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# Talk:The Johns Hopkins Medical Journal 15 (1904)

BULLETIN

OF

THE JOHNS HOPKINS HOSPITAL

Entered as Second-CIaaa Matter at the Baltimore, Maryland, Postofflce.

Vol. XV.— No. 1 54.]

BALTIMORE, JANUARY, 1 904.

[Price, 25 Cents.

CONTKNTS.

The Master-Word iu Medicine. By William Osleh, M. D.,

F. R. S., 1

Tuberculosis of the Uriuary System in Women. Report of Thirty flve Cases. By Guy L. Hunner, M. D., 8

The Second Hospital iu the Colonies, the "Code Springs of St.

Maries," Maryland, 1098. By J. Hall Pleasants, M. D., . 18

PAGE

Some Unusual Forms of Malarial Parasites. By Mart E. Rowlet,

M. D., 33

Notes and News, 83

Notes ou New Books, 34

THE MASTER-WORD IN MEDICINE.'

By William Osler, M. D., P. E. S., Professor of Medicine, Johns Hopkins University, Baltimore, Md.

Before proceeding to the pleasing duty of addressing the undergraduates, as a native of this province and as an old student of this school, T must say a few words on the momentous changes inaugurated with this session, the most important, perhaps, which have taken place in the history of the profession in Ontario. The splendid laboratories, which we saw opened tliis afternoon, a witness to the appreciation by the authorities of the needs of science in medicine, nmke possible the highest standards of education in the subjects upon which our Art is based. They may do more. A liberal policy, with a due regard to the truth that the greatness of a scliool lies in brains, not bricks, should build uj) a great scientific center which will bring renown to this city and to our country. The men in charge of the departments are of the right stam]). See to it that you treat them in the right way by giving skilled assistance enough to ensure that the vitality of men who could work for the world is not sapped by the routine of teaching. One regret will, I know, be in the minds of many of my younger hearers. The removal of tlie departments of anatomy and physiology from

' An address to medical students ou the occasion of the opening of the new Iniildinss of the Medical Faculty of the University of Toronto, October 1st, 11103.

the biological laboratory of the university breaks a connection which has had an important influence on medicine in this city. To Professor Ramsay Wright is due much of the inspiration which has made possible these fine new laboratories. For years he has encouraged in every way the cultivation of the scientific branches of medicine, and has unselfishly devoted much time to promoting the best interests of the Medical Faculty. And in passing let me pay a tribute to the ability and zeal with which Dr. A. B. Macallum has won for himself a world-wide reputation by intricate studies which have carried the name of this University to every nook and corner of the globe where the science of physiology is cultivated. How much you owe to him in connection with the new buildings I need scarcely mention to this audience.

But the other event which we celebrate is of nmch greater importance. When the money is forthcoming, it is an easy matter to Join stone to stone in a stately edifice, but it is hard to fiiul the market in which to buy the precious cement whicli can unite into an harmonious body the professors of medicine of two rival medical schools in the same city. That this Im.; been accomplished so satisfactorily is a tribute to the good sense of the leaders of the two faculties, and tells of their recognition of the needs of the profession of tlie province.

[No. i:

Is it too much to look forward to tlie absorption or alTiliation of the Kingston and London scliools into the Provincial University? The day has passed in which the small school without full endowment can live a life beneficial to the students, to the profession, or to the public. I know well of the sacrifice of time and money which is freely made by the teachers of those schools; and they will not misunderstand my motives when I urge them to commit suicide, at least so far as to change their organizations into clinical schools in affiliation with the central iiniversity as part, perhaps, of a widespread affiliation of the hospitals of the province. A school of tlie first rank in the world, such as tliis must become, should have ample clinical facilities under its own control. It is as much a necessity that the professors of medicine and surgery, etc., should have large hospital services under their control throughout the year, as it is that professors of patholog}' and physiologj' should have laboratories such as those in which we here meet. It shoiild be an easy matter to arrange between the provincial authorities and the trustees of the Toronto General Hospital to replace the present antiquated system of multiple small services by modern wellequipped clinics — three in medicine and three in surgery to begin with. The increased efficiency of the service would be a substantial quid pro quo, but there would have to be a self-den}iag ordinance on the part of many of tlie attending physicians. With the large number of students in the combined school, no one hospital can furnish in practical medicine, surgery and the specialties a training in the art an equivalent of that which the student will have in the sciences in the new laboratories. An affiliation should be sought with every other hospital in the city and province of fifty beds and over, in each of which two or three extra-mural teachers could be recognized who would receive for three or more months a number of students proportionate to the beds in the hospital. I need not mention names. We all know men in Ottawa, Kingston, London, Hamilton, Guelph and Chatham, who could take charge of small groups of the senior students and make of them good practical doctors. I merely throw out the suggestion. There are difficulties in the way; but is there anj-thing in this life worth struggling for which does not bristle with them ?

Students of medicine : may this day be to each one of you, as it was to me when I entered this school thirty-five years ago, the beginning of a happy life in a happy calling. Xot one of you has come here with such a feeling of relief as that which 1 experienced at an escape from conic sections and logarithms and from Hooker and Pearson. The dry bones became clothed with interest, and I felt that I had at last got to work. Of the greater advantages with which you start I shall not speak. Why waste words on what you cannot understand. To those only of us who taught and studied in the ding}' old building which stood near liere ir it given to feel the change which the years have wrought — a change which my old teachers, whom I see here to-da}' — Dr Richardson, Dr. Ogden, Dr. Thorburu and Dr. Oldriglit

— must find hard to realize. One looks about in vain for some accustomed object on which to rest the eye in its backward glance — all, all are gone; the old familiar places. Even the landscape has altered, and the sense of loneliness and regret, tlie sort of homesickness one experiences on such occasions, is relieved by a feeling of thankfulness that at least some of the old familiar faces have been spared to see this day. To me at least the memory of those happy days is a perpetual benediction, and I look back upon the two years I spent at this school with the greatest delight. There were many things tliat might have been improved — and we can say the same of every medical school at that period — but I seem to have gotten more out of it than our distinguished philosopher friend, J. Beattie Crozier, whose picture of the period seems rather hardly drawn. But after all, as some one has remarked, instruction is often the least part of an education, and, as I recall them, our teachers in their life and doctrine set forth a true and lively word to the great enlightenment of our darkness. They stand out in the backgroimd of my memory as a group of men whose influence and example were most helpful. In William E. Beaumont and Edward Mulberry Hodder, we had before us the highest type of the cultivated English surgeon. In Henry H. Wright we saw the incarnation of faithful devotion to duty — too faithful, we thought, as we trudged up to the eight o'clock lectiire in the morning. In W. T. Aikins a practical surgeon of remarkable skill and an ideal teacher for the general practitioner. How we wondered and delighted in the anatomical demonstrations of Dr. Eichardson, whose infective enthusiasm did much to make anatomy the favorite subject among the students. I had the double advantage of attending the last course of Dr. Ogden and the first of Dr. Thorburn on materia medica and therapeutics. And Dr. Oldright had just begmi his career of unselfish devotion to the cause of hygiene.

To one of my teachers I must pay in passing the tribute of filial affection. There are men here to-day who feel as I do about Dr. James Bovell — that he was one of those finer spirits, not uncommon in life, toiiched to fijier issues only in a suitable environment. Would the Paul of evolution have been Thomas Henry Huxley had the Senate elected the yoimg natui'alist to a chair in this university in 1851? Only men of a certain metal rise superior to their surroimdings, and while Dr. Bovell had that all-important combination of boundless ambition with cnergv' and industry, he had that fatal fault of ditfuseness, in which even genius gets strangled With i quadrilateral mind, which he kept spinning like a teetotum, one side was never kept uppermost for long at a time. Caught in the storm which shook the scientific world with the publication of tlie " Origin of Species," instead of sailing before the wind, even were it with bare poles, he put about and sought a harljor of refuge in writing a work on Natural Theology, which you will find on the shelves of second-hand bookshops in a company made rospcctalile at least by the presence of Paley. lie was an omniverous reader and transmuter, he could talk

January, 1901.]

])lea.santly, even at times transecuclentally, upon anything in the science ol' tlie day,, from protoplasm to evolution; but he lacked concentration and that scientific accuracy which only comes with a long training (sometimes indeed never comes), and which is tlie ballast of the boat. But the bent of his ininil was devotional, and early swept into the Tractarian movement, he became an advanced Churchman, a good .Anglican Catholic. As he chaffmgly remarked one day to his friend, the Reverend Mr. Darling, he was like the waterman in " Pilgrim's Progi-css,'"'" rowing one way, towards Eome, but looking steadfastly in tlie other direction, towards Lambeth. His " Steps to the Altar," and his " Lectures on the Advent " attest the earnestness of his convictions; and later in life, following the example of Linacre, he took orders and became another illustration of what Cotton Mather calls the angelical conjuction of medicine with divinity. Then, how well I recall the keen love with which he would engage in metaphysical discussions, and the ardor with which he studied Kant, Hamilton, Eeed and Mill. At that day to the Bev. Prof. Bevan was entrusted the rare privilege of directing the minds of the thinlciug youths at the Provincial University into proper philosophical channels. It was rumored that the hungry sheep looked up and were not fed. I thought so at least, for certain of them, led by T. Wesley Mills, came over daily after Dr. Bovell's four o'clock lecture to reason high and long with him

" Ou Providence, Foreknowleilge, Will aud FateFixed Fate, Freewill, Forekuowledge absolute."

Yet withal his main business in life was as a jjhysician, much sought after for his skill in diagnosis, and much beloved for his loving heart. He had been brought up in the very best practical schools. A pupil of Bright and of Addison, a warm personal friend of Stokes and of Graves, he maintained loyally the traditions of Guy's and taught us to reverence his great masters. As a teacher, he had grasped the fundamental truth announced by John Hunter of the unity of physiological and pathological processes, and, as became the occupant of the chair of the Institute of Medicine, he would discourse on pathological processes in lectures on physiology, and illustrate the physiology of bioplasm in lectures on the pathology of tumors to the bewilderment of the students. When in September, 1870, he wrote to me that he did not intend to return from the West Indies, I felt that I had lost a father and a friend; but in Robert Palmer Howard, of Montreal, I found a noble step-father, and to these two men, and to my first teacher, the Rev. W. A. Johnson, of Weston, I owe my success in life — if success means getting what you want and being satisfied witli it.

II.

Of the value of an introductory lecture I am not altogether certain. I do not remember to have derived any enduring iiciiclit from I he many that I have been called upon to hear, or from the not a few J have inflicted in my day. On the whole I am in favor of abolishing the old custom, but as this is a very

special occasion, with special addresses, I consider myself most happy to have been selected for this part of the programme. To the audience at large I fear that mut^h of what 1 have to say will ap]iear ti'ite and counnonplaco, but bear with me, since, indeed, to most of you how good soever the word, the season is long past in which it could be spoken 1o your edification. As I glance from face to face the most striking single peculiarity is the extraordinary diversity that exists among you. Alike in that you arc men and white, vou arc unlike in your features, very unlike in your minds and m 3^our menial training, and your teachers will mourn the singular inequalities in your capacities. And so it is sad to think will be your careers. For one success, for another failure ; one will tread the primrose path to the great bonfire, another the straight and narrow way to renown; some of the best of you will he stricken early on the road, and will Join that noble band of youthful martyrs who loved not their lives to the death; others, perhaps the most brilliant among you, like my old friend and comrade, Dick Zimmerman (how he would have rejoiced to see this day!), the Fates will overtake and whirl to destruction Just as success seems assured. When the iniquity of oblivion has blindly scattered her poppy over us, some of you will be the trusted counsellors of this community, and the heads of departments in this Faculty while for the large majority of you, let us hope, is reserved the happiest and most useful lot given to man — to become vigorous, wholesouled, intelligent general practitioners.

It seems a bounden duty on such an occasion to be honest and frank, so I propose to tell you the secret of life as I have seen the game played, and as I have tried to play it myself. You remember in one of the " Jungle Stories," that when Mowgli wished to be avenged on the villagers he could only get the help of Hathi and his sons by sending them the masterword. This I propose to give you in the hope, yes, the full assurance, that some of you at least will lay hold upon it to your jirofit. Though a little one, the master-word looms large in meaning. It is the open sesame to every portal, the great equalizer in the world, the true philosopher's stone which transmutes all the base metal of humanity into gold. The stupid man among you it will make bright, the bright man brilliant, and the brilliant student steady. With the magic word in your heart all things are possible, and without it all study is vanity and vexation. The miracles of life are with it ; the blind see by touch, the deaf hear with eyes, the dumb speak with fingers. To the youth it brings hope, to the middle-aged confidence, to the aged repose. True balm of hurt minds, in its presence the heart of the sorrowful is lightened and consoled. It is directly resijonsible for all advances in medicine during the past twenty-five centuries. Laying hold upon it, Hippocrates made observation and science the warp and woof of oiir art. Galen so read its meaning that fifteen centuries stopped thinking, and slept until awakened by the De Fahrica of Vesalius, which is the very incarnation of the master-word. With its inspiration Harvey gave an impulse to a larger circulation than he wot of, an impulse which we

[No. 154.

feel to-day. Hunter sounded all its heights and depths, and stands out in our history as one of the great exemplars of its virtues. With it Virchow smote the rock and the waters of progress gushed out; while in the hands of Pasteur it proved a very talisman to open to us a new heaven in medicine and a new earth in surgery. Not only has it been tlie touchstone of progress, but it is the measure of success in everyday life. Not a man before you but is beholden to it for his position here, while he who addresses you has that honor directly in consequence of having had it graven on his heart when he was as you are to-day. And the Master-Word is Work, a little one, as I have said, but frauglit with momentous sequences if you can but write it on the tables of your heart, and bind it upon your forehead. But there is a serious difficulty in getting you to understand the paramount importance of tlie work-habit as part of your organization. You arc not far from the Tom Sawyer stage with its philosophy " tliat work consists of whatever a body is obliged to do, and play consists of whatever a body is not obliged to do."

A great many hard things may be said of tlie work-habit. For many of us it means a hard battle; the few take to it naturally ; the many prefer idleness and never learn to love to labor. Listen to tliis : " Look at one of your industrious fellows for a moment, I beseech you," says Eobert Louis Stevenson. " He sows hurry and reaps indigestion ; he puts a vast deal of activity out to interest, and receives a large measure of nervous derangement in return. Either he alssents himself entirely from all fellowship, and lives a recluse in a garret, with carpet slippers and a leaden inkpot; or he comes among people swiftly and bitterly, in a contraction of his whole nervous system, to discharge some temper before he returns to work. I do not care how mucJi or how well lie works, this fellow is an evil feature in otlier people's lives." These are the sentiments of an overworked, dejected man ; let me quote the motto of Jiis saner moments : " To travel hopeful is better than to arrive, and the true success is in labor." If you wish to learn of the miseries of scholars in order to avoid them, read Part I, Section 2, Member 3, Sub-section XV, of that immortal work, the "Anatomy of Melancholy," but I am liere to warn you against these evils, and to entreat yon to form good habits in your student days.

