogen ions present.

The same applies to hydroxyl bases, where their strength depends upon the number of hydroxyl anions (OH) present.

The direct quantitative relation between chemical activity and dissociation has now been so frequently established that we often use dissociation to measure chemical activity, and also chemical activity to measure the amount of dissociation.

And this raises the question as to whether chemical activity is due solely to ions. Are molecules incapable of reacting


with one another ? It would be going too far, in the light of our present knowledge, to maintain this. There are substances known which apparently do not conduct at all (are completely undissociated), and yet react chemically. There are cases known of dry solids, which we suppose contain only molecules, reacting with one another. We have well characterized chemical compounds formed by the union of two parts of apparently the same general electrical character: thus phosphorus and chlorine, chlorine and bromine, chlorine and iodine, etc. Yet chemical reactions in which acids and bases are involved are now known to be reactions involving only ions, molecules as such not coming into play. And indeed the number of reactions which are known to be purely ionic, is very great, including the majority of the cases with which we have to deal in chemistry.

The application of the theory of electrolytic dissociation is by no means limited to chemical phenomena. It touches with equal success, certain sides of physics. With its aid we are now able to calculate the electromotive force of many forms of primary cells, knowing the concentration of the solutions of electrolytes used around the electrodes. We have also, for the first time, been able to locate the seat of ijotential in such cells, which has been an unsettled question every since the discovery of the battery by Galvani and Volta, at the close of the last century.

The theory of electrolytic dissociation was not applied to biological problems as early as to chemical and physical. This is probably due to the greater complexity of those phenomena in which life is involved. But a beginning has already been made in this direction. Kahlenberg and True have shown that the toxic action of a number of acids on a certain plant, is due to the hydrogen ions of the acids, and similarly the toxic action of a number of bases can be ascribed to the hydroxyl ion of the base.

Loeb has found that the power of a frog's muscle to absorb water in the presence of acids, is dependent upon the number of hydrogen ions present, — upon the dissociation of the acid.

The pharmacologists have actively employed the theory of electrolytic dissociation in the solution of a number of problems. In this connection the work of Dreser is especially to be mentioned, and the theory has also been extended to problems in disinfection, by Paul and Kronig.

The applications of the theory of electrolytic dissociation above considered, are but a very few, taken from a large number where its significance has been already recognized. While it has suggested much new experimental work in several branches of chemistry, and in the study of the electromotive force of elements, yet, it seems to me, that perhaps its greatest service thus far to science has been in correlating facts, pointing out relations hitherto unobserved, and thus leading us from unclassified to at least partly classified knowledge. This has resulted, in a number of cases, in wide-reaching generalizations. We are thus led one step nearer to the solution of the question, not simply how do substances behave in the presence of one another, but why do the phenomena observed take place ?

Chemical Labobatorv, .Ioii.ns Hopkins Umv.


140


JOHNS HOPKINS HOSPITAL BULLETIN.


[No. 87.


LOCALIZED SCLEROSES OF THE AORTA OF PROBABLE SYPHILITIC ORIGIN.

AND NECROPSY IN TWO CASES.


CLINICAL REPORT


By Clement A. Penrose, M. D., House Medical Officer, The Johns Hopkins Hospital.


At the request of Dr. Osier 1 presented (February 7, 1898) to the Medical Society the clinical i-epoit and necropsy in a case of circumscribed or nodular arterio-sclerosis of probable syphilitic origin and located quite definitely in two portions of the aorta. Since then we have been fortunate enough to obtain the notes in a second case, that died recently in the hospital, and showed also a well localized sclerosis of the aorta of a circumscribed or nodular type,' less advanced and with an even more positive etiology of syphilis.

Case I. J. K., age 36, married, white, an American, a barber by trade, was admitted Tuesday, Jan. 4, 1898, to ward F of the Johns Hopkins Hospital.

Famihi History. As a child had measles, mumps, whooping cough, and pneumonia. At 19 thought he had syphilis; remembered a primary sore, but could give no definite history of secondary symptoms or treatment. One year later an attack of gonorrhQ3a. Malarial fever at 24, and at 29 acute rheumatism, with a second attack one year ago. When a young man was a sailor, worked hard, and was not infrequently drunk.

Present Illness. Was well and strong until Nov. 1897, when symptoms of nou-compensatiou of the heart, shortness of breath, palpitation, oedema, etc., set in acutely, and increased in severity up to the time of admission.

Phi/sical Examination. A well-nourished, strongly built man, with symptoms of marked aortic and mitral insufficiency and the corresponding physical signs. Of especial interest is a roughened first heart sound in the second right interspace, pronounced dysjinoea relative to other symptoms, absence of any hardening of the radials, for the most part a normal or subnormal temperature, with comparatively slow rate of pulse and respiration (average 90 and 25 per minute), and lastly, a poor reaction to treatment.

The patient improved somewhat, left the hospital 12 days after admission to arrange some private matters, was away one week and returned in about the same condition as on first entry. He gradually sank, and died Jan. 24, 1898, with Cheyne-Stokes respiration for one hour, and slight convulsive movements for a few minutes before death.

Autopsy. The following conditions were found: a slight insufficiency of the aortic valves as indicated by the water test ; an absence of vegetations on any of the valves, which were normal, except for a slight thickening and shortening of one of the aortic segments, and considerable hypertrophy with some dilatation of the heart confined chiefly to the left ventricle. The heart muscle on section showed exquisite fatty degeneration, with here and there fibrous areas.

Of special interest was a circumscribed or nodular form of sclerosis, localized in two portions of the aorta, one patch of which involved the ascending and transvere sections of the arch and gave rise to an aneurismal dilatation about the size of one's fist (12 cm. long by 17 wide) extending posteriorly and to the right, containing no blood clots. The walls of '


the aorta in this region presented a rough, uneven surface; no atheromatous or calcareous degeneration was visible.

The descending portion of the arch and thoracic aorta were practically free from sclerosis until a point was reached a short distance above where it pierces the diaphragm. Here a second patch of sclerosis was found extending down about 8 cm. to the cffiliac axis, showing diffuse thickening with nodular elevations