At the outset, appreciate clearly tlio aims and objects cacli one of you should have in view — a knowledge of disease and its cure, and a knowledge of yourselves. 'J'he one, a special education, will make you a practitioner of medicine; the other, an inner education, may make you a truly good man, foursquare and without a flaw. The one is extrinsic and is largely accomplished by teacher and tutor, by te.xt and by tongue; the other is intrinsic and is the mental salvation to bo wrought by each one for himself. Tlie first may be had without the second; any one of you may become an acti! practitioner, without ever having had sense enough to realize that througli life you have been a fool; or you may have the second without the first, and, without knowing much of the ai-t, you may have the endowments of head and heart that make the little you do possess go very far in the community. With what I hope to infect you is the desire to have a duo proportion of each. So far as your professional education is concerned, what I shall say may make for each one of you an easy path easier. The multiplicity of the subjects to be studied is a difficulty, and it is hard for teacher and student to get a due sense )f proportion in the work. We are in a transition stage in our methods of teaching, and we have not everywhere got away from the idea of the examination as the " be-all and end-all ; " so that the student has continuallv before his eyes the magical letters of the degree he seeks. And this is well, perhaps, if you will remember that having, in the old phrase, commenced Baclielor of Medicine, you have only reached a point from which you can liogiii a life-long process of education. So many and varied are the aspects presented by this theme that I can only lay stress upon a few of the more essential. The very first step towards success in any occupation is to become interested in it. Locke put this in a very happy way when he said, give a pupil " a relish of knowledge " and you put life into his work. And there is nothing more certain than that you cannot study well if you are not interested in your profession. Your presence here is a warrant that in some way you have become attracted to the study of medicine, but the speculative possibilities so warmly cherished at the outset are apt to cool when in contact with the stern realities of the class-room. Most of j'ou have already experienced the all-absorbing attraction of the scientific bracches, and nowadays the practical method of presentation has given a zest which was usually lacking in the old theoretical teaching. The life has become more serious in consequence, and medical students have put away many of the childish tricks with which we used to keep up their bad name. Compare the jiicture of the " sawbones " of 1842, as given in the recent biography of Sir Henry Acland, with their representatives to-day, and it is evident a great revolution has been effected, and very largely by the salutary influence of improved methods of education. It is possible now to fill out a day with practical work, varied enough to prevent monotony, and so arranged that the knowledge is picked out by the student himself, not trust into him, willy-nilly, at the point of the tongue. He exercises his wits, and is no longer a passive Strassbourg goose, tied up and stuffed to repletion. How can you take the greatest possible advantage of your capacities with the least possible strain? By cultivating system. I say cultivating advisedly, since some of you will find the acquisition of sj-stematic habits very hard. There are minds congenitally systematic; others have a life-long fight against an inherited tendency to dilTuseness and carelessness in work. A few brilliant fellows try to dispense with it altogether, but they are a burden to their brethren and a sore trial to their intimates. I have heard it remarked that order is the badge of an ordinary mind. So it may be, but as practitioner? of medicine we have to be thankful to got into this useful class. Let nie entreat those of you who are here for the Jaxvauv. litol.] first time to lay to heart what I say on this matter. Forget all else, but take away this counsel of a man who has had to fight a liard battle, but not always a successful one, for the little order he lias had in his life : take away with you a profound conviction of the value of system in your work. I appeal to the freshmen especially, because you to-day make a beginning, and your future career depends very much upon the habits you will form during this session. To follow the routine of the classes is easy enough, but to take routine into every part of your daily life is a hard task. Some of you will start out joyfully as did Christian and Hopeful, and for many days will journey safely towards the Delectable Mountains, dreaming of them and not thinking of disaster until you find yourselves in the strong captivity of Doubt and imder the grinding tvranny of Despair. You have been over-confident. Begin again and more cautiously. Xo student escapes wholly from tliese perils and trials; be not dislieartened, expect them. Let each hour of the day have its allotted duty, and cultivate that power of concentration which grows with its exercise, so that the attention neither flags nor wavers, but settles with a bull-dog tenacity on the subject before you. Constant repetition makes a good habit fit easily in your mind, and by the end of the session you may have gained that most precious of all knowledge — the power to work. Do not imderestimate the difficulty you will have in wringing from your reluctant selves the stem determination to exact the uttermost minute on your schedule. Do not get too interested in one study at the expense of another, but so map out your day that due allowance is given to each. Only in this way can the average student get the best that he can out of his capacities. And it is worth all the pains and trouble he can possibly take for the ultimate gain — if he can reach his doctorate with system so ingrained that it has become an integral part of his being. The artistic sense of perfection in work is another mucli-to-be-desired quality to be cultivated. Xo matter how trifling the matter on hand, do it with a feeling that it demands tlie best that is in you, and when done look it over with a critical eye, not sparing a strict judgment on yourself. This it is that makes anatomy a student's touchstone. Take the man who does his " part " to ijerfection, who has got out all there is in it, wlio labors over the tags of connective tissue, and who demonstrates Meckel's ganglion in his part — this is the fellow in after years who is apt in emergencies, who saves a leg badly smashed in a railway accident, or fights out to the finish, never knowing when he is beaten, in a case of typhoid fever. Learn to love the freedom of the student life, only too quickly to pass away ; the absence of the coarser cares of after days, the joy of comradeship, the delight in new work, the liappincss in knowing that you are making progress. Once only can you enjoy these pleasures. The seclusion of the student life is not alwaj's good for a man, particularly for those of you who will afterwards engage in general practice, since you will miss that facility of intercourse upon which often the doctor's success depends. On the other hand, sequestra tion is essential for those of j'ou with high ambitions proportionate to your capacity. It was for such that St. Chrysostom gave his famous counsel, " Depart from the highways and transplant thyself into some enclosed ground, for it is hard for a tree that stands by the wayside to keep its fruit till it be ripe." Has work no dangers connected with it? What of this bogey of overwork of wliich we hear so much ? There are dangers, but they may readily be avoided with a little care. I can only mention two, one physical, one mental. The very best students are often not the strongest. Ill-health, the bridle of Theages, as Plato called it in the case of one of his friends whose mind had thriven at the expense of the body, may have been the diverting influence toward books or the profession." Among the good men who have studied with me there stand out in my remembrance many a young Lycidas, " dead ere his prime," sacrificed to carelessness in habits of living and neglect of ordinary sanitary laws, iledical students are mucli exposed to infection of all sorts, to combat which the bodv must be kept in first-class condition. GrosstestC; the great Bishop of Lincoln, remarked that there were three thing.necessary for temporal salvation — food, sleep, and a cheerful disposition. Add to these suitable exercise and you have tlu? means by which good health may be maintained. Not that health is to be a matter of perpetual solicitude, but habits which favor the corpus sanum foster the jneiis sana^ in whicti the joy of living and the joy of working are blended in one harmony. Let me read you a quotation from old Burton, the great authority on morhi eruditoruin. There are " many reasons why students dote more often than others. The first i.-, their negligence. Other men look to their tools : a painter will wash his pencils ; a smith will look to his hammer, anvil, forge; a husbandman will mend his plough-irons, and grind his hatchet, if it be dull ; a falconer or huntsman will have an especial care of his hawks, hounds, horses, dogs, etc. ; a musician will string and unstring his lute, etc. ; only scholars neglect that instrument, their brain and spirits (I mean) which they daily use." ' Much study is not only believed to be a weariness of the flesh, but also an active cause of ill-health of mind, in all grades and phase. I deny that work, legitimate work, has anything to do with this. It is that foul fiend Worry who is responsible for a large majority of the cases. The more carefully one looks into the cause of nervous breakdown in students, the less important is work per se as a factor. There are a few eases of genuine overwork, but they are not common. Of the causes of worrj in the student life there are three of prime importance to which I may briefly refer. An anticipatory attitude of mind, a perpetual forecasting, disturbs the even tenor of his way and leads to disaster. Years ago a sentence in one of Carlyle's essays made a lasting impression on me : " Our duty is not to see what lies dimly at a distance, but to do what lies clearly at hand." I have long maintained that the best motto for a student is, " Take 'Quotation mainly from Maisiliua Ficinus. [No. 154. no thought for the morrow." Let the day'ti work suffice; live for it, regardless of what the fviture has in store, believing that to-morrow should take thought for the things of itself. There is no such safeguard against the morbid apprehensions about the future, tlie dread of examinations and the doubt of ultimate success. Xor is there any risk that such an attitude may breed carelessness. On the contrary, tiie absorption in the duty of the hour is in itself the best guarantee of ultimate siiecess. " He that regardeth the wind shall not sow, and he that observeth the clouds shall not reap," which means you cannot work profitably with your mind set upon the future. Another potent cause of worry is an idolatry l)y which many of you will be sore let and hindered. The mistress of your studies should be the heavenly Aphrodite, the motherless daughter of Uranus. Give her your whole heart and she will be your protectress and friend. A jealous creature, brooking no second, if she finds you trifling and coquetting with her rival, the younger, early Aphrodite, daughter of Zeus and Dione, she will whistle you off, and let you down the wind to be a prey, perhaps to the examiners, certainly to the worm regret. In plainer language, put your afliections in cold storage for a few years, and you will take them out ripened, perhaps a bit mellow, but certainly less subject to those frequent changes which perplex so many young men. Only a grand passion, an all-absorbing devotion to the elder goddess, can save the man with a .congenital tendency to philandering, the flighty Lydgate who sports with Celia and Dorothea, and upon whom the judgment ultimately falls in a basil-plant of a wife like Rosamond. And thirdly, one and all of you will have to face the ordeal of every student in this generation who sooner or later tries to mix the waters of science with the oil of faith. You can have a great deal of both if you can only keep them separate. The worry comes from the attempt at mixture. As general practitioners you will need all the faith you can carry, and while it may not always be of the conventional pattern, when expressed in your lives rather than on your lips, the variety is not a bad one from the standpoint of St. James, and may help to counteract the common scandal alluded to in the celebrated diary of that gossipy old parson-doctor, the Rev. John Ward : " One told the Bishop of Gloucester that he imagined physitians of all men the most competent judges of all others' affairs of religion — and his reason was because they were wholly unconcerned witli it." III. Professional work of any sort tends to narrow the mind, to limit the point of view, and to put a hall-mark on a man of a most unmistakable kind. On the one hand are the intense, ardent natures, absorbed in tlieir studies and quickly losing interest in everything but their profession, while other faculties and interests " fust" unused. On the other hand are the bovine brethren, who think of nothing but the treadmill and the corn. From very different causes, the one from concen tration, the other from apathy, both are apt to neglect those outside studies that widen the sympathies and help a man to get the best there is out of life. Like art, medicine is an exacting mistress, and in the pursuit of one of the scientific branches, sometimes, too, in practice, not a portion of a man's spirit may be left free for other distractions, but this does not often happen. On account of the intimate personal nature of his work, the medical man, perhaps more than any other man, needs that higher education of which Plato speaks, " that education in virtue from youth upwards, which enables^ a man eagerly to pursue the ideal perfection." It is not for all, nor can all attain to it, but there is comfort and help in the pursiut, even though the end is never reached. For a large majority the daily round and the common task furnish more than enough to satisfy their heart's desire, and there seems no room left for anything else. Like the good, easy man whom Milton scores in the Areopagitica, whose religion was a "traffic so entangled that of all mysteries he could not skill to keep a stock going upon that trade," and handed it over with all the locks and keys to " a divine of note and estimation," so is it with many of us in the matter of this higher education. Xo longer intrinsic, wrought in us and ingrained, it has become, in Milton phrase, a " dividual movable," handed over nowadays to the daily press or to the hap-hazard instruction of the p^^lpit, the platform, or the magazines. Like a good many other things, it comes to a better and more enduring form if not too consciously sought. The all-important thing is to get a relish for the good company of the race in a daily intereoiirse with some of the great minds of all ages.. Now, in the spring-time of life, pick your intimates among them, and begin a systematic cultivation of their works. Many of you will need a strong leaven to raise you above the level of the dough in which it will be your lot to labor. Uncongenial surroundings, an ever-present dissonance between the aspirations within and the actualities without, the oppressive discords of human society, the bitter tragedies of life, the lacrymae rerum, beside the hidden springs of which we sit in sad despair — all these tend to foster in some natures a cynicism quite foreign to our vocation, and to which this inner education offers the best antidote. Personal contact with men of high purpose and character will help a man to make a start — • to have the desire, at least, but in its fulness this culture — for that word best expresses it — has to be wrought by each one for himself. Start at once a bed-side library and spend the last half hour of the day in comnimiion with the sainvs of humanity. There are great lessons to be learned from Job and from David, from Isaiah and St. Paul. Taught by Shakespeare you may take your intellectual and moral measure with singular precision. Learn to love Epictetus and Marcus Aurelius. Should you be so fortunate as to be bom a Platonist, Jowett will introduce you to the great master through whom alone we can think in certain levels, and whose perpetual modernncss startles and delights. ]\[ontaigne will teach moderation in all things, and to be " sealed of his tribe " is a six'cial privilege. We have in the profession only a few great literary heroes of tlie first rank, tlie friendship and counsel of two of whom you cannot too earnestly seek. Sir Thomas Brown's " Eeligio Medici " should be your pocket companion, while from the " Breakfast Table Series " of Oliver Wendell Holmes you can glean a philosophy of life peculiarly suited to the needs of a physician. There are at least a dozen or more works which would be helpful in getting that wisdom in life wliicli only comes to those w'ho earnestly seek it. A conscientious pursuit of Plato's ideal perfection may teach you the three great lessons of life. You may learn to consume your own smoke. The atmosphere of life is darkened by the murmurings and whimperings of men and women over the non-essentials, the trifles, that are inevitably incident to the hurly-burly of the day's routine. Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity and consume j'our own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaints. More than any other the practitioner of medicine may illustrate the second great lesson, that we are here not to get all we can out of life for ourselves, but to try to make the lives of others happier. This is the essence of the oftrepeated admonition of Christ, " He that findeth his life shall lose it, and he that Jo-cth his life for my sake shall find it," on which hard saying if the children of this generation would lay hold, there would lie less misery and discontent in the world. It is not possible for anyone to have better opportunities to live this lesson than you will enjoy. The practice of medicine is an art, not a trade, a calling, not a business, a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, the wise upon the foolish. To you as the trusted family counsellor the father will come with his anxieties, the mother with her hidden griefs, the daughter with her trials, and the son with his follies. Fully one-third of the work you do will be entered in other books than yours. Courage and cheerfulness will not only carry you over the rough places of life, but will enable you to bring comfort and help to the weak-hearted, and will console you in the sad hours when, like Uncle Toby, you have " to whistle that you may not weep." And the third great lesson }-ou may learn is the hardest of all — that the law of the higher life is only fulfilled by love or charity. Many a physician whose daily work is a daily round of beneficence will say hard things and will think hard thoughts of a colleague. Xo sin will so easily beset you iis uncharitablencss towards your brother practitioner. So strong is the personal element in the practice of medicine, and so many are the wagging tongues in every parish, that evil speaking, lying and slandering find a shining mark in the lapses and mistakes which are inevitable in our work. There is no rea son for discord and disagreement, and the only way to avoid trouble is to have two iiJain rules. From the day you begin practice never under any circumstances listen to a tale told to the detriment of a brother practitoner. And when any dispute or trouble does arise, go frankly, ere sunset, and talk the matter over, in wliich way you may gain a brother and a friend. Very easy to carry out, yon nuxy think ! Far from it; there is no harder battle to fight. Theoretically, there seems to he no difficulty, but when the concrete wound is rankling, and after Mrs. Jones has rubbed in the cayenne pepper by declaring that Dr. J. told her in confidence of your shocking bungling, your attitude of mind is that you would rather see him in purgatory than make advances towards reconciliation. Wait until the day of your trial comes and then remember my words. And in closing may I say a few words to the younger practitioners in the audience whose activities will wax, not wane, with the growing years of the century which opens so auspiciously for this school, for this city, for this country. You enter a noble heritage, made by no efforts of your own, but by generations of men who have unselfishly sought to do the best they could for suffering mankind. Much has been done, much remains to do ; a way has been opened, and to the possibilities )u the scientific development of medicine there seems to be no limit. Except in its application, as general practitioners, you will not have much to do with this. Yours is a higher and a more sacred duty. Think not to light a light to shine before men that they may see your good works; contrariwise, you belong to the great army of quiet workers, physicians and priests, sisters and nurses, all over the world, the members of which strive not neither do they cry, nor are their voices lieard in the streets, but to them is given the ministry of consolation in sorrow, need and sickness. Like the ideal wife (if whom Plutarch speaks, the best doctor is often the one of \iliom the public hears least; but nowadays in the fierce light that beats upon the hearth, it is increasingly difficult to live the secluded life in which our best work is done. To you the silent workers of the ranks, in villages and country districts, in the slums of our great cities, in the mining camps and factory towms, in the homes of the rich and in the hovels of the poor — to you is given the harder task of illustrating in your lives the old Hippocratic standards of learning, of sagacity, of humanity and of probity. Of learning, that you may apply in your practice the best that is known in our art, and that with the increase in that priceless endowment of sagacity, so tliat to all everywhere skilled succor may come in the hour of urgent need. Of a humanity that will show in your daily life tenderness and consideration to the weak, infinite pity to the suffering and a liroad charity to all. Of a probity that will make you under all circumtances true to yourselves, true lo your high calling, and true to your fellowmen. TUBERCULOSIS OF THE URINARY SYSTEM IN WOMEN. REPORT OF THIRTY-FIVE CASES. By Guy L. Hdnner, M. D., Associate in (hjnecolo<jij, .Johns Ilopldns Unircrsiiij, Baliiiiiore. This paper will deal chiefly with diagnosis. I shall speak briefly of the treatment and the final results, time forbidding a technical review of the operations. There will be no attempt to jjresent a systematic and comprehensive treatise on the subject of tuberculosis of the urinary system — this yon can find in the text-books and special monographs. I hope to present a few practical and lielpful facts and conclusions that may be drawn from a study of 35 cases which have occurred in the service of Dr. Howard A. Kelly and his associates. THE SECOND HOSPITAL IN THE COLONIES, THE "COOLE SPRINGS OF ST. MARIES," MARYLAND, KIDS.* By J. Hall Pleasants, M. D. SOME UNUSUAL FORMS OF MALARIAL PARASITES. By Mauy E. Rowley, M. D. {From the Clinico-Pathological Laboratory, Massachusetts General Ho.ii)ital. Photoi/raijhs by Louis A. Brown.) The varieties of parasites ordinarily to be found in the blood of Aestivo Autumnal Malaria are : I. Eing-shaped bodies. II. Crescents and ovoids. In the blood of three eases of this fever, I noticed a number of parasites quite different from the above. Those to which I desire to call attention are of two classes : I. The first set of bodies are intracellular, elongated and sausage-shaped, extending transversely across the red cell nearly from side to side. The body of the parasite contains irregular openings, iisually situated at its extremities. The chromatin is in the form of dots arranged in a short series parallel to the long axis of the parasite and about midway between its extremities (Figs. 1-6). Pigment was present in all the forms observed and was either scattered about the parasite without special arrangement or grouped at its ends.' ' In KoUe ifc Wassermanu's Atlas of Handbucli Path. Mikroorganismen, Berlin, are Hgured some forms of quartan parasites not unlilie tliose wbicli I liave found in aestivo-autumnal fevers. II. The other forms found would suggest a transition between the bodies just described and " crescents; " for example, Pig. 7, which shows a form distinctly curved on itself like a crescent, but of much looser structure, the chromatin arranged in a string of dots near one end, and the pigment at the periphery and not at the center as in most crescents. Figs. 8 and 9 are evidently crescents, but show much more of the corpuscle than is usually to be seen and approach quite distinctly the appearance of Fig. 7, which I should hesitate to call a crescent. We have, then, a suggestion of the means of formation of " crescents " out of the elongated intracellular forms above described, wliile these in turn can probably be connected (through intermediate forms) with the larger and heavier forms of ring bodies such as are shown in Figs. 1 and 3. I wish to express my appreciation of the kind assistance given me by Dr. Eichard C. Cabot in studying and interpreting the parasites above described. n^otes A^jy xews. Dr. Joseph Akerman, appointed House IMedical Officer in 1900, but did not serve, is Superintendent of the James Walker Memorial Hospital, Wilmington, N. C. Dr. Ilorliert W. Allen, House Medical Officer during 1900 and 1901, is Assistant in Clinical Pathology and in Medicine in the Medical Department of the University of California. Address : 546 Sutter Street, San Francisco, Cal. Dr. John JI. Berry, House Medical Oliicer during 1901 and 1902, is surgical assistant to Dr. W. G. Macdonald, of Albany, X. Y. Address: 1.86 State Street, Albany, X. Y. Dr. Joel I. Butler, House Medical Oflicer during 19iil und 1902, is Resident House Officer in Surgery in the Massachusetts General Hospital, Boston, Mass. Dr. \\L J. Calvert, appointed House Medical Officer in 1898, but did not serve, is Assistant Professor of Internal Jlodieine, University of Missouri. Address: Columbia, Mo. Dr. C. N. B. Camac, Assistant Resident Physician in 1896 and 1897, is Instructor in Medicine, Cornell Medical College, and Chief of Staff in the Department of General Medicine of the Cornell Dispensary. Address: 108 East 6511) Street, Xcw York City. Dr. M. B. Clopton, Assistant Eesident Surgeon in 1898 and 1899, is Visiting Surgeon to St. Luke's Hospital. St. Louis. Address: 260-1 Locust Street, St. Louis, Mo. Dr. Sydney 'M. Cone, Assistant Eesident Surgeon in 1891 and 1897, is Clinical Professor of Orthopedic Surgery, Baltimore Medical College. Address: 821 Park Avenue, Baltimore. Dr. George W. Dobbin, Assistant Resident Obstetrician from 1894 to 1896, and Eesident Obstetrician from 1896 to 1899, is Professor of Obstetrics, College of Physicians and Surgeons. Address: 56 West Biddle Street, Baltimore. Dr. William W. Farr, Assistant Resident Gynecologist during 1890 and 1891, resides at 39 Gowen Avenue, ]\[oimt Airy, Philadelphia, Pa. Dr. A. L. Fisher, House Medical Oliicer during 1900 and 1901, is Assistant in Surgery in the Medical Department of the University of California, and Assistant Visiting Surgeon to Mt. Zion Hospital, San Francisco. Address : 54() Sutter Street, San Francisco, California. Dr. 11. ,\. ImiwIit. House Medical Officer in 1901 and 1902, resides at 'i'he Cuiiil)crl:ind, Washington, D. C. THE JOHNS HOPKINS HOSPITAL BULLETIN, JANUARY, 1904. PLATE 1. FIG. 9. jANUAItY. TOOL] 23 Dr. I?. Edward Garrett, Assistant Resident Surgeon from 1895 to 1897, is First Assistant I'liysieian, Maryland Hospital for (lie Insane. Address: Catonsville, Md. Dr. McPlieeters Glasgow, Assistant Resident Gynecologist in 189G, resides at 151 North Spruce Street, Nashville, Tenii. Dr. Henry Harris, House Medical Officer during 1899 and 1900, is Assistant in Principles and Practice of Medicine, Cooper Medical College, First Assistant in the Medical Clinic, Cooper ]\redical Dispensary, and A^isiting Physician, Pacific Hebrew Orphan Asylum. Address: 502 Sutter Street, San Francisco, Cal. Dr. Thomas W. Hastings, House Medical Officer during 189S and 1899, is Instructor in Clinical Pathology, Cornell Medical College, and Assistant Attending Physician, Department of General Medicine, Cornell Dispensary. Address : 72 West 8rth Street, New York City. Dr. R. F. Hastrciter, House Medical Officer during 1901 and 1902, is Physician in Charge of the Milwaukee Branch of the Summit Lake Sanitorium, Physician to the Protestant Home for the Aged, and Instructor in Anatomy in the Wisconsin College of Physicians and Surgeons. Address: 203G Wells Street, Milwaukee, Wis. Dr. Joseph H. Hathaway, House Medical Officer during 1901 and 1902, is Resident Pathologist, Free Hospital for Women, Brookline, Mass. Dr. Carl H. Horst, House Medical Officer during 1902 and 1903, resides at 208 West Galaia Street, Butte, Montana. Dr. J. A. Luetscher, House Medical Officer during 1899 and 1900, resides at 1025 Madison Avenue, Baltimore. Dr. Irving P. Lyon, House Medical Officer during 1897 and 1898, resides at 531 Franklin Street, Buffalo, N. Y. Dr. J. D. Madison, House Medical Officer during 1898 and 1899, is Chief of the Medical Dispensary, and Adjunct Professor of Medicine, Wisconsin College of Physicians and Surgeons. Address: 199 23rd Street, Milwaukee, Wis. Dr. E. W. Meisenhelder, House Medical Officer in 1902 and 1903, is a member of the staff of the Barnes Hospital, Washington, D. C. Dr. J. F. Mitchell, House Medical Officer during 1897 and 1898, Assistant Resident Surgeon from 1898 to 1900, and Resident Surgeon from 1900 to 1902, is Professor of Surgical Pathology, Columbian University, and Surgeon to the Dispensary of the University Hospital, Washington. Address: 1311 Connecticut Avenue, Washington, D. C. Dr. G. II. P. Nuttall, Assistant Bacteriologist from 1891 to 1893, is President of the Tropical Medicine Section, British Medical Association, Examiner in Bacteriology and Tropical Medicine to the Royal Army Medical Corps, and Accessory Member of the Tropical Diseases Committee appointed by the Council of the Royal Society. Address: 3 Cranmcr Road, Cambridge, England. Dr. Mary S. Packard, House Medical Officer during 1897 and 1898, resides at 425 Angell Street, Providence, R. I. Dr. Clement A. Penrose, House Medical Officer during 1897 and 1898, resides at 21 West Mount Royal .\ venue, Baltimore. Dr. Lindsay Peters, Assistant Resident Obstetrician during 1897 and 1898, and Assistant Resident Gynecologist during 1898 and 1899, resides at 1414 Gervais, Street, Columbia, S. C. Dr. Hunter Robb, Resident Gynecologist from 1889 to 1892, is Professor of Gynecology, Western Reserve University. Address: 702 Rose Building, Cleveland, Ohio. Dr. Carey P. Rogers, House Jledical Officer during 1902 and 1903, resides at the Bisbee Building, Jacksonville, Fla. Dr. Maurice Rubel, House Medical Officer during 1901 and 1902, resides at 4452 Ellis Avenue, Chicago, 111. Dr. Glauville Y. Rusk, House Medical Officer during 1900 and 1901, is Assistant in the Pathological Institute of the State of New York. Address: Pathological Institute, Ward's Island, New York. Dr. Florence R. Sabin, House Medical Officer during 1900 and 1901, is Assistant in Anatomy, Johns Hopkins Medical School. Address: 1415 Linden Avenue, Baltimore. Dr. Georgiana Sands, House Medical Officer during 1898 and 1899, resides at 348 North Main Street, Port Chester, N. Y. Dr. C. P. Smith, Assistant Resident Surgeon during 1893 and 1894, is Surgeon to the Buffalo, Rochester and Pittsburgh Railway Company. Address: 481 Franklin Street, Buffalo, X. Y. ' Dr. C. N. Spratt, House Medical Officer during 1901 and 1902, is a member of the staff of the Massachusetts Charitable Eye and Ear Infirmary. Address: 233 Charles Street, Boston, Mass. Dr. A. L. Stavely, Assistant Resident Gjmecologist in 1891 and 1892, and Resident Gynecologist from 1892 to 1894, is Gynecologist to the Garfield Memorial Hospital, and Clinical Professor of Gynecology, Columbian University. Address : 1207 Connecticut Avenue, Washington, D. C. Dr. J. M. Taylor, Assistant Resident Gynecologist in 1900 and 1901, is located at the Pierce Building, Boise, Idaho. Dr. Harry Toulmin, Assistant Resident Physician in 1889 and 1890, is Assistant Medical DircH'tor of the Pcnn Mutual Life Insurance Comjiany. Address: 921 Chestnut Street, Philadelphia, Pa. 24 [No. 1' NOTES ON NEW BOOKS. A Narrative of Medicine in America. By James Ghegory MuitroRD, M .D., Assistant Visiting Surgeon to the Massacliusetts General Hospital and Instructor in Surgery In the Harvard Medical School. Octavo, 508 pages. (Pliiladelpliia and London: J. B. Lippincott Company, IDOS.) The work done, during the past few years on the history of medicine in the United States should be especially gratifying to all who take an interest in the recital of matters medical. The enthusiasm aroused for this study shows that the labors of Thacher, Beck, Toner and Quinan have not been in vain, for the subsequent delvings of Cordell, Packard and a host of others have brought to light much worthy of record about our doctors of former times and their surroundings. Mumford, already known by his writings on former Boston worthies, has recently published a most readable book, narrating many of the principal facts in the medical history of our own country. His charm of style causes the work to be with difficulty laid aside until the last page has been read. He starts with the colonial era — a time when most of the doctors obtained their knowledge from apprenticeships, for few there were who could go abroad to Leyden, Paris, Padua or Great Britain, for a more complete education. The early doctors in Virginia are here touched upon and some mention is made of good old Deacon Fuller, of Mayflower fame. John Winthrop, Jr.. is also referred to but is erroneously spoken of as Governor, in 1G57. of the New Haven Colony instead of Connecticut, and asserted to be a founder of the Royal Society. As a matter of fact the Royal Society was organized in 1660, but was not incorporated until two years later, at which time Winthrop was proposed for membership by William Brereton and admitted some twenty days thereafter. Other names, though not quite so luminous, are given full attention by Mumford. In his list of eighteen of the best known early Massachusetts physicians, Giles Firmln is written as Giles Fairman. An interesting man he was and we wish some account of him had been given other than the mere recital of his name, for he, in those early days, " did make and read upon the one Anatomy (skeleton) on the country very well" but despairing of earning his living as a doctor was " strongly set upon to study divinitie." His studies else must be lost, he says, for he found physick " a meene help," and later he did follow this course, returned to England and died in the ministry. We must take strong exception to the statement that the seventeenth century record of Maryland was all but inarticulate. Previous numbers of this Bulletin have contained the record of those early times, as well as Dr. Quinan's articles in the Maryland Medical Journal and Dr. Cordell's recent book. These, with other data now accessible, show that the first suggestion for a hospital in the colonies was made in Maryland in 1638 (see Father White's letter to Cecilius, second Lord Baltimore) ; that the first carefully recorded autopsy was done five years later in this colony and was probably performed by George Binx, who is elsewhere styled Licentiate in Physick. There was. however, another doctor on the jury, Robert Ellyson, a barber-surgoon. This autopsy was on an Indian boy shot by his master and the report shows well how thorough and successful efforts were made to trace the course of the bullet and find its scat of lodgement. Then, too, some fifty-five yeais later the first sanitarium in the colonies was established at " Coole Springs" (now Charlotte Hall), St. Mary's Co., Maryland. Thomas Gerard and Luke Barber, alike prominent as x'l'ysicians and statesmen, should have received some mention. On page 29, it is stated that the physicians of the period no where sided with the madr.ess of witchcraft. We wish this were true but the account of Bryan Rossiter's autopsy on " Kellies child " (see September number of this Bulletin), shows there was at least one notable exception to this statement. We regret that no reference is made to certain well-known Connecticut doctors of this period who have been brought clearly to light by the labors of Russell and others. Gershom Bulkeley, especially, should have been rescued from an undeserved oblivion. In the story of the eighteenth century the trials and ultimate success of Boylston in introducing inoculation is attractively presented, but we think that Dr. Adam Thompson of Prince George's County, Maryland, should also have been named as he originated the " American Method " of inoculation. This method consisted mainly in the preliminary use of mercury and was also extensively employed by Muirson of Brookhaven, L. I., (Ezra Stiles in his diary says he was the first to use it) and Benjamin Gale, one of Connecticut's most famous clerical physicians. The latter especially should not have been slighted, for he was " one of the pre-Revolutionary American physicians who have left published records of valuable medical observations" (Welch). tn the pages following Colden, Cadwallader, the Charleston coterie, Morgan, Shippen and others of their time come in for their share of notice, and the founding of the early hospitals and medical schools in this country, is well told. The story of the Revolu tion, with the sorry ending of Church's career as well as the cruel injustice meted out to Morgan, makes an interesting chapter. For Benjamin Rush more space is reserved, and rightly we think, than for any of the others. Elihu Hubbard Smith, the founder of the first medical periodical in America, has a whole chapter devoted to him. Great ability is shown in selecting for special mention the most prominent physicians and surgeons of the early part of the nineteenth century. Among those of lesser notice, Waterhouse is said to have been the first to introduce vaccination to his countrymen. A common error, it is true, for John Crawford of Baltimore, practiced vaccination simultaneously with Waterhouse, in the summer of 1800. Dr. James Smith, also of Baltimore, is not spoken of at all, yet he did more than any one in this country to popularize vaccination and has been called by Quinan " the Jenner of America." The later physicians and surgeons are finally considered — Chapman, Francis, Gibson, Jackson and Drake being given special mention. It seems to us that Charles Frick, of Baltimore, is entitled to be mentioned in this group, for he, cut off in his prime, was a well-known physician of marked scientific attainments. The story of the ether tontroversy and the founding of the American Medical Association, are well told in two of the concluding chapters. Altogether the author has written a most pleasing narrative and we congratulate him most heartily upon it. W. R. S. A Text-Book of Operative Surgery. Covering the Surgical Anatomy and Operative Technic Involved in the Operations of General Surgery. By Warrex Sto.ne Bickuam, Phar. M. M. D., Assistant Instructor in Operative Surgery, College of Physicians and Surgeons, New York; Late Visiting Surgeon to Charity Hospital, New Orleans, etc. Octavo of 984 pages, with 539 illustrations. (Philadelphia, New "5 orfc, London: W. B. Saunders and Company, 1903.) In this volume of nine hundred eighty-four pages the author attempts to describe most of the operations of general surgery, and a number of special operations of gynecology as well as of the surgery of the eye, ear, and genito-urinary tract. The descriptions are necessarily concise, but in most cases are suflficiently full to give a fairly satisfactory idea of the operations under consideration. The ilhistrations are numerous and add very decidedly to the value of the book. A special feature which the author in Januaky,, 1901. 1 25 trocUices is a brief description of sursif'al anatomy preceding the description of the operation. We question the value of this lor we believe that in most cases the surgeon will get his anatomv much more satisfactorily from a text-book than from such a brief review as is given in this book. As would be expected at a time when the progress of surgery is so rapid, many procedures are included which are not to be found in most of the older standard text-books; for example all the later methods of intestinal anastomosis are quite satisfactorily described, the modern methods of amputation, operations on the brain and heart, the Matas operation for aneurysm, etc. The author states in his preface that he has omitted the principles of operative surgery and anaesthesia, as well as the operations of plastic surgery, many of the operations more properly classed as the operations of special branches of surgery, and some of the variations of the operations of general surgery. Some of these omissions very greatly lessen the value of the book and we fail to see the reason for omitting some operations usually considered as belonging to general surgery while others are included; for example such operations of tn.e specialty of gynecology as hysterectomy and oophorectomy are included while a large proportion of operations on the male urethra, testicles, scrotum and prostate have been omitted as belonging to special genitourinary surgery. We regret also to notice the omission of several important methods introduced by American surgeons, which are considered by many competent men the most satisfactory operations of their class; for example, Mayo's vertical over-lapping method of operating for the radical cure of umbilical hernia, Finney's gastroduodenostomy as a substitute for the older methods of plyloroplasty. Fowler's method of decortication of the lung for chronic empyema (often improperly credited to De Lorme), Halsted's latest method of operating for the radical cure of hernia, and his improvements on the operation for excision of the breast for carcinoma. Some of these are included in a recent text on surgery by a foreign writer. A number of out of date procedures are given, such as Loreta's divulsion of the pylorus, which has been abandoned by its originator, as well as practically every other surgeon in favor of other more effectual methods; cholecystendysis which is now practically never used. Such omissions and inclusions are a common fault of practically all textbooks, but to our mind the greatest fault of this book is that frequently several methods are described without any suggestions being given as to their comparative advantages or disadvantages, or the conditions under which each operation would be preferable; for example we read in the description of sequestrotomy, " bone chips may be used in the cavity — or the entire thickness of the soft parts including periosteum may be inverted into the bottom of the cavity from each side and held in place by a nail or peg, or the cavity may be packed throughout with gauze." We believe that there are certain conditions under which some of these procedures would oe absolutely contra-indicated, and that in most cases there is a choice which methods shall be adopted. Without a surgeon has experience enough to know which method would best be used it avails him little to know the operative technic. The lack of completeness of the book and the fact that in many cases it does not give any advice as to the choice of operation, will make some other book on operative surgery necessary for the less experienced surgeon, or for the general practitioner who is occasionally called upon to operate, and it contains no features of such value as to make it especially helpful to the experienced surgeon, who already has on his shelves the standard works on operative surgery. The systematic arrangement and concise, accurate descriptions together with numerous, excellent, illi^trations of the sections on amputations, excisions, and liga tions of arteries, the operations most frequently practiced by students on the cadaver, however, make the book well suited for use in the laboratory of operative surgery. Atlas and Epitome of Operative Surgery. By Dii.Otto ZuckeuKA>-i)i„ privat-docent in the University of Vienna. Second edition, revised and enlarged, authorized translation from the German, edited by J. Ciiai.meus Ua'Costa, M. D., with 40 colored plates and 278 illustrations in the text. (Philadelphia and London: W. B. Saunders and Company, J002.J In the preface to the first edition of this volume the authors state that the book was designed mainly for students and that the operations described fully are those most suited for practical instruction in operative surgery on the cadaver. " Other operations, whose performance falls largely to the lot of the skilled surgeon, and whose practice upon the cadaver appears less important, are described concisely." As might be expected from this introduction a large portion of the book, over one-third the entire number of pages, is taken up with a description of amputations and the ligation of the main arteries of the body. Amputations are described in the main quite satisfactorily. In the remaining two hundred pages all the other operations are given; for most practitioners the most important part of operative surgery. It is almost unnecessary to state that in such a short space the descriptions of the operations are not only concise, but in many cases so brief as to be of no value to the operative surgeon, who is in search of information. A striking example of this is found in the description of operations on the biliary passages, which, at the present day, are of such great importance. Within the limits of a single page three important operations are "concisely" described; cholecystectomy, choledochotomy, and cholecystenterostomy. Three operations for hemorrhoids are also described on one page. It is needless to say that any adequate description is impossible within such short space. The book is distinctively German, and many operations frequently employed by American surgeons are entirely omitted. As an example of this may be mentioned Halsted's operations for the radical cure of hernia;, and excision of the breast for carcinoma; the overlapping method for large umbilical hernias, and the simpler methods of operating for femoral hernia. Another decided disadvantage of the book Is that when several operations are mentioned nothing is said with regard to which is considered the operation of choice under various circumstances. The illustrations are numerous, many of them being showy colored illustrations, but for the purpose of the student and operative surgeon ihey are many of them far from satisfactory. With judicious, careful editing the book might have been made of considerable value, but the editorial notes are limited to a few lines of fine print scattered here and there through the book. The book may be well suited to the use of German students, but there are several hooks in English which we believe are better adapted to the use of American students. THE JOHNS HOPKINS HOSPITAL BULLETIN. The Hospital Bulletin contains 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 XIV is now completed. The subscription price is 2.00 per year. The set of fourteen volumes will be sold for 50.00. 26 [No. 154. THE JOHJ^S HOPKINS HOSPITAL EBPOETS. Volume I. 433 pages, 99 plates. Volume II. 570 pages, with 28 plates and figures. Volume III. 7GG pages, with 69 plates and figures. Volume IV. 504 pages, 33 charts and illustrations. Report on Typliold Fever. By William Osler, M. D., with additional papers by W. S. Thayeb. M. D., and J. Hewetson, M. D. Report in NenroloETT* 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 \'entricles in Certain \'ertebratcs; The Intrinsic Nerves of the Submaxillary Gland of Mug imt^crtluft ; The Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. By Hbnhi J. Berkley, 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 Gyneeology. Hydrosalpinx, with a report of twenty-seven cases; Post-Operative Septic Peritonitis; Tuberculosis of the Endometrium. By T. S. Collen, M. B. Report in Patliolo^y. Deciduoma Malignum. By J. Wiiitridge Williams, M. D. Volume V. 480 pages, with 33 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. Barhj:r, M. B. Stadies In Typhoid Fever. By William Osleh, M. D., with additional papers by G. Blumer, M. D., Flexner, M. D., Walter Reed, M. D., and H. O. Parsons, M. D. Simon Volume VI. 414 pages, with 79 plates and figures. Report in IVenroIogy, studies on the Lesions Produced by the Action of Certain Poisons on the Cortical Nerve Ct-11 (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. — .\lcohol Poisoning.— E.xperimental Lesions produced by Chronic Alcoholic Poisoning (Ethyl Alcohol). 2. Experimental Lesions produced b.v Acute Alcoholic Poisoning (Ethyl Alcohol) ; Part 11. — Serum Poisoning. — Experimental Lesions induced hy the Action of the Dog's Serum on tlie (Cortical Nerve Cell; Part 111. — Ricin Poisoning. — Experimental Lesions induced b.y 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; Astlienic Bulbar Paralysis. By Henry J. Berkley, M. D. Report In Patholoey. Fatal Puerperal Sepsis due to the Introduction of an Elm Tent. By Thomas S. CULLBN, 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 DifTnsum Bcnignum. 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 Toxalfjumin Intoxications. By SiMOS' Flkxner. M. D. Volume VI f. 537 pages with illustrations. I- A Critical Review of Seventeen Hundred Cases of Abdominal Section from the standpoint of Intra-peritoneal Drainage. By J. G. CJlark, M. D. II. The Etiology and Structure of true Vaginal Cysts. By James Ernest Stores, M. D. HI. A Review of the Pathology of Superflcial Burns, with a Contribution to our Ivnowledge of the Pathological Changes in the Organs in cases of rapidly fatal burns. By Charles Russell Bardeen, M. D. IV. The Origin, Growth and Fate of the Corpus Luteum. By J. G. Clark, M. D. V. The Results of Operations for the Cure of Inguinal Hernia. By Joseph O. Bloodgood, M. D. Volume VIII. 553 pages with illustrations. On the role of Insects, Arachnids, and MjTiapods as carriers in the spread of Bacterial and Parasitic Diseases of Man and Animals. By George H. F. Nuttall, M. D., Ph. D. StadicH in Typlioid Fever. By William Osler, M. D., with additional papers by J. M. T. Finney, M. D., S. Flexner, M. D., I. P. Lyon, M. D., L. P. Hamburger, M. D., H. W. Cushino, M. D., J. F. Mitchell, M. D., C. N. B. Camac, M. D., N. B. Gwyn, M. D., Charles P. Emerson, M. D., H. H. Yodsg, M. D., and W. S. Thayer, M. D. Volume IX. lOGO pages, 66 plates and 210 other illustrations. Contribations to the Scienee of Medicine. Dedicated by his Pupils to William Henry Welch, on the twenty-fifth anniversary of his Doctorate. This volume contains 38 separate papers. Volume X. 51G pages, 12 plates and 25 charts. structure of the Malarial Parasites. Plate I. By Jesse W. Lazear, M. D. The Bacteriolog.v of Cystitis, Pyelitis and Pyelonephritis in Women, with a Consideration of the Accessory Etiological Factors in these Conditions, and of the Various Chemical and Microscopical Questions Involved. By Thomas R. Brown, M. D. Cases of Infection with Strongyloides Intestinalis. (First Reported Occurrence in North America.) Plates II and HI. By Richard P. Strong, M. D. On the Pathological Changes in Hodgkin's Disease with Especial Reference to its Relation to Tuberculosis. Plates IV-\'U. By Dorothy M. Reed, M. D. Diabetes Insipidus witli a Report of Five Cases. By Thomas B. Fhtcher, M. B. (Tor.) Observations on the Origin and Occurrence of Cells with Eosinophile Granulations In Normal and Pathological Tissues. Plate VIII. By W. T. Howard, M. D., and R. G. Perkins, M. D. Placental Transmission with Report of a Case during Typhoid Fever. By Frank W. Lynch, M. D. Metabolism in Albuminuria. By Chas. P. Emerson, A. B., M. D. Regenerative Changes in the Liver after Acute Yellow Atrophy. Plates IX-XII. By W. G. MacCailum, M. D. Surgical Features of Tj-phoid Fever. By Thos. McCrae, M. B., M. R. C. P. (Lond.), and James F. Mitchell, M. D. The Symptoms, Diagnosis and Surgical Treatment of Ureteral Calculus. By Benjamin R. Schenck, M. D. Volume XI. 555 pages, with 38 charts and illustrations. Now ready. Pneumothorax: A historical, clinical and experimental study. By Charles P. Emerson, M. D. Clinical Observations on Blood Pressure. By Henry W. Cook, M. D., and John B. Briggs, M. D. The value of Tuberculin in Surgical Diagnosis. By Martin B. Tinker, M. D. The set of eleven volnnies -will be sold for sixty dollars, net. Voliiiiie.s I nnd II T\-iII not lie sold separately. Volnnies III, IV, V, VI, VII, VIll, X, and XI will be sold for five dollars, net, each. Volume I.\ T»-ill be sold for ten flollars, net. CONTENTS. Historic Outline of Cardiac Pathology and Clinical Aspects of Chronic Myocarditis. By C. N. B. Camac, A. B., M. U., . . 27 The Efficiency of the Periureteral Arterial Plexus, and the Importance of its Preservation in the More Radical Operations for Carcinoma Cervicis Uteri. By John A. Sampson, M. D., 39 Two Cases of Leukokeratosis Buccalis; Comparison with the Histological Changes in a Case of Tylosis Palmie et Plantie. By Sylvan Rosenheim, M. D., 47 The Effects of X-Rays upon Lower Animal Life and the Tube Best Suited to their Destruction. By Kennon Dunham, M. D., . . 51 An Anopheles Mosquito which Does not Transmit Malaria. By Leonard K. Hikshberg, A. B., M. D., 53 Proceedings of Societies : The Johns Hopkins Hospital Medical Society, 57 Demonstration of Medical Cases [Dr. McCuae]; — Demonstration of Surgical Cases [Dr. Follis];— Some Recent Cases of Extra-Uterine Pregnancy [Dr. Cullen] ; — A Case of Typhoid Arteritis [Dr. Steiner] ; — The Treatment of General Infections, with Especial Reference to the Use of Silver Nitrate in Such Cases [Dr. Hume]; — Exhibition of Cases of Typhoid Meningitis [Dr. Cole] ; — The Late Effects of Typhoid Fever on the Heart and Blood- Vessels [Dr. Thayer] ; — A Preliminary Report on a New Method of Treating Tinnitus Aurium [Dr. Reik]; — Exhibition of Appendices Showing Unusual Conditions [Dr. Burnam] ; — Aneurism of Arch of Aorta and Innominate [Dr. Osler] ; —A Case of Generalized Neuritis from Lead [Dr. ThomasJ ; — A Case of Blastomycetic Infection [Dr. Gilchrist] ; — Metabolism in Pregnancy [Dr. Slemons] Notes on New Books 67 HISTORIC OUTLINE OF CARDIAC PATHOLOGY AND CLINWAL ASPECTS OF CHRONIC MYOCARDITIS.^ By C. N. B. Camac, A. B., M. D., Visiting Physician to City Hospital; Chief of Medical Staff, Cornell University Medical College Dispensary, Xeir York City. I. Introduction. II. Historic outline— Chronological Charts. Ancient Literature. 1. Morgagni, 2. Avenbrugger, 3. Corvlsart, 4. Laennec. III. Anatomy — Radiographs. IV. Physiologj' and Physiologic Chemistry. V. Pathology. PathologicalClassiflcationinContrast to Clinical Classification. VI. .litiology. VH. Clinical Symptoms and Signs— Diagnosis. VIII. Prognosis. IX. Troatmout. X. Modern Literature— Conclusion. PLATE IV. Fig. 1. — Hunt. Feb. 12. Before bath So. 1, strengtli No. 1. Point max. imp., 5th space, 13J^ cm. from median line; after bath, point m•^x. imp., .Tth space, 11 em. from median line. Feb. 13, no bath given. Point max. imp., .5th space, 10 cm. from median line. Feb. 14, bath No. 2, strength No. 1. Point max. imp. after bath 5th space, S cm. from median line. Feb. 15, no bath given. Point max. imp. not located. No signs (physical or post-mortem) of elfusion. Fig. 2. — Larber. Before bath No. 1, strengtli No. 1, point max. imp. 14 cm. from median line. After bath, point max. imp., 12 cm. from median line. Length of time in bath, five minutes. Figs. 1 and 2 illustrate the iinineduiti- influence of the baths upon the point max. imp. Fig. :5.-C'oulbourn. Oct. 13, 1896. I, strength No. 1. Riaht border 2-'., eiglit minutes. Cardiac outline before bath No. m. from median line. In bath Fig. 4. — Coulbourn. Oct. IS, 1896. Cardiac outline after bath No. 6, strength No. 1. Kight border I ..; cm. from median line. In bath eight minutes. Note. — In Figs. 3 and 4 the outline on the right side of the chest extends too far laterally. It did not extend beyond the nipple. There was no change in this line after treatment. Figs. 3 and 4 illustrate change of 1% cm. iu cardiac area after six baths of strength No. 1. Fkom the "Suott Tke.4T.\iest " OF Cardiac Diseask by C N. B. Camac, M. D. ; J. A. M. A., Aug. 28, 1S97. February, 1904.] 39 THE EFFICIENCY OF THE PERIURETERAL ARTERIAL PLEXUS, AND THE IMPORTANCE OF ITS PRESERVATION IN THE MORE RADICAL OPERATIONS FOR CARCINOMA CERVICIS UTERI. By Jonx A. Sampson, ^I. D. Resident Gynecologist, The Johns Hopkins Hospital. Instructor in Gynecology, Johns Hopkins University. A knowledge of the clinical eflBciency of the blood-supply of the tireters is most important in all operations involving the ureter, and especially so in the more radical operations for carcinoma cervicis uteri. Clinical experience has taught us that the operative treatment of cancer of the cervix of the uterus has been unsatisfactory, for only about 12 per cent of the cases operated upon in this hospital are free from recurrence at the end of 5 years. (Statistics taken in October, 1902.) The only hope of bettering these statistics is by operating on the cases earlier, and doing the most radical operation possible in so-called favorable cases, for in these there is the best chance for a cure. The question arises: what is the most radical operation that can be done without too great a primary mortality? A study of the parametrium ia those cases in which the more radical operation has been done shows that it is necessary to remove as much of the parametrium as possible, and that it is very difficult to diagnose clinically the presence of carcinoma in the parametrium, for the growth may metastasize to verj- small parametrial lymph-nodes, which may not have a diameter of over 1 to 1.5 mm., and cannot be palpated even after the specimen has been removed. From a study of the pathological findings, the indications of the operation which was described by me' over a year ago are only too evident. This operation consists in the removal of the lymphatics from the sides of the pelvis and ^vith them the litems and growth, en masse, and all the tissue from pelvic wall to pelvic wall. The question arises : What should be done with the lower ends of the ureters? If the lower 3-4 cm. of the ureters are removed with the growth and the renal ends of the ureters are implanted in the bladder there is danger of an ascending renal infection, for cystitis is an only too frequent sequel of such an operation. On the other hand, if the pelvic portion of the ureters are dissected free, ureteral necrosis may occur and at the same time the tissue has not been removed intact. I have done 11 of the more radical operations for carcinoma of the uterus, resecting one or both ureters in 3 cases. Three of the 11 cases have died, one on the 5th day from intestinal obstruction, and two from ascending renal infection, one dying on the 9th day and the other on the 17th day. In these last two cases the ureters were resected in one and not in the other. In the eight cases in which the ureters were not resected, they were dissected free as two cords and all the tissue from pelvic wall to pelvic wall was removed. Of these cases, one died of ascending renal infection, and ureteral necrosis occurred in one of the remaining 7 cases. These cases demand a better knowledge of the anatomy and physiology of the ureters and bladder and the etiological factors in the causation of cystitis, ascending renal infection and necrosis of the ureters. I have studied the etiological factors in the causation of renal infection and have published the results of these studies. In this article " attention was called to the importance of lowered local resistance and to the fact that injury to the kidney was a most important accessory etiological factor, and also that a stricture of the ureter was probably the most frequent cause of the lowered renal resistance. As cystitis occurs so frequently in these operations and as the ureter is implanted in a bladder which is very apt to become infected, the kidneys are not as well protected when the ureter is implanted as when it has its natural ureteral orifice. Nevertheless, as I shall try to show in this and subsequent articles, the advantages of the resected over the bared ureter are many, and as apparentl}- the cystitis may be controlled by making a vesicovaginal fisttila, future clinical experience may decide in favor of the resection of the ureters. In eleven cases in which' I have followed the bladder conditions after these operations, both by cystoscopic examination and by taking cultures, a marked cystitis has occurred in seven cases, in two of which it resulted in renal infection and death. In four cases the bladder appeared normal on cystoscopic examination, and yet in two of them when cultures were taken the colon bacillus was found present. An accidental vesico-vaginal fistula existed in three of these four cases and apparently controlled the bladder infection in these three cases. The clinical efficiency of the blood-supply of the ureters must be understood whether one shall resect the ureters or dissect them free in these operations. Such knowledge can only be gained by a study of the blood-supply of the ureter, combined with animal experimentation and clinical experience. The Blood-Supply of the Ureter. In reading over the descriptions of the blood-supply of the ureter, which may be found in the various Anatomies and other works dealing with the surgery of the ureter, one is impressed with the meagre account usually given, and the great variability of its source, for it is seldom that any two authors will agree, and furthermore very little seems to be Icnown in regard to the efficiency of the blood-supply. This latter point is of the greatest surgical importance. Quaiii ' makes the following statement in regard to the blood-supplj' of the ureter: "The ureter is supplied with blood from small branches of the renal, the spermatic, the internal iliac, and the inferior vesical arteries. The veins end in various neighljoring veins." Morris ' treats the subject a little more fully : " The arteries which supplj' the ureter are branches of the renal, the spermatic or ovarian, and the vesical; they anastomose freely together in the walls of the ureter, and the blood is returned by corresponding veins." In this manner one will usually find the blood-supply of the ureter disposed of in most of the Anatomies and in the surgical works on the ureter. The best description of the blood-supply of the ureter which I have been able to find has been given by Disse.° According to him the arteries supplying the ureter come from many sources. The pelvis of the kidney is supplied by a branch from the renal artery which extends down over the abdominal portion of the ureter. The spermatic artery also furnishes a branch to the abdominal portion of the ureter as it crosses the ureter. The pelvic portion of the ureter is supplied by branches from the middle hemorrhoidal and inferior vesical arteries. These main arteries run along the ureter and are attached to its wall by loose connective tissue. The large arterial branches, visible to the naked eye, lie in the adventitia of the ureter and run in a longitudinal direction in such a manner that the ureter is encompassed by these vessels. From these larger vessels, branches arise at short intervals, which pierce the muscular coats of the ureter and extend to the propria; here they divide and give rise to small branches extending in a longitudinal direction from the bladder to the kidney. These small arteries are separated from the larger branches of the adventitia by means of the miiscular coat. From the small arteries of the propria, capillary systems extend in two directions, one to the epithelium, and the other to form a capillary network inside of the muscular layer. The veins begin within the propria and receive the blood from the capillary network within this membrane. From these small veins, relatively larger vessels are formed which give rise to a venous plexus situated inside of the muscular layer. The main branches of this plexus lie principally in a longitudinal direction and are united together by other vessels. This is called the venous plexus of the mucosa. From this plexus the blood empties into still wider venous branches which lie in the adventitia, alongside of the main arterial trunks. During the last year 1 made several experiments in order to determine the efficiency of the blood-supply of the ureter in human beings and the part played by each ureteral artery in nourishing the ureter. In five instances the arteries of the ureter for its entire length were injected by inserting a canula into the renal artery through the incised aorta, using an aqueous solution of Prussian blue in two cases and a 15 per cent solution of gelatine colored with ultra-marine blue in the other three. See Figs. I, II and III. In another instance the internal iliac artery was injected with a 15 per cent solution of gelatine colored with ultra-marine blue, and as a result the arteries of the ureter were injected for its entire length, and, on opening the kidney, a few small vessels in the kidney .substance were found to be filled with the blue mass. Fig. V was drawn from this specimen. I have injected the internal iliac artery in another case, the ovarian in one, and the abdominal aorta in two, first clainj)ing the renal and iliac arteries in the latter two cases, so that the coloring material could not enter these vessels. This latter group of cases was not quite as satisfactory as the first six cases referred to, as the work was done after the organs had been removed; nevertheless, they all demonstrated the free anastomosis of the arteries of the ureter giving rise to a periureteral arterial plexus ami also that probably one could inject the entire plexus through any ureteral artery if the plexus were intact. Through this plexus there is established an arterial communication between the kidney and the bladder. The periureteral arterial plexus from which the ureter is nourished is formed as follows: Branches, which we may call uretero-subperitoneal arteries, arise from the larger vessels, as the aorta, the renal, ovarian, iliac, uterine, etc., arteries. The source of these branches varies in different cases. See Figs. I, II, III and IV. These uretero-subperitoneal arteries usually divide into two branches, first a ureteral branch which helps to form the periureteral arterial plexus ; second, a subperitoneal branch, which supplies the tissue about or near the ureter. The ureteral arteries on reaching the ureter divide into asscending and descending branches both running along the ureter, and united to it by loose fibrous tissue ; the ascending branches anastomose freely with the descending branches of the ureteral artery above, and the descending with the ascending branches of a lower ureteral artery; thus there arise about the ureter, relatively large arterial trunks, running in a longitudinal direction from the kidney to the bladder. From these large trunks smaller branches arise which are more deeply imbedded in the perimuscular fibrous tissue of the ureter than the larger branches, and some of these anastomose with each other, thus forming, with the main trunks, a peri-ureteral arterial plexus extending the entire length of the iireter, up over the pelvis of the kidney and accompanying the ureter through the bladder. From this plexus, still smaller vessels arise which penetrate the walls of the ureter. In addition small twigs may arise from the plexus which leave the ureter to supply the tissue about it (Br. P. Fig. I), and these twigs may anastomose with branches of other vessels supplying these parts (Anas. Br. P. Fig. I). The subperitoneal divisions of the uretero-subperitoneal vessels supply the tissue about the ureter and also, in places, the peritoneum. These vessels may anastomose with each other and with branches from neighboring vessels, including lu'anches from the ureteral plexus, and thus may serve as a means of nourishing the ureter. The ureter may indirectly receive additional nourishment from other anastomoses, as the uterine and vesical arteries of one side anastomose with thos.' of the other, and in addition there is a free anastomosis between the uterine and ovarian arteries and the branches from the latter anastomo.se with branches from the renal. The periureteral arterial plexus thus receives its blood-supply from definite ureteral arteries and may be nourished indirectly through tlie anastomosis of these arteries and branches from the plexus itself with the branches of vessels supplying the tissue about the ureter. It is easy to demonstrate the anastomoses of the vessels in the outer fibrous coat of the ureter. A very important question associated with the efBciency of the blood-supply of the ureter is to know whether or not there is a free anastomosis between the branches of the deeper ureteral arteries. In sections cut from specimens injected with Prussian blue the free anastomosis of the capillaries can be very easily demonstrated. On the other hand, I have never been able to demonstrate whether or not there was any anastomosis between the small arteries found within the muscular coats. These vessels are not very numerous and are very small, as is shown in Fig. Y, where the internal iliac artery was injected with a 15 per cent solution of gelatine colored with ultra-marine blue. Ultra-marine blue being granular, only the arteries are injected, the granules being too large to pass into or through the capillaries. From a knowledge of the blood-supply of the ureter it would seem that many liberties could be taken with the ureter without causing necrosis. As, for instance, the ureter could be dissected free from the bladder to the kidney, severing all vessels coming to the ureter between those organs, and yet necrosis would not occur if the periureteral arterial plexus was intact. Also in instances where the arteries supplying the ureter were tied, the anastomosis of branches from the plexus with the branches of neighboring vessels as well as the other arterial anastomoses which I have mentioned, would aid in maintaining the nourishment of the ureter. On the other hand, one would suppose that the destruction of the periureteral arterial plexus for only a short distance would lead to necrosis of the ureter, for even if there should be a free anastomosis of the deep arteries of the ureter, on account of their size and small numbers, one would not suppose that they would be capable of maintaining the nourishment of the ureter for any great distance. One must resort to animal experimentation as well as clinical experience in order to fully determine the efficiency of the blood-supply of the ureter. Experiments ox Dogs, Demonstrating the Efficiency OF THE Blood-Supply of the Ureter. The blood-supply of the ureter of the dog has been studied by several investigators, ilargaroucci " thought that the principal source was derived from two small branches of the renal artery which accompanied the ureter as far as its opening into the bladder. Monari ' has made some very interesting experiments in regard to the efficiency of the blood-supply of the ureter in dogs. He calls attention to the fact that the vessels supplying the dog's ureter run, in the perimuscular connective tissue, parallel to the ureter and are imited to each other by numerous branches. He states that the ureter should not become necrotic when it is isolated for its entire length. He showed that the ureter of a dog could not only be freed for its entire length, but could also be free from the connective tissue surrounding it for a distance of l'-3-13 cm., and if replaced in this tissue necrosis could not occur. On the other hand, when he isolated the ureter for a distance of 6 cm. and placed gauze about it, necrosis occurred. Protopopow ' has written a very extensive article on the anatomy and physiology of the ureter, in which he describes the blood-supply of the dog's ureter, calling attention to the free anastomosis of the vessels in its outer coat, thus demonstrating an arterial anastomosis between the bladder and the kidney. He states that he does not know if such a condition exists in human beings. I have made several experiments in order to determine the efficiency of the blood-supply of the ureter in dogs. There is an arterial plexus about the ureter of a dog very similar to that found in man. It receives branches from the vessels near it and presents variations much as are found in human beings. The main trunks of this plexus tend to arrange themselves in two relatively large branches, one on each side of the ureter, which are loosely bound to the ureter. The smaller branches arising from these trunks anastomose with each other, thus forming the meshwork of the plexus, and are more closely united to the ureter than the larger vessels, as is also the case in man. On this account it is quite easy to injure the large trunks but not the smaller branches. I. In seven dogs, the ureter was isolated for its entire length and an attempt was made to strip off the periureteral arterial plexus with my finger-nails. The dogs were killed in from 1 to 4 weeks and ureteral necrosis occurred in only two eases. In 5 cases the descending aorta was injected with a 15 per cent gelatine colored with ultra-marine blue, and very satisfactory injections of the ureter were obtained. It could be seen in these specimens that in trying to strip off the arterial plexus, I had removed only portions of the main arterial trunks and the large veins, while most of the smaller branches, which are imbedded more deeply in the outer coat of the ureter and form the meshwork of the plexus, were uninjured and were able, in five instances, to maintain the arterial plexus, and thus the blood-supply of the ureter. II. In three dogs the ureter was isolated for about 4 cm. and in order to completely destroy the plexus, the ureter was scraped on all sides with a very sharp knife for a distance of 2 cm. Necrosis occurred in each instance. III. In three dogs a ureter was isolated for nearly its entire length and then the larger vessels of the plexus were torn off by the finger-nails and mouse-tooth forceps, as in the first experiments. Both uterine vessels were tied, thus ligating the ureteral artery which completes the lower end of the plexus and arises from the uterine. Necrosis occurred in each instance. IV. An attempt was made to simulate the condition sometimes found after the more radical operations for cancer of the uterus. In eight dogs the ureter was isolated for about its lower one-third and the tissue about it, including portions of the larger vessels of the plexus, were torn off as above. Both uterine arteries were tied and necrosis occurred in seven of the eight cases. Y. In two dogs the above was done, except the uterine ar 42 [No. 155. tery on only one side was tied. Necrosis occurred in one case. VI. In 2.5 nretero-vesical implantations in dogs, there was but one failure and that occurred in one of nine cases where organisms had been introduced into the bladder, in order to see the results of implanting the ureter in the presence of infection. In three of these nine cases the kidney became infected, and in each instance there was quite a marked stricture of the ureter at the seat of the implantation. VII. In another dog tlie ureter was freed and stripped, as in previous operations. A small rubber tubCj 8 cm. long, was split, and, by springing it apart, the ureter was placed within its lumen. Necrosis of the ureter occurred for a length of 7.5 cm. It is evident that in a dog the ureter may not only be freed for its entire length, but its larger vessels may in part be destroyed by stripping them off, yet necrosis will not necessarily occur, for the plexus may be maintained by the smaller branches which are more adherent to the ureter and are very difficult to remove, and also by such portions of the larger trunks which have not been destroyed. On the other hand, when the ureter is scraped with a sharp knife, thus destroying the smaller branches as well as the larger, then necrosis will occur, even though the distance be very .short. Again, when the ureter is freed but a short distance and the plexus interfered with, and in addition the arteries supplying the lower end of the ureter are ligated, then necrosis is very apt to occur; for the portion of the ureter stripped and also that below the injury, must receive most of its blood-supply from the blood-vessels in the plexus above the injury, and the stripping may interfere with the blood reaching these parts through the injury to the plexus. In injury to the ureteral plexus, veins are destroyed as well as arteries, but as there is a very free anastomosis between the veins of the ureter, one would expect much less trouble from injury to the vein. Nevertheless, it must embarrass the circulation to a degree, varying with the extent of the injury. Infection, exudates and foreign material, as gauze, must all he considered as accessory etiological factors in the causation of ureteral necrosis. So far, the results of the study of the blood-supply of the iireter in man and experiments on animals tally. The next question which must be considered is what may be learned from clinical experience. Clinical Cases showing the Efficiency of the BloodSupply OF THE Ureter. The clinical efficiency of the blood-supply of tlie ureter lias been demonstrated by many operators. In 1893, Kelly," in attempting to remove the; uterus in an advanced case of carcinoma of the cervix, ligated both internal iliac and ovarian arteries. The growth was not all removed and ureteral necrosis did not occur, although the left ureter was imbedded in cancerous tissue and was dissected free. In 1896, Pryor" advocated the ligation of both internal iliacs in advanced cases of cancer of the uterus with the view of starving tlie growth. He refers to instances where these vessels have been ligated for other purposes and the pelvic organs have not been injured by the procedure. The following year he " reported a case where he ligated both internal iliac arteries for post-operative recurrence of carcinoma cervicis uteri in the vaginal vault. Necrosis of the pelvic organs did not occur. Kronig has reported three cases of extensive carcinoma of the cervix of the uterus, where he had ligated both internal iliac and ovarian arteries with satisfactory palliative results. Iwanow " has reported five cases of inoperable carcinoma cervicis uteri where he had ligated the round ligament, the ovarian and internal iliac arteries with results similar to Kronig's cases. From a review of such cases reported in the literature it becomes evident that the simultaneous ligation of the internal iliac, ovarian arteries and round ligament does not lead to necrosis of the ureters ; for, as would be inferred from a study of the blood-supply of the ureter, as long as the arterial plexus is intact, necrosis would not occur. In addition, the other pelvic organs where the blood-supply has been injured by the ligation of these large vessels, would receive nourishment through the ureteral plexus, for by means of a canula inserted in the renal artery alone, one may not only inject the entire ureter, but also the uterus and bladder will be found to be partially injected. See Figs. II and III. Cases may be found in the literature where the ureter has been freed for a long distance and yet ureteral necrosis apparently has not occurred. Sanger" reports two such cases where the ureter was dissected free, in the removal of two intraligamentary cysts, without any apparent injury to tlie ureter. Chrobak," in the removal of an intraligamentary myoma, isolated the ureter for a distance of 8 cm. and at the close of the operation sutured the peritoneum over it and the patient recovered without any symptoms referable to the injury. Eiihl," during a hystero-myomectomy, found that the ureter passed through an intraligamentary myomatous nodule for a distance of 7 cm. The ureter was dissected free and the convalescence was uneventful. In 1894, Durante " removed a large adeno-cystoma of the ovary which was intraligamentary and had pushed the organs from the wall of the pelvis, including the left ureter, which was dilated to a diameter of 17-18 mm. It was found necessary to free the ureter from the kidney to the bladder. At the close of the operation the ureter fell back into the abdominal cavity like a loose cord. The convalescence was uneventful. Frequently in this hospital the ureter has been exposed for long distances in the removal of intraligamentary cysts and myomata, and yet in not a single instance has necrosis followed sucli a procedure in these cases. One realizes tliat when both internal iliac arteries are ligated, as in the cases above referred to, the arteries supplying the pelvic portion of the periureteral arterial plexus are destroyed, but necrosis does not occur, for the plexus is intact, and if so, it coidd probably be supplied by the renal artery February, 1904.] 43 alone. On the other hand, when the ureter is dissected free, tliere is danger of injuring this ple.xus. Yet one realizes that still necrosis may not occnr, for the ple.xus may not be injured, or such injury as may occnr may be compensated by the smaller vessels of the plexus. Operators, both in this country and abroad, frequently ligate both internal iliac vessels and dissect the ureters free in hysterectomy for cancer of the uterus, and yet necrosis does not necessarily occur. On the other hand, necrosis of the ureters does sometimes occur in the more e.xtensive operations for cancer of the uterus. Clinical Cases Showing that Necrosis of the Ureters May Occur. There have been six instances of ureteral necrosis in 156 hysterectomies for cancer of the uterus in this hospital, and in each instance, in addition to ligating the uterine or anterior branch of the internal iliac artery or the internal iliac artery itself, the ureter has been exposed and dissected free. These procedures would not only probably cut off all vessels supplying the lower portion of the ureter, but by dissecting the ureter free the periureteral arterial plexus was also injured, thus interfering with the blood-supply coming from above. These cases will be reported in full in a subseqvient article on ureteral necrosis. Instances of ureteral necrosis following hysterectomy for cancer of the uterus may be found reported by several writers. Of interest are the cases of Wertheim. He had five cases of post-operative ureteral fistula in his second series of thirty cases of hysterectomy for carcinoma cervicis uteri. Three of these cases were double, making in all eight instances. His operation consisted, first, in the isolation of the pelvic portion of the ureters from a point above their entrance into the parametrium down to the bladder. Thus the ureters were out of harm's way and a wide dissection of the parametrium was possible. The uterine arteries were ligated where they crossed the ureter. At the instigation of Wertheim, Feitel " studied the bloodsupply of the ureter in infants, especially as related to the operation of hysterectomy for carcinoma of tlie cervix. Feitel showed that the upper part of the pelvic portion of the ureter receives its blood-supply from the mesial side, i. e., from the aorta, the common and internal iliac vessels, and the lower portion receives its blood-supply from vessels lateral to the ureter, i. e., the uterine and vesical arteries. When it is necessary to expose the ureter, he advises that the upper part of the pelvic portion should be exposed by opening the peritoneum lateral to it, carrying the incision across the ureter, at the middle of the pelvic portion, and continuing down along the lower pelvic portion of the ureter mesial to it. Thus the nutrient vessels will not be injured. Wertheim,"" in his next thirty cases, followed the suggestion of Feitel and did not dissect the ureter free as in the previous cases, but carried his dissection down mesial to the ureter, i. e., between the cervix and the ureter, in order to avoid vessels coming to the lateral side of the ureter. As a result of this procedure tiiere were only two ureteral fistulre in the thirty cases, as compared with eight in the previous thirty cases; and in these instances in which necrosis occurred the fistula resulted from dissecting free I lie ureters, which were adherent to the growth, and thus he injured the periureteral arterial plexus. The Eelation retween the Ureters and Carcinoma Cervicis Uteri. In order to understand tiic dilficulties in freeing the ureters in hystercetoniy, one must undertand the anatomical relation between the ureters and the cervix of the uterus. If one will examine the ureters at autopsy, a very good idea may be obtained of certain anatomical features which are of the greatest importance in all operations involving the lower end of the ureters. If the abdominal portion of the ureter is exposed and partially freed, and traction is made upon it, it can be drawn out from what is apparently a sheath, which seems to be derived from the subperitoneal connective tissue and is continuous with that surrounding the kidney above and accompanies the ureter into the pelvis below. Cross-sections of the abdominal portion of the ureter do not bring this out very clearly and it requires some play of the imagination to make out a definite sheath about this portion of the ureter. If the dissection is carried down into the pelvis, this apparent ureteral sheath becomes more definite, and cross-sections of this portion of the ureter show a definite sheath about the ureter which seems to be but a thickening of the pelvic tissue through which the ureter plays and is apparently continuous with the subperitoneal connective tissue about the abdominal portion of the ureter. In Fig. V, which represents a cross-section of the ureter taken about 1.5 cm. above the uterus, one can see the definite ureteral sheath and how it is apparently derived from the tissue about the ureter and acts as a protection to the ureter and the periureteral arterial plexus. If the dissection is carried on down to the bladder, the lower jjortion of the ureter will be found to be reinforced by muscular bundles which apparently extend up from the bladder over the ureter. Waldeyer"^ has called attention to the fact that there is pictured in Krause's anatomy, longitudinal muscular bundles which extend from the l)ladder up to the ureter, but the cut is not accompanied with any description. Waldeyer describes them as longitudinal muscular bundles, which are united to each other by connective tissue and separated from the ureter by a space which can be injected. This sheath has a thickness of .5 to .75 mm., and he says extends 3-4 cm. up in the ureter. The lumen he considers to be a lymph-space. Disse" refers to Waldeyer's sheath and says that these musculai' l)undles which are greatly hypertrophied, do not arise from the bladder as they appear to do, but from the ureter, and suggests that their hy]iertrophied condition as well as the space between them ami the ureter arises from the contractions of the bladder pulling on the outer ureteral coat. There are present about the pelvic portion of the ureter possibly two sheatlis instead of one. the so-called sheath of Waldeyer, which Disse claims arises from a hypertrophy and 44 [No. 155. splitting of tlie outer ureteral muscular coat, and the second sheath, which apparently encircles the upper portion of the former sheath, blending with it, and extending upwards along the ureter. Further studies may show that this second sheath is but a continuation of the other, but from the few cases I have studied, it would seem to be different in origin, and although it blends with the other, it encircles the upper end of it, and extends further up along the ureter. The relation between the two sheaths needs further investigation. Tliis latter sheath apparently arises from the tissues about the jielvic portion of the ureter and is continuous with the subperitoneal tissue surrounding the abdominal portion of the ureter. This sheath, which may be called the pelvic or ureteral .sheath, is composed of fibrous tissue with an occasional muscle-bundle. Its lumen is, for the most part, filled witli adipose tissue and fine fibrous tissue strands, thus acting as a cushion surrounding the ureter. One finds in the hardened specimens empty spaces which may be lymph-spaces, or possibly artefacts. This sheath is of great importance, for it not only furnishes a channel in which the ureter may slide as it contracts, but is also a protection to the ureter from the invasion of cancerous growths or inflammatory processes, and during operations in that portion of the pelvis. Of special interest in connection with this work is the fact that the periureteral arterial plexus lies within this sheath and is thus protected by it. See Figs. V and VI. If one will study serial sections of the parametrium, one can see how adherent this ureteral sheath may be to the other structures in that part of the pelvis, especially the utero-vaginal and vesico-vaginal plexuses of veins, for it is from these structures that it is apparently partially derived. It is evident that the isolation of this sheath in the parametria! portion of the ureter is very difficult on account of its association with the structures above referred to, niiich more so than in that portion of the ureter above the parametrium, for here it lies just beneath the peritoneum and by freeing the peritoneum the ureter with its sheath may be moved about on the peritoneal flap. When the ureter is bared in these more radical operations, it is dissected out from this sheath and lies as a loose cord in the pelvis and there is the liability not only of necrosis from injury to the plexus, but the ureter has been deprived of its sheath and must now become fixed in scar-tissue, and thus its function will be interfered with and there is the opportunity for ureteral adhesions and partial or complete ureteral obstruction; and we realize how important an accessory etiological factor stricture of the ureter is, in the causation of renal infection. These statements have been confirmed by experiments on dogs and also, in one instance, where I made a uretero-vesical implantation for necrosis of the ureter, I found the ureter imbedded in dense scar-tissue. What shall be done in hysterectomy for cancer of the uterus ? Feitel and Wertheim solved the problem as far as the prevention of ureteral necrosis is concerned. When Wertheim removed the parametrium mesial to the ureter in order not "to injure the vessels supplying that portion of (lie ureter which comes in lateral to the ureter,"' he did something of still greater importance as far as the blood-supply of the ureter is concerned, viz. : that the ureter with its periureteral arterial plexus, as well as its sheath, is probably not injured. As stated, Wertheim did this in 30 cases and necrosis resulted in only two and in these the growth had extended out to the ureters, making it necessary to bare the ureters and thus the sheath was not only destroyed but the plexus was probably injured sufficiently, to cause necrosis of the ureters. We realize that when the parametrium is involved either by a direct extension of the growth or by metastases, it takes but very little involvement to go to or beyond the ureters, as I shall show in a subsequent article; therefore, when Wertheim did a hysterectomy inesial to the ureters and also removed the pelvic lymph-nodes, the intermediate tissue between the primary growth and tlie pelvic lymph-nodes about or lateral to the ureter had been left behind. If one were sure of the prevention of ascending renal infection, the resection of the ureters would be the most rational procedure, for the ureters could be cut off just as they enter the parametrium 1.5 cm. below the place from which illustration. No. Y, was made and afterwards the peritoneal flap carrying the ureter with its sheath could be carried down to the bladder, and after implanting the ureter into the bladder, the sheath with the peritoneal flap could be sutured to the bladder, and thus the plexiis would be iminjured and the ureter would be provided with a sheath which could help to prevent stricture and protect the blood-supply of the ureter. In addition, all tissue from pelvic wall to pelvic wall could have been removed and with it the early extension and metastasis of the growth into the parametrium. Some may claim that when the parametrium is involved either by direct extension or by metastasis, the case is hopeless. If so, the vaginal operation is the one of choice in all cases. This statement needs confirmation, and it is too early to make any definite statements either way, and the more radical operation is demanded on the basis of the pathological findings and the results of the less radical operations. If the cystitis and ascending renal infection can be controlled by making a vesico-vaginal fistula and if the implantation can be made without too much tension, thus avoiding a stricture, then this is the operation of choice, for it offers the greatest chance for a cure. The suturing of the ureteral sheath and the peritoneum to the bladder will undoubtedly in great measure relieve tlie tension of the implantation. The dissecting free of the ureters is difficult, more so than resecting them. While there is less danger of ascending renal infection there is a greater chance of ureteral necrosis. A hysterectomy mesial to the ureters offers less chance of a cure than the above and also little danger of either ascending renal infection or ureteral necrosis. Conclusions. 1. The ureter is nourished by a periureteral arterial plexus, (he main trunks of which run in a longitudinal direction, from the kidney to the bladder, in the outer loose perimuscular I Febri-auy, 1904.] 45 fibrous ooats of tlie ureter. From tliese longitudinal vessels, smaller branches arise, some of which anastomose freely with each other, thus forming the mesh-woi-k of the plexus. These smaller branches are for the most part more deeply imbedded in the outer coat of the ureter than the main trunks, which in places nuiy be but loosely united to the ureter. 2. This plexus is nourished mainly by the ureteral arteries which arise from branches of large vessels along the course of the ureter, as, the aorta, the renal, ovarian, iliac, uterine, and other arteries. The ureteral vessels are not the same in all cases, as a branch from one artery, as for instance, the ovarian, present in one case may be absent in another and its place taken by a branch from another artery, as the aorta, a ureteral branch of which may not be present in the first case. See Figs. I. 11. Ill, and IV. .3. The plexus may receive additional nourishment from small branches arising from the plexus, which supply the tissue about the ureter and may also anastomose with the branches of other vessels supplying these parts. 4. It is possible to inject the entire plexus from such arteries as the renal and internal iliac, and also probably from any one artery which furnishes a ureteral artery. 5. The ureter with its plexus is protected by the tissue in which it lies, and in the pelvis this tissue is converted into a definite sheath, which is apparently derived from the tissue through or along which the ureter passes. This sheath acts as a protection to the ureter and its plexus from the invasion of cancerous growths and inflammatory processes, and should be recognized in all operations involving the pelvic portion of the ureter. 6. Animal experimentation shows that many liberties may be taken wdth the ureter and even when the plexus is injured that the blood-suppiy of the ureter may be maintained by the smaller branches of the plexus which are more deeply embedded in the outer coat of the ureter than the larger vessels, and so are more difficult to injure. The ureter of a dog may not only be dissected free for its entire length, but even the plexus may be injured and yet necrosis may not occur. On the other hand, the complete destruction of the plexus for only a short distance, or the partial destruction of the same, which ordinarily would not cause necrosis if combined with the ligation of the vessels supplying the vesical end of the plexus, is apt to cause necrosis. 7. Clinical experience confirms the results of anatomical studies and animal experimentation and shows that w'hile many liberties may be taken w-ith the ureter, the plexus should be guarded in all operations involving the ureter. The ureter has been freed for its entire length and yet necrosis has not occurred. Both internal iliac, the ovarian and the vessels of the round ligament have been tied with similar results. On the other hand, when the ureter is dissected free from some adherent mass, even for a short distance, as, for instance, from a carcinomatous cervix of the uterus, there is danger of necrosis, for the larger vessels of the plexus may not alone be destroyed, but also the smaller branches which are more intimately united to the ureter. In operations for cancer of the cervix this danger is increased where vessels supplying this portion of tiie ureter are ligated, as, the uterine, anterior brancli of the iiilcnial iliac or the internal iliac artery. I cannot see that there is any operative advantage to be gained in ligating either the internal iliac or its anterior branch, over the ligation of the uterine alone, and there is this disadvantage that the chance of ureteral necrosis is not only increased but there is danger of lowered local resistance for the portion of the pelvis supplied by these vessels which would predispo.se these parts to infection. 8. Other accessory etiological factors must be considered in the causation of ureteral necrosis; as, infection, exudates, destruction of tissue about the ureter as would result from the use of a cautery, foreign bodies against the ureter (as gauze), pressure on the ureter, stricture of the ureter, and lowered general resistance. In addition, injury to the ureteral veins, although there is a free anastomosis between the veins in the wall of the ureter, must embarrass the ureteral circulation to a degree varying with the extent of the injury and so woidd interfere with the nutrition of the ureter. 9. Hysterectomy in carcinoma cervicis uteri, where the parametrium is removed mesial to the ureter, must leave cancer either in the form of metastases or as an extension of the growth into the parametrium in many cases. On the other hand, the chance for ureteral necrosis is slight, for the ureteral plexus surrounded by the pelvic ureteral sheath is uninjured. 10. The more radical operation with dissecting the ureter from its sheath offers a greater chance for cure than the above, but there is the danger of iireteral necrosis, for by freeing the ureter the vessels supplying that portion of the plexus are destroyed and the lower 3-4 cm. thus freed must be nourished by blood coming from the upper portion of the ureter through the periureteral plexus, and unless great care is taken this may be injured sufficiently to cause ureteral necrosis. In addition, the ureteral sheath has been destroyed and that portion of the ureter becomes imbedded in scar-tissue, and its fiinction is impaired with the danger of partial or complete ureteral obstruction, with the accompanying lowered renal resistance and liability to renal infection. 11. Eesection of the lower 3-4 cm. of the ureters and the implantation of the renal end of the ureters into the bladder offers the greatest chance for a cure, and at the same time there should be less chance for ureteral necrosis, for the ureter above the parametrium can be brought down to the bladder with its plexus intact, surrounded by the pelvic ureteral sheath, and after implanting the ureter into the bladder its sheath may be sewed to the bladder and also the peritoneal flap in which this portion of the ureter with its sheath lies. The drawback to this procedure is the possibility of renal infection and stricture of the ureter from implanting the ureters under tension. The renal infection may possibly be controlled by the formation of a vesico-vaginal fistula and the freeing of the bladder and suturing the pelvic ureteral sheath with the peritoneal flap to the bladder should relieve the tension of the implantation. 46 [No. 155. 12. Whichever course is followed in these operations, from the basis of anatomical studies and confirmed by animal experimentation and clinical experience, the periureteral arterial plexus and also the ureteral sheath should he preserved. As stated, this is in a measure met by resecting the lower portion of the ureters and implanting their renal ends into the bladder, as described above. This is the only operation justifiable where the growth has involved the ureteral sheath. On the other hand, in so-called favorable cases, one could free the tissue between the two jjelvic walls and instead of resecting the ureters, the ureters with their sheath could be freed from an incision made through the parametrium lateral to the ureters, and thus all the tissue would be removed except the ureters and their sheath, and the dangers of ureteral necrosis and stricture would be reduced to a minimum. This plan looks well on jjaper, but the sheath is very adherent to the surrounding tissues and a careful dissection would prolong an already exhausting operation : and again, the chances of leaving minute metastases in the pelvis are greater than when the ureter is resected. For only by the use of the microscope can one with surety diagnose the presence of cancer in the parametrium. However, clinical experience alone can decide which method offers the greatest percentage of cures combined with the lowest primary mortality. I am sure that many of us who are only too well acquainted with the mental and physical torture, the pain, the vesical and rectal fistulse, etc., so generally associated with the clinical course of cancer of the cervix not operated upon, and the fact that such a large per cent recur after operation, which means that they have not escaped the above mentioned misery, will agree that any operation, no matter how severe, which gives the highest percentage of cures, is the one to be developed, not only in the advanced cases, but especially in the early ones, for in these there is the greater chance for a cure. Keferences. 1. Sampson : The Importance of a More Kadical Operation in Carcinoma Cervicis Uteri, as Suggested by Pathological Findings in the Parametrium. Johns Hopkins Hospital Bulletin, 1902, XIII, 299-307. 2. Sampson: .\scending Eenal Infection; with Special Eeference to the Keflux of Urine from the Bladder into the Ureters as an Etiological Factor in its Causation and Maintenance. .Johns Hopkins Hospital Bulletin. 190.'5, XIV, 334352. 3. Quain: Quain's Anatomy. Longmans, Green & Co., London, 189C. A'ol. III. Part IV. 205. 4. Morris: Surgical Diseases of the Kidney and Ureter. Cassell & Co., London, 1901. Vol. II, 284. 5. Disse: Von Bardeleben, Ilandbuch der Anatomic. Gustav Fi.scher, Jena, 1902, Band VII, Theil 1, S. 110-111. 6. Margaroucci : Quoted by Monari and Protopopow. 7. Monari: Ueber Ureter-Anastomosen. Beitriige zur Klin. Chirurgie, 1896, XV, 722-723. 8. Protopopow: Beitriige zur Anatomii' uiid Physiologie der Ureteren. Arch. f. die Gesam. Physiologie (Pfliigers), 1897, LXVI, 21-22. 9. Kelly : Ligation of both Internal Iliac . Arteries for Hemorrhage in Hysterectomy for Carcinoma Uteri. Johns Hopkins Hospital Bulletin, 1894, V, 53. 10. Pryor: The Surgical Anatomy of the Internal Iliac Artery in Woman and a More Eadical Operation for Malignant Disease of the Uterus. Am. Jour. Obs., 1896, XXXIII, 801-817. 11. Prvor: Transperitoneal Simultaneous Ligation of Both Internal Iliac Arteries for Kecurrence in the Cicatrix Following Vaginal Hysterectomy for Carcinoma Uteri. American Journal of Obstetrics, 1897, XXXV, 511-517. 12. Kronig: Die doppelseitege L^nterbindung der Aa. hypogastrica und ovarica zur palliativen Behandlung des uterus carcinoma. Cent. f. Gyn., 1902, XXVI, 1073-1074. 13. Iwanow: Zur Kasuistik der Palliativebehandlung des uterus karzinoms durch Unterbindung der Becken gefasse. Berich fiber die geburtshilflich-gjiiakologische Sektion des VIII Pirogowschen Kongresses russischer Arzte in Moskau. Zent. f. Gyn., 1903, XXVII, 118-119. 14. Sanger : L'reteren chirurgie biem Weibe, medicinische Gesellschaft zu Leipzig, Xov., 1898. Eeported in Miinchener med. Wochenschrift, 1899, XLVI, 33. 15. Chrobak : Demonstration eines Falles von subserosem Uterus myom, Frcilegung des Ureter. Geb. imd Gyn. Gesellschaft in Wien, 1893. Eeported in Cent. f. Gj-n., 1893, XVII, 346. 16. Euhl : L'eber einer seltenen Fall von Ureteren verlauf bei Beckentumoren und dessen praktische Bedeutung. Cent. f. Gyn.. 1898, XXII, 1056-1058. 17. Durante: Bolletino della E. Accademia medica di Eoma. Anno XX, Vol. XV, 59. Eef. Boari, Anat. del Uretere, and Frommel, X, 351. 18. Wertheim : Ein neuer Beitrage zur Frage der Eadikaloperation beim Uterus-krebs. Archiv fur Gjoiaekologie, 1902, LXV, 1-39. 19. Feitel : Zur arteriellen Gefass versorgung des Ureters, insbesondere der Pars pelvina. Zeitschrift zur Geb. und Gyn., 1901, XLVI, 269-281. 20. Wertheim: Kurzer Bericht fiber eine 3. Serie von 30 L""terus krebs-operationen. Cent. f. Gyn., 1902, XXVI, 250-251. 21. Waldeyer: Ureter-scheido. ^'erhandlungen der Anatomischen Gesellschaft, 1892, 259-260. 22. Disse: L. C, S. 107 and 109. THE JOHNS HOPKINS HOSPITAL BULLETIN. The Hospital Bulletin contains 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 XIV is now completed. The subscription price is ?2.00 per year. The set of fourteen volumes will be sold for 50.00. THE JOHNS HOPKINS HOSPITAL BULLETIN. FEBRUARY, 1904. PLATE V. Ui'. 1*. lijuiuli I'riiiii tlie iiLMiuri'teral iirterial plexus, sup|jlyintf tlio tissue about the uietir. Anast. Br. I'. Anaatoinosi.s betwccu the subperitoneal branch of the aortic uretero-subperitoneal artery, and a branch arlsiuj; from the plexus. Sup. Ves. Anast. Anastomosis of the superior vesical artery of one side with the superior vesical artery of the other side. Fu;. I. — The Pekiukktekai, Auteiuai, Plexus ekom a Woman 31 Yeaus Olii, X 4/.5. Left Uretbk. The reft renal and riirht internal iliac arteries were injected witli a LI per cent solution of ijclatine, colored with ultramarine blue. The organs were removed and hardened in 10 per cent formalin. The draw in^ was made from the dissected hardened specimen. The periureteral arterial jilcxus in this instance is derived from branches ot the aorta, renal, ovarian, internal iliac, uterine, and va^'lnal arteries, marked. A, R, (), I, I', and V. Uterus drawn upwards and to thi> riyht, the tube and ovary have hern removed. Contracted bhulder, drawn downwards iiinl to llie rinht. Ovario-Kenal Anast. Anastomosis between the subjieritoneal branches of the uretero-subperitoneal arteri(^s, arisini; from the renal and ovarian arteries. • * Anastomosis between the uterine and ovarian arteries, cut awiiy by the removal of the tube and ovary. Fig. it. — The Pekiuueteral Aktekial Plexus fkom a Gnu. 7 Years Oli>, x 1. Left Ureter. The left renal artery was injected with an aqueous solution of Prussian blue. The organs were removed and hardened in 10 per cent formalin. The drawiui;' was made from the dissected hardened siiecimen. The origin of the plexus differs slitthtly from that shown in Fig. L The aortic bran<'h is absent, and the branch from the ovarian artery arises from that artery after it has crossed the ureter. There are two branches from the internal iliac artery and one from the uterine. • * Utero-ovarian anastomosis, cut away by the removal ot the tubes and ovaries. Uterus drawn upwards and slightly to the right. Distended bladder, drawn downwards. THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1904. PLATE VI. Fio. III. — The Periuretekal Arterial Plexus from a Girl o Years Old, x 1. Right Ureter. Both remil arteries were injected with a 1.5 per cent solution of gelatine, colored Willi ultramarine blue. The orjjaus were removed and hardened in 10 per cent formalin. The drawing was made from the dissected, hardened specimen. This represents another variation in the arteries giving rise to the periureteral arterial plexus. There are two branches, K and K', from the renal, one from the aorta. A, one from the ovarian, which is recurrent, O, and has the form of an anastomosis of an artery derived from the plexus witli a subperitoneal branch of the ovarian artery. The pelvic portion of the plexus is nourished by a branch, 1, from the internal iliac, a branch M. V., from the middle vesical, which, in this instance, arises from the uterine also a branch, V, from the vaginal artery, which ap)iroaches the ureter from its jiosterior surface. • * Uterf>-ovarian anastomosis. Uterus drawn upwards and slightly to the left. Bladder ilrawii downwards. Fig. IV The Periureteral Arterial Plexus from a Newborn Girl, x 1. Left Ureter. The abdominal aorta was injected with an aqueous solution of Prussian blue. The organs were removed and hardened in 10 per cent formalin. The drawing was made from the dissected hardened specimen. This again represents another variation in the origin of the periureteral arterial plexus. There is one branch, R, from the renal, the ovarian branch is not present, the other branches were derived from the aorta, A, internal iliac, I, and uterine, U, arteries. The uterus is drawn u]Jwards and to the right. These four illustrations represent four variations in the origin of the periureteral arterial plexus, wliich might be found in four adult specimens. Compare the relation in size between the hypogastric artery and its branches in the infant and the adult, and the relatively greater size of the ovarian and uterine arteries in adult woman. The ureter in this illustration has purposely been drawn, a trifle enlarcred. THE JOHNS HOPKINS HOSPITAL BULLETIN, FEBRUARY, 1904. PLATE VII. SUcIJe y-t Carcinoma Ureter, Vrrtercl SAeafA P^yi-Vreterat Cr^ertal Plexus o -; f  i.utnen at-Shtei/i •* «» t Vreterai Sheath. Fig. V. — Cross Section of Uketer Showing the Perihretekal Arterial Plexus, and the Ureteral Sheath, in a Woman 31 Tears Old, x .5. Right Ureter. The left renal and the right internal iliac arteries were injected with a 1.5 per cent solution of gelatine, colored with ultramarine blue. The organs were removed and hardened in 10 per cent formalin. Tlie drawingwas made from a cross section of the right ureter taken about 1.5 cm. above the uterus. Same case as one from which Fig. I was made. For the sake of clearness only the ureteral arteries are drawn, as in jected. The capillaries and the veins were not injected. The periureteral arterial plexus situated within the ureteral sheath can be seen cut across, as well as small arteries within the ureter. This sheath of fibrous tissue which apparently is derived from the pelvic connective tissue, in this situation is adherent to the peritoneum and in freeing the peritoneum from the wall of the pelvis this portion of the ureteral sheath remains attached to the peritoneal flap thus formed This sheath serves as a protection to the ureter and its periureteral arterial plexus. See Fig. VI. Fio. VI. — Relation of Carcinoma Cekvicis Uteri to the Uketek. Transverse section of the parametrium and one-half of the cervix from a specimen of hysterectomy for carcinoma cervicis uteri in which the lower portion of the right ureter was sacrificed and the renal end of the ureter implanted into the bladder, x2}{. Gyu. No. 10,494. Gyn. Path. No. 7.51.5. Section, right side, lower third of the parametrium. The carcinoma has extended out into the parametrium and has invaded the ureteral sheath thus causing it to hypertrophy and serve as a protection to the ureter from the growth, and later this progressive hypertrophy of the sheath will compress the ureter giving rise to a stricture and renal insufficiency. The periureteral arterial plexus can be seen in transverse section, situated about the ureter within the sheath. One can see that the growth does not have to extend far into the parametrium in order to reach the ureter. FEBlirAEY. 1904.] 47 TWO CASES OF LEUKOKEKATOSIS BUCCALIS; COMPARISON WITH THE HISTOLOGICAL CHANGES IN A CASE OF TYLOSIS PALMiE ET PLANTiE. By Sylvan Rosenheim, M. D., Assistant in Laryngolocjij, Johns Hopkins University. (From the Clinic of Dr. Mackenzie, Johns Hopkins Hospital.) Dermatologists have been acquainted with disease of the skin, characterized principally by an increase in the horny layer for a much longer time than with similar disease of the mucous membrane. Consequently it is not surprising that the terms icthyosis (Hulke), tylosis (Hutchinson), keratosis (Kaposi), and psoriasis, applied to the former, have been used to describe the latter, since the clinical picture is so similar. Moreover, the disease was at first described by dermatologists and syphilographers and usually in connection with similar diseases of the skin. Alibert and Plumbe, in a case of icthyosis of the skin, describe similar whitish patches on the tong-ue. THE EFFECTS OF X-RAYS UPON LOWER ANIMAL LIFE AND THE TUBE BEST SUITED TO THEIR DESTRUCTION.' By Kennon Dunham, M. D. Cincinnati. Ohio. > I. The immediate object of this research was to ascertain wliat effects, if any, X-rays have upon several of the lower forms of animal life; to discover if any of such organisms are destroyed by X-rays and if so, what technique best produces such destruction. II. The reason for such research is based upon the analogy existing between such lower organisms and the new cells of a malignant growth. What I really wish to establish is a scientific method by which to determine the best form of tube with which to treat such growths; and it seems but fair to allow, upon such analogj', the supposition that the condition of tube that is most destructive to one of these forms will be most destructive to the other. AN ANOPHELES MOSQUITO WHICH DOES NOT TRANSMIT MALARIA. By Leonard K. Hirshberg, A.B., M.D. (From the Pathological Laboratory of the College of Physicians and Surgeons.) Anopheles punctipennis abounds in the neighborhood of Eoland Park, a suburb of Baltimore, as was demonstrated by us ' some time ago. Even at that time, in a careful investigation of the health records and specimens sent to Dr. William E. Stokes, City Bacteriologist, I was unable to trace any autochthonous cases of malaria in that neighborhood. After carefully searching through much of the literature ' on mosquitoes and malaria, and not finding any malaria traceable to A. punctipennis as carriers of the parasite, it was determined last summer to put the question to a proof. The few cases of malaria which occur in Baltimore have their origin as a rule at Sparrow's Point and upon the Eastern Shore of Maryland. At the former place, situated some twelve miles from the city, we found Anopheles maculipennis in abundance, but found no other species of Anopheles in numbers. Malaria is constantly endemic there and most of the Baltimore cases are imported from that place. Anopheles maculipennis captured there contained malarial parasites in the stomach walls. On the other hand, I have never been able to demonstrate the parasites in the walls of .4. punctipennis found at Eoland Park or elsewhere. CONTENTS. PAGE The Relation of Leucocytes with Eosinophile Granulation to Bacterial Infection. By Eugene L. Opie, M. D., 71 The Relation between Carcinoma Cervicis Uteri and the Ureters, and Its SigniBcance in the More Radical Operations for that Disease. By Johx A. Sampson, M. D., 72 Georsje CUeyne, an Old London and Bath Physician (1(571-174.'!). By Thomas McCrae, M. D., M. R. C. P., 84 A Case of Amaurotic Family Idiocy. By Eknest Sachs, ... 94 Summaries or Titles of Papers by Members of the Hospital or Medical School Staff Appearing Elsewhere than in the Bulletin, 9.5 Notes on New Boolis, 100 Books Received, 106 THE RELATION OF LEUCOCYTES WITH EOSINOPHILE GRANULATION TO BACTERIAL INFECTION PEELIMINAEY PUELICATIOlSr. By Eugene L. Opie, M. D. Associate in Pathology, Johns Hopkins University; Fellow the Rochefeller Institute for Medical Research. (Fro)n the Pathological Laboratory of the Johns Hopkins Uideersily and Hospital.) Certain bacteria (Bacillus tuberculosis, Bacillus choleras suis) producing somewhat chronic, fatal infection in guinea pigs, cause the eosinophile leucocytes to disappear gradually from the circulating blood. After death few eosinophile cells can be found in those tissues in which they are usually present in abundance. Hence the study of tissues removed at autopsy gives little indication of the behavior of the eosinophile leucocytes during the course of bacterial infections. During more acute infections produced by inoculating bacteria into the peritoneal cavity of guinea pigs (Bacillus mucosus capsulatus of Friedlander, Bacillus pyocyaneus, Streptococcus pyogenes) eosinophile leucocytes quickly disappear almost completely from the periplieral circulation. After the inoculation of an organism (Bacillus pyocyaneus), producing an infection from which the animal is capable of recovering, eosinophile leucocytes almost completely disappear from the peripheral circulation so that within twentyfour hours the proportion may fall from five or ten per cent to less than one per cent. The number of eosinophile leucocytes then gradually increases and at the end of four or five days both the relative and absolute number of these cells may considerably exceed that present in the peripheral circulation before inoculation. At the end of six or seven days the number of eosinophile leucoc}'tes is again normal. Read before the .lohns Hopkins Hospital Medical Society, March 7, 1904. GEORGE CHEYNE, AN OLD LOiNDON AND BATH PHYSICIAN. (1GT1-1T43.)' By TiioirAS McCr.ve, U. D., M. R. C. P., Associate in Medicine, The Johns Ilopl-ins Unirrrsifi/. and Ncsidcnl Pliysicinn, The Johns Hopkins Hospital. " XJie palate hills more Ih.an the sword. — Old Proveub. The advice has been given to the younger of our profession to leave the reading of new books to the older men and to devote ourselves to the writings of previoiis generations. By so doing we may be delivered from what has been termed " an inapt derision and neglect of the ancients." Perhaps too truly might the words of Job be applied to some of us, " No donbt but ye are the people and wisdom sliall die with you."' However that may be deserved, it does not require mucli study of the works of those who have gone before to realize that wisdom was not born with us. Much wisdom is of all time and the fact cannot be brouglit home too strongly. To some of us the acceptance of this comes slowly. There are few impressions stronger than the personal realization that many ideas we are apt to think peculiar to our own time have long since been old. To find certain things dating back to Hippocrates gives one a comforting sense of the permanence of the profession. A CASE OF AMAUROTIC FAMILY IDIOCY. By Ernest Sachs. (^From f?ie Nenrolofjifal Clinir, The Johns Hopkins Hospital Dispensary.) The case reported here is of interest as being the first example of this disease observed at the Jolins Hopkins Hospital, and though it was impossible to obtain an autopsy, it is, nevertheless deemed worth while to put it on record as another example of a rather rare condition. I am indebted to Dr. Thomas both for the privilege of following the case as well as of reporting it. D. K. — Nerv. Dis. No. 14634, age 14 months, was first seen at the neurological dispensary of the hospital on June 6, 1903. The diagnosis was at once apparent from the general condition and the typical retinal picture. F. H. — Father and mother both healthy and well; not related to one another. They arc Russian Jews. No history of syphilis in either parent. This is the third child. The oldest, 5 years, a boy, is healthy and has never shown any symptoms of a similar trouble. The second child when several years old died of diphtheria. There is no history of a similar disease in either the father's or mother's family. P. H. — This patient was a full term child, the labor was normal and the child seemed perfectly healthy. No history of convulsions or any .symptoms pointing to hereditary syphilis. When six weeks old the child had bronchitis ; has had some cough at intervals ever since. When 1 year old had measles and from this time mother dates the illness. Child was breast fed, the feeding being supplerjjented with cow's milk of excellent quality. C'liild has never spoken or crawled. 'I'he bowels have always been constipated and are moved with considerable difficulty. P. E. — Patient is a weak, sickly looking child. Its face is expressionless, but at times seems to smile. Cannot hold its head up, it falls back or forward. Pupils are equal and moderately dilated, and react to light. Child takes notice of objects and follows them about, but does not seem to see so well at the periphery. Child seems to hear. Starts violently at a sudden sound. Every now and then has a spasmodic jerk of its muscles. Some stiffness of arms on passive motion ; no contractures. At a sudden sound legs and arms are stiffened. Ecflexcs. — Deep reflexes much exaggerated in arms and legs. Jaw jerk is active, and associated with this is a contraction of the orbicularis. No ankle clonus but an active tendo Achillis reflex. Flexor response of all the toes on plantar stimulation. No local atrophy; no paralysis of any muscles. Sensation seems to be present everwhere. The prick of a pin is responded to at times by a jerking all over the body. The ophthalmoscopic examination revealed the characteristic picture of this disease. The patient was referred to the eye department where Dr. Randolph made the following note : " Around the fovea in botli eyes there is a cherry red spot, surrounded by a gray area. Tlie optic discs look a little pale." From this time on the patient, although watched carefully and seen repeatedly, grew progressively weaker. In October Makcii, lUOl.] JOHNS HOPKINS HOSPITAL |BULLET1N. 05 the following note was made : " Child is getting weaker ; no loiiirei' fiiii hold anything in its hands. Has been weaned. S}-mptoms remain as previously descriljed." About this time the child developed difficulty in deglutition and could not swallow its food. This .symptom continued and became morn marked. Vision seemed completely gone, and the patient no longer responded to a bright light or speech, but starts at a loud sound. The patient continued, to get weaker. Eigidity of arms and legs became very much more marked. Slight contractures appeared in the legs. On several occasions the child had attacks of explosive laughter which seemed to come without any apparent outside stimulus. The child grew continually weaker, lost weight and Ijccame very much emaciated, presenting a typical picture of marasmiis, and died February 29, 1904. Remarls. — This case is undoubtedly an example of the spastic form of amaurotic family idiocy. It shows all the cardinal .symptoms of the condition as well as two features which have only been observed in a few instances by Falkenhein, namely, the explosive laughter and disturbances in deglutition. The most recent views about this disease with a fairly complete bibliography may be found in the Journal of Nervous and Mental Disease, January, 1903. SUMMARIES OR TITLES OE PAPERS BY MEMBERS OF THE HOSPITAL OR MEDICAL SCHOOL STAFF APPEARING ELSEWHERE THAN IN THE BULLETIN. John J. Abel, M. D. The Function of the Suprarenal Glands and the Chemical Nature of their So-Called Active Principle. — ('Qiitribiitions to Medical Research, Dedicated to Victor C. Vaughan, Ann Arbor, 1903. Samuel Ambekg, M. D. Sublingual Growth in Infants. — American Journal of the Medical Sciences. August, 1903. Charles Eussell Baedeen, M. D. Variations in the Internal Architecture of the M. Obliquus Abdominis Externus in Certain Mammals. — Anatomischer Anzeiger, June 24, 1903. John S. Billings, Jr., M. P. The Work Performed by the Diagnosis Laboratory of the Department of Health in Connection with Ehrliclfs Diazo Eeaction during 1902. — New York Medical Journal, April 18, 1903. The Value of Confirmatory Cultures in Diphtheria. — Kew York Medical Journal, September 12, 1903. The Administration of Antitoxine in Diphtheria by the Department of Health During 1902.— Vc«; York and Philadelphia Medical Journal, December 12, 1903. E. Bates Block, ^I. I). Parotitis Following Typhoid Fever. — Alluula Journal Record of Medicine, February, 1903. Male, age 34 years, developed parotitis of the left side on the 47th day of the disease. 16 days after his temperature reached normal. The involvement of the parotid .i;land was followed by a rise of temperature to 101.3° F. and ran an irregular course for five days. There was no evidence of suppuration. The original paper mentions the various inflammatory lesions produced by the typhoid bacillus, and the occurrence of parotitis following other diseases of the abdominal, or pelvic, viscera, or generative organs. The Eelation of the Nervous System to Unilateral Sweating. — Transactions of the Medical Association of Georgia, 1903, page 291. A Russian tailor, aged 47 years, was admitted to Dr. Thomas' Clinic in the Johns Hopkins Hospital Dispensary on the 23rd of April, 1901, complaining of excessive paroxysmal sweating on the right side of the head and body which had existed for twelve years and was most marked on the right half of the face, head and shoulder and the upper part of the chest, and limited sharply by the mid-line. The right ear and the left side of the face and body did not sweat during the paroxysms. The mouth was drawn a littk upward at the right corner which extended further lateral than to the left, the right labio-nasal groove being much deeper and more distinct than the left. During the paroxysms, the right side of the face becomes redder than the left. The right fore-arm and hand sweat more than the left. After cleaning the face with neutral alcohol, the sweat was always found to be slightly acid and contained sodium chloride. Sensation was normal for all varieties. Many experiments were tried, to observe the effect on the sweating. Drinking hot water caused most profuse perspiration, the sweat pouring in streams down the right side of his face. The right side of the face became warmer and redder than the left during the sweating attacks, and the axillary temperature ranged from 0.1° P. to 0.5.° F. higher in the right axilla than the left. In thirteen observations on the pupils, both during the sweating attacks, and between them, the right pupil was slightly smaller than the left ten times, while on three occasions both pupils appeared equal. The pupillary reactions were all retained. There was myopia of both eyes, greater in the right. After pilocarpine injections, the sweating began first, and was more pronounced, on the ri.ght side. After a general discussion of the literature, a case of per 96 [No. 156. ipheral nerve paralysis was reported, which seemed to indicate that a complete nerve paralysis was accompanied by anidrosis, while a partial paralysis was accompanied by hyperidrosis, while on a return of the nerves to normal function, the sweat secretion also became normal. Statistics were collected from 107 cases, and the syndrome of myosis. redness, increased temperature, and unilateral sweating on the same side was present in such a large majority of cases that they must at least be regarded as the rule. The temperature on the sweating side in thirty-two cases, was increased in twenty-seven, equal in four, decreased in one. (In the case reported above, the right axillary temperature was 0.2° F. lower than the left between the sweating attacks). Redness was present in twenty-nine cases, and not present in three cases, out of thirty-two cases in which a note was made on this point. Myosis has not proven such a constant concomitant. Thus in forty-seven cases, the pupils were larger on the sweating side in nine, smaller in twenty-three, equal in fifteen, but it is very probable that a slight difference in the size of the pupils in the last group was unnoticed in some cases. Moreover, many of these cases in which the pupils were equal or larger, were evidently not cases of sympathetic affection, so that the occurrence of myosis has really a greater relative frequency than appears in this table. In regards to sex, there were fifty-seven males to twenty-five females affected with unilateral sweating. Forty-four cases occurred on the right side, and thirty-three on the left. In eighteen cases some affection of the parotid gland was noted. Further statistics may be seen in the original article. Joseph C. Bloodgood, M. D. Rare Case of Appendicular Abscess Sittiated between the Layers of the Mesentery of the Small Intestine. — American Jniirnal of ihc Medical Sciences, October, 1903. Intestinal Obstruction Following Operation for Reducible Left Inguinal Hernia Due to a Loop of Small Intestine caught in Freitz's Fossa. — Annals of Siirfieri/, December, 190 o. George Blumer, M. D. A Note on the Embryonal Glandular Tumors of the Kidney. — Albany Medical Annals, .Vugusl, lii.i:;. and H. C. Gordinier, M. D. A Case of Chronic Lymphatic Leukaemia without Enlargement of the Lymph Nodes. — Medical News, October 31, 1903. .loii.v Jii{.\i)KORD Briggs, M. D. A Note on the Association of a Rise in Systolic Blood Pressure, with the Onset of a Perforative Peritonitis in Typjioid Fever. — Boston Medical and Surgical Journal, September 24, 1903. T110MA.S R. Brown, M. D. The Blood in Health and Disease with a J{eview of the Recent Important Work on this Subject. — The Tnfrrnafinnal (llinirs. Vol. 4, 18th .Series. Enteroptosis, its lOtiolog}', Svinptoinatology, Treatment, and Prognosis. — American Medicine, Vol. 6, August 15, 22, 29, 1903. The Diuretic Value of Salt Solution I'jncmata, Es pecially After Renal Operations. — Maryland Medical Journal, August. 1903. The Value of Leucocyte Counting in Differentiating Post-Operative Auto-Intoxication from Peritonitis. — Maryland Medical Journal, August, 1903. — The Gastric Contents in Gastroptosis. — New York and Philadelphia Medical Journal, September 26, 1903. — The Value of Albuminuria in Differentiating Pyelitis from Cj'stitis. — New Ynrl- and Philadelphia Medical Journal, October IT, 1903. Urinary Hyperacidity. — Netv York and Philadelphia Medical Journal, November 1-i, 1903. C. H. Bunting, M. D. The Effects of Lymphotoxins and Myelotoxins on the Leucocytes of the Blood and on the Blood-forming Organs. — University of Pennsylvania Medical Bulletin. July-August, 1903. Primary Sarcoma of the Spleen with Metastases. Report of a Case. — University of Pennsylvania, Medical Bulletin, July-August, 1903. W. J. Calvert, M. D. Plague Serum in Three Cases. — Boston Medical and Surgical Journal, January 8, 1903. Transmissibility of Plague. — American Medicine, January 24, 1903. Plague Bacilli in the Blood. — Centralblatt f. Bakter iologie, Parasitenhunde v. Infrrtionsl-ranl-heiten. 1 abt., XXXIII Bd., No. 4. 1903. Comment on Plague Memorandum. — American Medicine, March 7, 1903. Tropical Diseases: General Introduction. — Buck's Reference Handbook of the Medical Sciences, V^ol. VII, 1903. Record of Parasitic Infections in the Philippines. — Boston Medical and Surgical Journal, October 23, 1903. C. N. B. Camac, M. D. A Preliminary Report of the Venous Hum in Relation to the State of the Blood. — Medical News, March 21, 1903. Demonstrated from cases that the venous hum may be and frequently is present with normal blood. Some Observations on Aneurism and Arteriosclerosis. — The Matter Lecture, delivered December 1, 1903, at the College of Physicians, Philadelphia. A historic review of the development of our knowledge of vascular diseases and pathological and historical consideration of the initial changes in the vessel wall in arteriosclerosis and aneurism. John G. Clark, M. D. Address in Obstetrics, delivered before the Meeting of the Medical Society of the State of Pennsylvania, York, September 22, 1903. I. The Treatment of Cancer of the Uterus by Roentgen Rays. II. The Etiology of Eclampsia. — University of Pennsylvania Medical Bulletin, November, 1903. Lessons from the Life of Pasteur. — Northwest Medicine, Vol. I, No. 6, 1903. Histogenesis of Glandular Cysts of the Ovary. — Transactions of the American Gynecological Society, 1903. March, 1904.] 97 Hexky \V. Cook, M. 1). The Accurate Estimation ot Pulse Tension. — The Old Dominion Journal of Medicine and Surgery, October, 1903. — Virginia Medical SemiMonthly, November 13, 1903. Thomas S. Cullen, M. B'. Uterine Myomata and their Treatment. — Canada Lancet, July, 1903. Sarcomatous Transformation of Myomata. — Journal of the American Medical Association, October 24, 1903. Adeno-Myome des Uterus. Berlin, 1903. George W. Dobbin, M. D. Management of Normal Labor. — Buck's Reference Handbook- of the Medical Sciences, 1903. ARTUtR W. Eltixg, M. D. The Unusual Symptoms of the ^Yeakened Foot, with Illustrative Cases. — Albany Medical Annals, April, 1903. John M. T. Finney, M. D., and Omar B. Pancoast, M. D. Enterostomy, with Eeport of Cases. — American Medicine, August 22, 1903. The paper calls attention to certain additional indications for the performance of the operation of enterostomy: 1. To drain temporarily a distended intestine, thus allowing it to regain its normal tome. 2. To enable one to nourish a patient whose stomach and rectum are unaolo to retain or absorb a sufficient amount of nourishment. After calling attention to several general considerations which had been noticed in the author's experience, seven cases of enterostomy were reported for various causes. Simon Flexxer, ]\I. D. A Xote on Autolysis in Lobar and Unresolved Pneumonia. — University of Pennsylvania Medical Bulletin, July-August, 1903. An Aspect of Modern Pathology. — American Journal of the Medical Sciences, August, 1903. and HiDEYO jSTogdchi, M. D. On the Plurality of Cytolysins in Snake Venom. — University of Pennsylvania Medical Bulletin, July-August, 1903. \V. W. Ford, M. D. Classification and Distribution of the Intestinal Bacteria in Man. — Studies from the Royal Victoria Hospital, Vol. I, No. 5, ilay, 1903. T. B. FuTCiiER, M. B. The Occurrence of Gout in the United States. — The Practitioner, July, 1903, p. (J. 1. The apparent infrequency of gout In the United States is due in large part to failure to recognize the disease. 2. Out of 15,69 7 medical cases admitted to Dr. Osier's wards at the Johns Hopkins Hospital during a period of 14 years, there were 41 casts of gout, or 0.26 per cent of the total number ot medical patients. For the same number of years at Saint Bartholomew's Hospital there were 124 cases out of a total of 33,356 medical admissions, or 0.37 per cent of the medical cases. 3. The ratio of admissions of gout to the two hospitals is respectively a little greater than as 2 is to 3; or, in other words, the admissions of gout to a general hospital are a little less than one-third more freauent in London than in Baltimore. 4. All of the 42 cases were males. There was only one colored patient in the sei ies. The negro race appears to possess a relative immunity from the disease. The largest number of cases, 13, occurred in the fifth decade. Of special interest is the fact that 32 of the patients were native-born Americans. 5. The majority of the cases appear to have earned rather than inherited their gout. Alcohol and lead seemed to be the most potent aetiological factors. 6. Thirty-nine of the 42 cases had reached the chronic stage before they came under observation. In 19 of the cases tophi were present. 7. Among the most interesting complications may be mentioned four cases of gouty bursitis; one case of parotitis, one of pericarditis, one of retrocedent gout with symptoms simulating intestinal obstruction. 8. There was evidence of disease of the kidneys in the majority of cases. Albuminuria occurred in 32 and hyaline or granular casts in 26 instances. 9. Arterio-sclerosis ot varying degree was present in 29 cases and a mitral systolic murmur in 8. 10. The diPiculty of differentiating the disease from rheumatism was illustrated by the fact that four of the cases were repeatedly diagnosed as the latter on their early admissions to the hospital, the appearance of tophi later revealing the true nature of the disease 11. The series illustrates the great importance of examining the ears and the vicinity of the joints for the presence of tophi in all cases of multiple arthritis of doubtful origin. Some Points on Metabolism in Gout: With Special Eeference to the Eelationship between the Uric-Acid and the Phosphoric- Acid Elimination in the Intervals and During Acute Attacks. — The Practitioner, August, 1903, p. 181. The analyses in the cases reported above suggest very strongly a close parallel relationship between the uric-acid and phosphoric-acid excretion in gout. They further point in favor of the view that both are products of nuclein-disintegration. In the quiescent intervals both phosphoric acid and uric acid are markedly reduced below normal. Two or three days after the acute arthritic symptoms commence the phosphoric acid and uric acid gradually increase until they reach the average output, or even the upper limit for normal. As the acute manifestations subside both steadily fall and remain below the lower limit for normal until the onset of the next acute attack. A Study of the Cases of Amoebic Dysentery Occurring at the Johns Hopkins Hospital. — The Journal of the American Medical Association, August 22, 1903, p. 480. In nearly fourteen years 120 cases of amoebic infection have been admitted to the Johns Hopkins Hospital. Of these, 119 were cases of amoebic dysentery and amoebic abscess of the liver, the remaining case being one of amoebic abscess of the floor of the mouth. Of the 120 cases' 118 were admitted to the medical wards. During this time there were 15,817 medical admissions, the amoebic dysentery cases constituting 0.74 per cent of the cases. Of the 119 cases of dysentery, 82 were apparently contracted in Baltimore and 13 in the State of Maryland outside Baltimore, or a total of 95 cases within the borders of Maryland. The largest number of cases occurred in the third decade. The youngest patient was a child two years and eight months old. and the oldest a man of 71. A point of special interest is the comparatively large number of cases in children under 10 years. Eleven cases, or 9.4 per cent, occurred in the first decade, 6 of these belonging in the first hemi-decade. There were lOS males and 11 females. The series comprised 107 whites and 12 blacks, or a proportion of 9 to 1. The total ratio of whites to blacks in the hospital is about 7 to 1. A secondary anaemia of moderate grade occurs. Occasionally there is a polycythemia. The average leucocyte count in the uncomplicated dysentery cases was 10,600. In the hepatic abscess cases it was 18,350. Hepatic 98 [No. 156. abscess occurred in 27, or 22.6 per cent, of the cases. Nine of these ruptured into the right lung and 2 into the right pleura. Three opened into the inferior vena cava. In 10 cases of the 18 abscess cases that came to autopsy there vi'as a single large abscess in the upper part of the right lobe. In 8 cases there were multiple abscesses. Perforation of the colon with peritonitis occurred in 3 cases, and severe intestinal hemorrhage in 3 cases. Five cases were complicated by malaria; 1 by typhoid; 1 by pulmonary tuberculosis; and 1 by a strongyloides intestinalis infection. The agglutinative blood reaction with Bacillus dysenteriae was negative in all cases tried. A marked feature of the disease is the great tendency to relapse. The mortality was high; 2S. or 23. .5 per cent, terminated fatally. Hepatic abscess is a serious complication, 19 of the 27 cases terminating fatally. Five were cured out of 17 operated on. Two of the hepato-pulmonary abscess cases were discharged very much improved. One abscess case did not remain to be treated. Quinine irrigations still seem tc- give the best results in the treatment of the dysentery. T. Caspar Gilchrist, M. D., and W. Royal Stokes, M. D. The Presence of Pecnliar Calcified Bodies in L\ipns-like Tissue. — Journal of Cutaneous Diseases, October, 1903. Henry Harris, M. D. A Case of Progressive Muscular Atrophy of Spinal Origin. — California State Journal of Medicine, January, 190.3. Importance of cold and fatigue shown aetiologically in a case resulting two weeks after excessive cold and fatigue while the patient was traveling in Alaska. William H. Howell, Ph. D., M. D. Obervations upon the Cause of Shock, and the Effect upon it of Injections of Solutions of Sodium Carbonate. — Contributions to Medical Research, Dedicated to Victor C. Vaughan, Ann Arbor, 1903. Guy L. Hunner, M. D. An Interesting Complication in the Diagnosis of Gallstone. — American Medicine. May 2, 1903. Two cases are reported, in one of which was made a possible, and in the other a positive diagnosis of gallstone. Operation in each case demonstrated that the symptoms were due to the omentum being adherent to a former operation wound. The symptoms were probably caused by traction on the parietal peritoneum at the base of the mesocolon. One Hundred Consecutive Cases of Myoma of the Uterus. — Ame7ican Medicine, July 11, 1903. The writer reports one hundred consecutive cases of myoma of the uterus occurring in the gynecological service at the Johns Hopkins Hospital. Eighty per cent of these patients were between 30 and 49 years of age. Eighty per cent were married and 32 per cent of these had never been pregnant. Of the 54 women who had been pregnant, 11 or about 20 per cent had borne but one child, and G had never carried a child to viable age. One patient had miscarried six times, the fetus never going beyond the fifty month. Of the 54 women who had been pregnant, 20 had miscarried at some period in life. At times the diagnosis between fibroid tumor and pregnancy can not be made even when the patient is fully anesthetized. Of the chief sjmpfoms noted, 35 patients complained of an abdominal tumor. Pain, either in the abdomen or pelvis, or in the form of dysmenorrhoea, was complained of by 53 patients. Increased menstrnal flow was noted in 41 cases and copious hemorrhages at or between the menstrual periods in 15 cases, making 56 per cent in which myoma was associated with unusual loss of blood. Gastric symptoms were prominent in 6 cases. Sixteen patients complained of bowel symptoms, and 28 patients of bladder symptoms. Carcinoma of the fundus occurred in 3 cases, of the cervix in 2 cases. Sarcoma was present in 2 cases. Adenomyoma existed in 2 cases. The following operations were done for the 100 cases: Myomectomy, 19; panhysteromyomectomy, 14; supravaginal hysterosalpingooophoromyomectomy, 40; supravaginal hysteromyomectomy, leaving one or both ovaries, 16; vaginal myomectomy, 5; vaginal hysteromyomectomy, 6. Six patients died In five of them the tumor was complicated by serious pelvic inflammatory disease. One died on the sixth day from septicemia, one on the third day from general peritonitis, one on the fourth day from thrombosis of the left common iliac vein with embolus carried to the pulmonary artery, one suffered with an infected tumor and died in 10 hours from shock, which was profound even before operation. Two died in 20 hours and 4 hours, respectively, from shock due to loss of blood at operation. Tuberculosis of the Urinary System in Women. Report of Thirty-Five Cases. — Charlotte Medical Journal, November, 1903. Henry M. Hued, M. D. The Duty and Responsibility of the University in Medical Education. — Science, July 17, 1903. — Yale Medical Journal, July, 1903. Henry Barton Jacobs, M. D. Maryland's Need of a Mountain Sanatorium for Indigent Consumptives. — Maryland Medical Journal, October, 1903. Howard A. Kelly, M. D. The Early History of Appendicitis in Great Britain. Glasgow Medical Journal, August, 1903. On the Labia Urethrae and Skene's Glands. — American Medicine, September 12 and 19, 1903. The Selection of Methods in Abdominal Hysterectomy. — Journal of Obstetrics and Gyncecology of the British Empire, 1903, Vol. IV. J. H. ]\I. Knox Jr.. M. D. A Contribution to the Study of the Summer Diarrhoeas of Infancy. — Journal of the American Medical Association, July 18, 1903. W. Harmon Lewis, j\I. D. Wandering Pigmented Cells Arising from the Epithelium of the Optic Cup, with Observations on the Origin of the M. Sphincter Pupillte in the Chick. — American Journal of Anatomy, Vol. II, No. 3. Irving P. Lyon, M. D. Artcrio-sclerosis and the Kidney. — Transactions of the Medical Society of the State of New York, 1903, p. 96, and reprinted in Albany Medical Annals, March, 1903. Blood E.xamination in General Practice. — Transactions of the Medical Society of the State of Neiv York, 190.3, p. l.'il. and rejirintcd in Buffalo Medical Journal, June, 1903. A Statistical Study oC a Rural Cancer District in the State of Now York — Brookfield. Fourth Annual Re March, 1904.] 99 port of tlie Work of the Cancer Laboratory of the Xew York State Board of Health, for the year 1902-3, Albany, 1903, pp. 97-119. A Cancer District in the Towns of Plaiufield and Edmeston, New York. Fourth Annual Report of the Work of the Cancer Laboratory of the N'ew York State Board of Health, for tlie year 1902-3, Albany, 1903, pp. 120-123. A Review' of Echinococcus Disease in North America. — American Journal of the Medical Sciences, January, 1902. This paper analyzes 241 American cases, citing the original report of each case, where published, and adding many unpublished cases. The cases are considered under the following headings: Age; Sex; Nationality; Geographical Distribution, by States and Provinces; ALatomical Location, by Organs Involved; Diagnosis; Is the Disease on the Increase in America? ; The Distribution of the Disease in Animals in America; The Occurrence in Dogs of the Adult Tapeworm. Taenia Echinococcus; Prophylaxis; Commercial Considerations. "W. G. MacCallum, M. D. On the Production of Specific Cytolytic Sera for Thyroid and Parathyroid, with Observations on the Physiology and Pathology of the Parathyroid Gland, Especially in its Relation to Exophthalmic Goitre. — Medical News, October 31, 1903. 'Thomas McCkae, M. D. Acute Articidar Rheumatism. A Report of the Cases in the Johns Hopkins Hospital, 1902-1903. — American Medicine, August 8, 1903. J. D. Madison, M. D. A Case of Brain Tumor in .a Woman Seventy-Eight Years of Age. — American Journal of Insanih/. .January. 1903. T. P. Mall, il. D. On the Circulation through the Pulp of the Dog's Spleen. — American Journal of Anatomy, Vol. II, No. 3. On the Transitory or Artificial Fissures of the Human Cerebrum. — American Journal of Anatomy, Vol. II, No. 3. Spleen. — Buck's Reference Handbook of the Medical Sciences, 1903. Second Contribution to the Study of the Pathology of Early Human Embryos. — Contributions to Medical Research, Dedicated to Victor C. Vaughan, Ann Arbor, 1903. Harry T. Marshall, M. D. Osteoma.— Buck's Reference Handbook of the Medical Sciences, 1903. Side Chain Theory of Paul Ehrlich.— 5mcA:'s Reference Handbook of the Medical Sciences, 1903. G. Br.owx Miller, IL D. Congenital Dilatation of the Gall Bladder and Bile Ducts. — The American Journal of Obstetrics, Vol. XLVIII, No. 2, 1903. The patient, a girl 2i/^ years old, was born with a very large abdomen, which measured a few days after birth 24V'> inches in circumference. She was well developed, learned to walk about the usual age, and except some trouble with digestion and inconvenience due tc the size of the abdomen, was apparently in good general health. Her stools varied from clay color to a light brown. The size of the abdomen was due to a tumor, which proved to be an enormous dilatation of the gall bladder and bile ducts, and occupied most of the abdominal cavity. Three litres of thin bile containing mucus were evacuated after stitching the tumor to the abdominal wall. No gall stones could be found. The bile continued to flow through the fistula and the stools showed an absence of bile for three months, when after a great outflow of thick bile-stained mucus the fistula closed and the stools assumed a normal color. She is now quite well, 1% years after the operation. The liver was represented by a very small left lobe and a mass of liver substance the area of the palm of the hand and about 1-2 cm. thick, lying intimately adherent to the cyst and separated from the left lobe by an interval of 5 cms. The ligaments of the liver were attached to the cyst. G. H. F. NuTTALL, M. D. In Meiuoriam : Walter Reed. — Journal of Hygiene, Vol. 3, pp. 292-296. • In Memoriam: Edniond Nocard. — Journal of Hygiene, Vol. 3, pp. 517-522. and A. E. Shipley, M. A. Studies in Relation to Malaria. II. (Concluded). The Structure and Biology of Anopheles. — Journal of Hygiene, Vol. 3, pp. 166215. E. L. Opie, M. D. Disease of the Pancreas; Its Cause and Nature. — •/. B. Lippincott Company, Philadelphia and London, 1903. Protozoa-like Bodies of Carcinoma, Smallpox and Leukffimia. — Twentieth Century Practice of Medicine, Vol. XXI, p. 553. Plasmodium Malariae. — Buck's Reference Handbook of the Medical Sciences, 1903. — SjTnptoms and Treatment of Pancreatic Disease. International Clinics, 1903. WiLLiAJi OsLER, M. D. Chronic Cyanosis, with Polycythjemia and Enlarged Spleen : A New Clinical Entity. — American Journal of the Medical Sciences, August, 1903. On the So-Called Stokes-Adams Disease (Slow Pulse with Sj'ncopal Attacks, etc.). — The Lancet, August 22, 1903. The Home in Its Relation to the Tuberculosis Problem. — Medical Neivs, December "12, 1903. Typhoid Fever and Tuberculosis. — American Med icine, December 26, 1903. Mart S. Packard, M. D. An Encapsulated Diplococcus in Mastoiditis. — Journal of Medical Research, March, 1903. Otto G. Ramsay, M. D. A Discussion of the Etiology and Modern Treatment of Eclampsia. — Yale Medical Journal, September, 1903. Robert L. Randolph, M. D. The Bacteria Concerned in the Production of Eye Inflammations. — Journal of the American Medical Association, October 3, 1903. Hunter Robb, M. D. The Mortality following Operations for Pus in the Pelvis. — Journal of the A merican Medical Association . Januarv, 1903. 100 [No. 156. — The Vaginal Incision in Sepsis following Abortion. — American Gijnecolo(jy, June, 1903. Ovariotomy. — Buck's Reference Uandhoolc of the Medical Sciences, June, 1903. Benjamin K. Schenck, M. D. Results in a Series of Fortyeight Kidney ri.\ations. — Detroit Medical Juuinal, December, 1903. Some Essential Points in the Use of the Kelly Female Cystoseope. — Journal of the Michigan State Medical Society, December, 1903. An Eighty-eight Ponnd Ovarian Cyst Successfully Eemoved from a Patient Seventy-seven Years of Age. — Journal of the American Medical Association, December 19, 1903. Charles E. Simon, il. D. A Case of Myelogenous Leukaemia with Severe Unusual Features (absence of eosinophilic leucocytes). — American Journal of the Medical Sciences, Vol. CXXV, June, 1903, p. 984. On the Occurrence of Ehrlich's Dimethylamidoben zaldehyde Reaction in the Urine. — American Jovrnal of the Medical Sciences, Vol. CXXVI, September, 1903, p. 471. Frank R. Smith, M. D. Extracts from the Writings of Wilhelm Griesinger, a Prophet of the X^ewer Psychiatry. — American Journal of Insanity, July and October, 1903. Walter R. Steiner. M. D. Report on the Progress of Medicine, 1902.- — Transactions of the Connecticut Medical Society, 1903, pp. 113-125. William S. Thayer, M. D. On Arteritis and Arterial Thrombosis in Typhoid Fever. — New York State Journal of Medicine, January, 1903, III, 21-28. Preliminary Report of the Tuberculosis Commission of Maryland, December 14, 1903. Henry M. Thomas, M. D. The Anatomical Basis of the Argyll-Robertson Pupil. — American Journal of the Medical Sciences, December, 1903. J. II. J. Upiiam, M. D. Some of the Unusual Complications of Chronic X'opliritis. — Columbus Medical Journal, 1903. Water-borne Diseases. — Columbus Medical Journal, 1903. Louis W. Warfield, M. D. Acute Ulcerative Endocarditis Caused by Meningococcus (Weiclisclbaum). — University of Pennsylvania Medical Bulletin, July-August, 1903. A Mild Case of Acute Dysentery Yielding Bacillus dysentcriac (Shiga) in Large Numbers. — Bulletin of the Ayer Clinical Laboratory of the Pennsylvania Hospital, No. 1, October, 1903. A Plea for the Microscoj)ic Examination of the Blood in Die Continued and Remittent Fevers Common to our Southern States. — Atlanta Journal-Record of Medicine, November, 1903. Some Practical Points tauglit by the Discovery of B. dysenteriae in the Stools of Infants Suffering from Sum mer Diarrhoea. — Medical Record, Vol. 64, November 7, 1903. — The Report of a Series of Blood Cultures in Typhoid Fever. Andrew H. Whitridge, M. D. The Significance of Intermittent Albuminuria in Life Insurance Work, with a Report of a Case. — Medical Examiner and Practitioner,. November, 1903. J. Whitridge Williams, M. D. Obstetrics. A Text-Book for the Use of Students and Practitioners, 1903. — D. Appleton tC- Co., New York, pp. 845. Indications for and the Most Approved Methods of bringing about Premature Labor and Accouchement Force. — American Gynecology, Vol. Ill, 1903, pp. 13-31. • A Sketch of the History of Obstetrics in the United States up to 1860. — American Gynecology, 1903, pp. 366294, 340-366. Also Siehold-D ohm's Geschichte der Geburtshulfe. Vol. Ill, Tiibingen, 1903. J. L. Yates, M. D. Notes on the Experimental Production of Specific Cytolysins for the iVdrenal, Thyroid and Parathyroid Glands of Dogs. — University of Pennsylvania Medical Bulletins, July-Augiist, 1903. Dissecting Aneurysm of the Aorta, with a Report of a Case. — Wisconsin Medical Journal, December, 1903. Hugh H. Young, M. D. Conservative Perineal Prostatectomy. A Presentation of New Instruments and Technic. — Journal of the American Medical Association, October 24, 1903. n^otes on new books. Human Placentation; an Account of the Changes in the Uterine Mucosa and in the Attached Fetal Structures during Pregnancy. By J. Clakexce Webster, B. A.. M. D. (Edin.)^ P. R. C. P. E., F. R. S. E. With 233 illustrations. {Chicago: W. T. Keener and Co., 1001.) The author of this book deserves credit for the breadth of view with which he approaches his subject. It is, he says, his conviction that a satisfactory knowledge concerning the development of the human placenta can only be obtained by carrying on a careful phylogenitic study in connection with the direct investigation of the human uterus. In pursuance of this idea, he has not only examined the pregnant uterus in all its different stages of development, but has made a careful study of the same periods in a number of animals, e. g., the rat, pig, sheep and cow. He has, moreover, examined a number of complete abortions in the early weeks, besides investigating the normal mucosa of the nonpregnant uterus, without which he does not think the changes occurring in pregnancy can be rightly understood. These elaborate and painstaking researches cover a period of eleven years. Their results are clearly and concisely presented, and their value is greatly enhanced by the number of excellent illustrations, which were prepared largely by the author himself, and represent much time and pains. It is, perhaps, a matter for regret that they should be separate from the text, since this arrangement necessitates a constant shifting of attention; but, on the other hand, it has the advantage of enabling the reader to follow the plates with their accompanying descriptions consecutively, and March, 1904.] 101 thus gain a better general impression of the process of evolution they depict than woulii otherwise be possible. The American Textbook of Obstetrics. Edited by RiciiAitD C. Noiuus. M. D.. and Roiskkt L. Dickenson, M. D., Art Editor. Second edition, revised; with nearly 9t)0 illustrations. (PhiladeJphia and London: W. B. Saunders and Company, li)U,i.) The object of this volume, as stated in the preface, is, par excellence, that " of making clear those departments of obstetrics which are at once so important and usually so obscure to the medical student." As this is its avowed purpose, it is perhaps unreasonable to object that too much time and space are devoted to the pathologic side of labor and too little to the physiologic or normal side. Nevertheless, it is impossible to forbear a protest as to the unnecessary prominence given to the unusual and abnormal aspects of labor. Out of 1054 pages (exclusive of indices) contained in the two volumes only 173 are devoted to normal labor, including its mechanism, and it is impossible to avoid the reflection that a student educated along these lines might come to the first labor case, for which he is individually and primarily responsible, fully prepared to do a podalic version or a Caesarean section, but not altogether equal to the demands of a normal parturition. Apart from this defect, however, the book is prepared in the best possible manner. The choice of writers, originally carefully and prudently made, has been correspondingly carried out in the changes which death has made necessary in this, the second edition, and their respective subjects have received thorough treatment. Some of the chapters, those, for instance, on dystocia and the pathology of pregnancy, are written in a style unusually animated and interesting, while the constant introduction of illustrative cases, briefly cited, adds greatly to their readable qualities. Both volumes are liberally illustrated, and the illustrations have been executed on a carefully considered scheme which gives them additional value. The invariable selection, for instance, of the left half for sagittal sections, in preference to the practice hitherto employed, of using right or left indifferently, is a most desirable change. A little too much realism may possibly characterize some of them, but on the whole they are suitable and valuable, especially those in the section on dystocia arising from abnormalities of the fetus. The section on the new-born infant is unusually full and complete, as well as that on obstetric surgery. The manner in which the names of contributors are presented is not, in our opinion, sufficiently emphatic. They are appended, in parenthesis, to the titles of their respective sections in the table of contents, and the fact that the type used for the author's name is smaller than that used for the title of the subject must cause it (we speak from experience) to be sometimes overlooked. In spite of such defects, however, the work is well calculated to fill a valuable place in the literature of its subject, namely, that of presenting the views of a number of individuals, each especially well informed on the subject of which he treats, in such a manner as to form an harmonious whole. Modern Obstetrics; General and Operative. By W. A. Newmax DoRLAND, A.M., M. D. Second edition, revised and enlarged; with 201 illustrations. {Philadelphia and London: W. B. Saunders and Co., 1001.) This volume is characterized by an unusual and very pleasing display of common sense on the part of the writer. The section on normal labor, he fitly denominates " Physiologic Obstetrics," and lays strong emphasis on the fact that although in our present advanced stage of civilization parturition is too often accompanied by difficulties and dangers wholly unknown under simpler <onditions of life, it should never be forgotten that labor is essentially a purely physiologic process. The pathological side of the book, however, in no way suffers from the prominence given to the physiological. The utmost care has evidently been taken to collect the fullest possible information in regard to every abnormal condition and the essentials have been discreetly selected and concisely expressed. The chapter on puerperal sepsis is especially valuable, treating as it does of a condition only recently understood, and one in regard to which our knowledge is still undergoing evolution. Dr. Dorland's division of this subject into two classes — general and local — is sensible and useful, and his treatment of the different indirect manifestations accompanying each condition is well calculated to give them the prominence they deserve. In considering the question of diagnosis between puerperal sepsis and other pathologic conditions, Dr. Borland remarks acutely that " the general physician is so averse to admitting, even to himself, that he has a case of sepsis on his hands that he is very prone to argue himself into believing that his patient is suffering from an attack of some other intercurrent affection, as an enteric fever or an influenza." In our large cities, obstetrics is becoming yearly more and more the work of a specialist or semi-specialist, but elsewhere it is, and must remain, almost entirely in the hands of the general practitioner, and therefore the truth contained in the above remark, and the hints accompanying it for the guidance of the physician at large in this particular, are especially worthy of attention. All the most modern forms of treatment of puerperal sepsis are given very fully, and the reasons for or against each are stated with fairness. The section on diseases of the genito-urinary tract is also very complete, especially as regards puerperal eclampsia, which receives its due meed of consideration. It is perhaps to be regretted that the text is quite so much burdened with statistics and percentages, but this is a trivial defect. The number of illustrations is not large, but it is sufficient, and it is, on the whole, rather pleasurable than otherwise to find ourselves reading a text-book in which the process of thought is allowed opportunity for exercise without pictorial distraction, in contrast to the numbers of such volumes in which the succession of illustrations is so constant and so rapid that reflection and deduction are rarely allowed fair play. No book is without faults, and one who looks for them here will, of course, be able to find them, but the work is a valuable one and the literature of the subject is the better for it. Atlas and Epitome of Labor and Operative Obstetrics. By. Db. OsKAR ScHAEFFER, Privat Docent in Obstetrics and Gynecology in the University of Heidelburg. Authorized translation from the fifth revised German edition; with 14 lithographic plates in colors and 139 other illustrations. (Pliiladelphia: W. B. Saunders and Co., 1901.) This book, as its name indicates, is essentially a volume of illustrations, the text being really but complemental in function. To express the amount of information requisite for such a purpose in so condensed a form is not an easy matter; the writer, however, is evidently thoroughly familiar with the practical details of his subject and possesses a grasp of its fundamental principles sufficiently firm to permit of his attaining his object in a satisfactory manner. To say that condensation is carried a little loo far may be treason to the purpose of the book, nevertheless, a ]iassing doubt arises as to whether the information imparted would not in the end be better assimilated if it were somewhat loss condensed; or rather, to put the matter on a broader basis, whether other and fuller methods of instruction are not really Miose best adapted to the real end in view, namely, the acquisition of knowledge. This is not the time and place, however, to engage in the discussion of so fundamental a question, and the 102 [No. 1.56. number of editions through which the book has passed seem to afford sufficient guarantee that it meets with popular requirements. The general arrangement of the book is excellent, and its main divisions are well calculated to give the student a clear understanding of the broad outlines of the subject. The illustrations which form so integral a part of the work are well chosen for their purpose, and arranged to advantage. A word of favorable comment is due to the translator, whose work is not only accurate and clear, but. so far as the extreme condensation of style permits, is smooth and easy. A Text-Book of Pathology and Pathological Anatomy. By Dr. Hans Schmaus; translated from the sixth German edition by A. E. Thayer, M. D.; edited with additions by James EwiNG, M. D. 602 pages, with 351 engravings, including 35 colored plates. (Philadelphia and JS'ew York: Lea Bios. £ Co., 191)2.) As we already have several satisfactory elementary text-books of pathology written in the English language, it is difficult to appreciate the necessity of a translation of Schmaus's text-book. But granting the desirability of a translation, it is unfortunate that more care was not given to the English in which it is clothed. One is impressed throughout the book by the fact that he is reading a translation. There is a close adherence to German order and a studied avoidance of the English idiom, which seems often to obscure the meanings, and would leave a beginner in pathology quite in the dark. The general scope of the booli is well stated by the editor in the preface, in the following words: "The author has not attempted to compete with the more discursive works of his countrymen, but has endeavored to write a shorter, more compact but equally comprehensive book, embodying all the important principles and facts that should be brought before students of pathologj'. There is a notable absence in these pages of the argumentative style, the quotation of authorities and the pursuit of personal opinion that are prominent features in the larger works and likewise absent is the full discussion of many topics that properly belong to a work of jeference." As a work of that nature, the book is to be commended. It is short and compact, so much so that the chapters at times seem but a series of definitions. It is comprehensive, including sections on general pathological processes, on parasites and on special pathologj'. There is almost an entire absence of the quotation of authorities for statements, and yet in spite of lack of " pursuit of personal opinion " one finds positive statements on subjects not generally accepted as entirely settled. The illustrations are, as a rule, good, though some of the colored plates, those which are printed in but a single color, would seem to be a useless expense, for though bright colors may be pleasing to the eye and also an important factor in making a book sell, the true value of a colored plate is supposed to lie in the detail that may be brought out by contrasting colors. But all in all it may be said that, barring the English, the author and editor have well fulfilled their intention. It is toward their " intention," or the condensed, comprehensive, elementary text-book in the abstract, that further criticism is directed. It does not seem to the reviewer that pathology in all its phases is a subject that can be treated in a highly satisfactory manner in a book of 600 pages of large type well leaded, and with a goodly proportion of space taken up by illustrations. Subjects must necessarily be treated in a sketchy, inexact, unscientific manner, without evidence to warrant conclusions drawn, or discussion of mooted questions, a condition which must fail to meet the demands of the student of pathology, who is, as a rule, an individual of a more, rather than less, mature mind, which has outgrown the habit of swallowing unquestioned what is placed before it. Nor does it seem just to the student to give him but one side of a question; for example, in speaking of cirrhosis of the liver, to tell him only, that " the essential element is the formation of granulation tissue between the lobes and its conversion into contracting cicatricial tissue with consequent atrophy of the hepatic cells" when "the other half-Rome" believes the hepatic atrophy primary. Even if the student were not able to decide for himself between the two views, statement of both would leave him with an open mind. To fall from the abstract to another concrete example; how firm a basis for the understanding of the etiology of dysentery is given the student, when to the author's statement that " In tropical cases the presence of amoebae is characteristic and it is questionable whether our dysentery of hot weather is identical with the tropical type," is appended the editor's parenthetical note, " Both are probably referable to a specific bacillus — Bac. of Shiga."? If author and editor are in doubt, is not the reader entitled to a plain statement of pathological findings lest he be in worse darkness than simple ignorance? Briefly the ideal text-book seems, to the reviewer, one in which facts and their intepretation are clearly separated — and labelled — in which authority for statements is given, and in which important questions shall be discussed and the opinion of the author given in a critical review of existing opinions. Clinical Pathology of the Blood. By James Ewing, A. M., M. D., Professor of Pathologj-, Cornell University Medical College, New York City. Illustrated with 43 engravings, and 18 colored plates drawn by the author. Second edition, revised and enlarged, (yeic York and Philadelphia: Lea Brothers d Co., 1903.) In discussing this book, it should be borne in mind that its subject is " clinical pathology." It is the work of a pathologist, not of a clinician, and all the matter contained therein which concerns the clinical side of the question is quoted from literature. But the pathologj' of blood diseases is, perhaps, more than that of any other one branch of medicine, a subject of speculation and theory, with scarcelj' a single chapter (even the origin of red blood cells) resting on a basis of generally accepted ideas. Hence we may expect each edition to differ markedly from the preceding. This book is of very great assistance to those who are following current literature. It is, in fact, chiefly an epitome of literature, most of which deals with parts of the subject in which the author claims no authority or experience; hence his conclusions, based not on his own work but on the study of literature, are often inconclusive, the words " possibly " and " probably " being often repeated. We regard it unfortunate that a set of new plates was not prepared for this edition. The representations of leucocytes and malarial parasites are surely inadequate. Had some of the English writers seen these plates earlier, they would never have wasted their term " chromocytes " on red blood cells. The author's English is not above reproach. No one can dispute his right to coin a new word if he wishes to do so, but he should be careful not to take too many liberties with old terms. The word " englobe " (page 176 et alt.) is a case in point. The use of " eflagellation (page 431), "spore" and " sporulation " (page 435 et alt.) applied to the malarial parasite, and " endothelia " (page 178), referring to cells, is, we think, open to criticism, although it may be a matter of taste. But surely the term " crioscopy " (xu/ot ram instead of xpfos- cold) will please college fraternity men more than teachers, and the description of the same will be appreciated by the physical chemist who does not consider the " laws " governing cryoscopy as absolutely " invariable," nor " elements " a proper term for the substances in solution, and Donng's name is repeatedly misspelled. In the chapter on blood plates (which, by the way, deserves mention in the index), page 18G, the very important method of IJeetjen deserves more mention, and, even though his opinions March, 1904.] 103 are not accepted, the very positive opinions expressed must offend some of the best authorities on the subject. The change mentioned on page 239 in the bulli of blood in leuiviemia may occur in some cases, but the reverse also occurs. The chapter on malaria is not at all satisfactory. We wonder if it has the same effect on others living in regions where malaria is common and who have plenty of opportunity to study fresh blood specimens in preference to using " improvised" (page 435) polychrome methylene blue; yet if the author can really get the details he pictures in the organism he is to be congratulated; it is the plates which to us seem " improvised." Considering the subject of the book, here is just the place one would expect to find the mosquito side of the subject well discussed, yet it is much neglected. For a discussion of recent theories on the many problems of blood, this book is interesting, but beyond this little can be said in its praise. Functional Diagnosis of Kidney Disease, with Especial Reference to Renal Surgery. By Dr. Leopold Casper and Dr. Paul Friederich Riciiter. (Philadelphia: P. Blakiston's Son d Co., 1903.) This little book appeared at a very opportune time, for cryoscopy was fast becoming the popular fad, and these two observers are particularly able to estimate its value. All the ordinary methods of determining the functioning power of each kidney, the vital problem for the surgeon, are discussed. The authors conclude that the only method of value is to examine the urine secreted simultaneously by each kidney, and to do this catheterization of at least one ureter is necessary. These urines are examined as regards both the molecular concentration, determined by the freezing method, and the excretion of sugar after the injection of phloridzen. The cases cited are very instructive. The Practical Medicine Series of Year Books; under the General Editorial Charge of Gustavus P. Head, M. D. Vol. VI. General Medicine. Edited by Frank Billings, M. D., and J. H. SALisBtjRT, M. D. (Chicago: The Year Book Puhlishers, J/O Dearborn Street, May, 1903.) This is a good, clear, satisfactory resume of the literature chiefly on diseases of the digestive organs, published during the year 1902. The many reviews are suflSciently long and are well digested. A Guide to the Practical Examination of Urine. For the Use of Physicians and Students. By James Tyson, M. D., Pro _ fessor of Medicine, University of Pennsylvania. Tenth edi P tion, revised and corrected. (Philadelphia: P. Blakiston's Son <& Co., 1902.) This excellent work has now reached its tenth edition. It is small, compact and contains just what and only what a physician needs to guide him in ordinary urine analysis. That, however, it is a good book for students we are not quite so sure. At least once in his education a student should read and practice a good deal of urine analysis which may not now be practical, but a knowledge of which is necessary if he would understand much of current work, which we hope may be practical in the near future. Clinical Examination of the Urine and Urinary Diagnosis. A Clinical Guide for the Use of Practitioners and Students of Medicine and Surgery. By J. Bergen Ogden, M. D., Assistant in Clinical Pathology, Boston City Hospital. Illustrated. Second edition, thoroughly revised. (Philadelphia, New York, London: "II'. B. t<aiindcrs <£ Co., 1903.) This is a splendid text-book, and much to be recommended. The chapters on qualitative examination are especially good; as regards the quantitative work, we very much doubt if it fulfills the author's hope that the student and practitioner who have not had special training in urinary analysis may by its use obtain accurate results. Methods of quantitative analysis cannot be thus condensed in half a page, and a student witliout previous training would be forced to use a book like Neubauer and Vogel, which, although written for those with previous training, discusses minutely each step of a process which this author merely states. For instance, we can imagine the perplexity of one who tries for the first time to determine total nitrogen. (The indexing of this chapter is peculiar.) On the other hand the hypobromite methods of urea determination are carefully described although we fear their value is doubtful, and the Schijndorff method, in our opinion, the best, although the hardest, is omitted. It may seem a small point, but experience has taught us its value, and that is to avoid the use of the term " polariscope " for the instrument used in the quantitative estimation of sugar (page 162). As a physical instrument the polariscope has a scale which reads degrees, and tubes of 10 cm. length or some multiple of this, and such an instrument is seldom used in the clinic. That the instrument may read per cent of glucose, either the scale or the length of tube is modified, hence the term " saccharometer " is safer. Of course, if the observer has had no experience with the polariscope of the physical laboratory this point will not trouble him, but if his preliminary education has been thorough the instrument of the clinical laboratory will bother him, for he will try to use the specific rotation of glucose as the coefficient of the reading. The chapter on ^ oxybutyric acid is, we think, very insufficient. This body is of considerable clinical interest and approximate quantitative determinations are within reach of one with a polariscope without undertaking the terrible procedure the author describes, which is the only one for isolation. The difference, rotation of a urine before and after fermentation, and, better still, the difference between the amount of sugar calculated with the polariscope and careful titration with Fehling's solutions will, due allowance being made for other optically active bodies, give an idea of the amount of the acid present. The chapter on urinary sediments is excellent. We, however, also have had " exceptional opportunities for the study of cells from the ureter, but confess our inability to recognize from an epithelial cell its source in the urinary tract (see page 246). The part on Diagnosis almost takes one's breath away. It occupies over one hundred pages. The classification of forms of nephritis may be pathological, but clinically it is too fine, and the aid the urine gives us in differentiating them could have been put in ten or fewer pages. Recognizing, however, that it is not safe to criticise an excess of the knowledge of another over our own, we confess with humility that we have not yet attained unto the skill in the urinary diagnosis which the author of this chapter must possess. While we believe that in the chapters on chemistry the author has condensed methods to such an extent that it is difficult to follow their description, and while we think that the chapters on diagnosis are much too minute, we believe the hook to be the best in English, and recommend it with pleasure. Tuberculosis of the Female Genitalia and Peritoneum. By John B. MuRPiiT, M. D. (Chicago: 1903.) This is an elaborate presidential address delivered before the Chicago Surgical Society in October, 1903. In the first portion of the monograph, Murphy deals exhaustively with the avenues through which the organisms gain entrance to the pelvic structures. The literature on the subject is carefully reviewed. Tuberculosis of the vulva and vagina is interestingly discussed from the clinical and pathological standpoints. The chapter on tuberculosis of the cervix is full and most instructive. Consid 104 [No. I.jO. erable space is allotted to tuberculosis of the body of the uterus, and Murphy sums up by saying, " The diagnosis in most cases must be cleared up by an examination of the uterine scrapings." We thoroughly agree with him in advocating complete removal of the uterus. He prefers the vaginal route, since by this avenue there is less danger of contaminating the peritoneum. Murphy thinks that the portion of the tube first involved is that within about half an inch of the uterus and that the lodgment at this point is due to extreme narrowing of the tube lumen. Prom several experiments Murphy found that tuberculous tissue introduced into the abdomen, produce lesions in the lower half of the abdomen, and in the few months intervening between the inoculation and the animal's death that neither the mucosa of the tubes nor that of the uterus showed any evidence of tuberculous involvement. Excellent details of the clinical phenomena of cases of tuberculosis of the tubes are given and a very careful and conservative treatment recommended. Tuberculosis of the ovary is briefly and yet satisfactorily discussed. Tuberculosis of the peritoneum is accorded a liberal consideration. The various modes of infection are outlined, especial emphasis being laid on the role played by tuberculous Fallopian tubes. These expell from time to time caseous material into the pelvis and occasion exacerbations of the tubercular peritonitis. Murphy thinks that primary tuberculosis of the appendix is frequently responsible for subsequent tubercular peritonitis. Peritonitides of this character are grouped as follows: (1) The disseminated exudative and non-confluent serous variety. (2) The nodular ulcerative or perforative variety. (3) The adhesive fibro-plastic cystic circumscribed abscess partition or obliterative variety. (4) Tubercular peritonitis with mixed infection. Under treatment. Murphy says, " The surgical or medical treatment of tuberculosis of the peritoneum involves four propositions: (1) To remove or shut off the source of supply to the peritoneum of new tubercular debris. (2) To remove the products of the infective process from the peritoneum. (3) To increase the tissue proliferation for the encapsulation of the foci already present. (4) To avoid mixed infection. After reviewing the results of others. Murphy shows his faith in operative interference by the following: "The value of operative intervention can no longer be said to be in question." In the disseminated serous variety mere abdominal section is of little value. For success it is necessary to remove the original focus, which is likely to be a Fallopian tube, the appendix, or possibly a mesenteric gland. It is in this class of cases that the most gratifying results have been noted. In the nodular ulcerative and perforative variety, and also in the adhesive form, the sphere of surgical interference is limited and is on the i^hole unpromising. Murphy lays especial stress on the dangers of producing ftecal fistula in these cases as the intestines are often intimately blended with the abdominal wall and are readily cut into as the peritoneum is being opened. Or, again, when gentle traction is made on adherent intestinal loops, they are liable to rupture. In dealing with the mixed infection variety where circumscribed abscesses exist, or where general suppuration is present, he advises evacuation followed by closure without drainage. Drainage was abandoned on account of the uncontrollable and permanent purulent discharge that followed where the open treatment had been employed. This contribution of Murphy's has entailed much labor, is of Interest to the pathologist and contains many practical hints for the surgeon and general practitioner. It is worthy of a thorough perusal by every medical man. The Surgical Diseases of the Genito-Urinary Organs. By E. L. Keyes, a. M., M. D., LL. D., and E. L. Keyes, Jii., A. B., M. D., Ph. D. With one hundred and seventy-four illustrations In the text and ten plates, eight of which are colored. (New York and London: D. Appleton and Company, 1003.) This volume of 800 pages is a second revision of Van Buren and Keyes' Genito-Urinary Diseases with Syphilis, which was written some thirty-five years ago. Since the first appearance of this book the tendency has been to make it less venereal and more genitourinary, hence the change in title. In the present edition syphilis has been entirely eliminated, as it is a genital disease only in its manner of attack. Gonorrhoea, however, although a venereal disease, has received the extended consideration which its overshadowing importance demands. It is so intimately associated with the inflammatory conditions of the urethra and so far-reaching in its effects that it merits the space and careful attention given it. We hesitate to criticise the opinions of the authors based, aa they are, on such wide and extensive personal experience. But on such important questions as the treatment of prostatic hypertrophy, ureteral catheterization and the use of the cystoscope we feel that their attitude is too conservative. In the treatment of prostatic hypertrophy in the class of cases suitable for a cautery operation we doubt very much if any who have had a considerable experience with the Bottini operation would admit the advantage claimed by the authors for Chetwood's operation. We are very much surprised to find the indications for cystoscopy summarized as follows: (1) In tuberculosis of the bladder to decide a question of operation; (2) ureteral catheterization; (3) tumor, and (4) in obscure cases, for diagnosis. Just what is included under the last heading, obscure cases, will depend largely on the individual operator's interpretation of the term obscure, but in no way can it be interpreted to apply to cases of hypertrophy of the prostate. To quote, " Many surgeons constantly employ the cystoscope for the diagnosis of hypertrophy of the prostate, stone in the bladder and cystitis. I do not consider it a proper routine method of diagnosis for any of these conditions." In our experience there is no method of examination so simple and giving data at once so accurate and indispensable in cases of hypertrophy of the prostate as cystoscopy. Indeed, we do not understand how a surgeon can intelligently perform any of the cautery operations without first making a careful cystoscopic examination of the prostatic orifice. And the same holds good for any operative interference with the prostate. We are sorry the silk filiform bougies with steel followers and the Kollmann dilators have not found greater favor with the authors. We believe they deserve greater consideration than they have received. But these are doubtless minor points about which there is at present a great variety of individual opinion. And they do not detract from a text-book which is easily the best we have in this branch of surgery. It is also the best book on the subject to put into the hands of students. Diseases and Injuries of the Eyes, with their Medical and Surgical Treatment. By Geouge Lawso.v, F. R. C. S. Eng., Surgeon Oculist-in-ordinary to her Majesty the late Queen Victoria; Consulting Surgeon to the Royal London Ophthalmic Hospital and to the Middlesex Hospital. Sixth Edition, with 249 illustrations. Revised and in great measure rewritten by Aitxoi.i) Lawson', F. R. C. S. Eng.. Assistant Surgeon to the Royal London Ophthalmic Hospital; Consulting Surgeon to the Paddington Green Children's Hospital, etc. (London: .Smith. Elder rf Co., 15 Waterloo Place, 1903.) Eighteen years have elapsed since the last previous edition of this work was issued, and probably the majority of ophthalmologists practicing to-day are entirely unfamiliar with it, but those who do recall that it was a standard manual in its day, or who March. 1904.1 105 have been in the habit of referring to it even later, regard it very highly because of the excellence of its practical advice on the treatment of the various eye affections. The son has done well to retain this distinctive feature. A better illustration of the advances that have taken place in ophthalmology in the last two decades could scarcely be found than is afforded in a comparison of the fifth and sixth editions of this work. The volume of material has been multiplied three or four times and still the enlarged edition contains the concise, condensed form of the smaller. The increase consists of new subjects introduced, numerous new illustrations, and a new and broader treatment of old topics. We can very heartily commend the book to all persons interested in a study of eye diseases, especially to the specialist as a reference book, on account of the broad and complete consideration of pathology and treatment. One feature that particularly pleases us is the attention given to errors of refraction. It is refreshing to see an English text-book treat this subject so well and we hope our European confreres may soon be following the good example. There are a few points in the chapter on hypermetropia that might be criticised, and there are evidences that the Americans are still leading in the amount of care and attention given to the correction of small errors, especially of an astigmatic nature. However, we need not push the criticism too hard, since we have evidence of a marked advance and the future is hopeful. Any allusion to the differences between American and foreign practice reminds us that the book contains very slight reference to American work, almost ignoring it, in fact, and, by virtue of that fact, we miss some of the seemingly really important advances in ophthalmology. Neither do we find any mention of the newer remedies, such as protargol, argyrol, etc. In the chapter on Diseases of the Lachrymal Apparatus no more attention is paid to the work of Bowman, a fellow-countryman of the author, or of Theobald than if they had never existed. The book is, throughout, rather the expression of the author's personality, and we like it for that fact, but the epoch-making discoveries I refer to should not be ruthlessly cast aside. We have shown elsewhere that the opposition to large probes is without any reasonable support, and we wonder at the persistent refusal even to try them. Beyond these few slight adverse criticisms, we wish to record our endorsement of Lawson's work. It is a very valuable addition to our working library and a book that we shall certainly appeal to frequently. The publisher's part has been very well done and the paper upon which it is printed is particularly deserving of remark. H. O. R. A System of Physiologic Therapeutics. Edited by S. Solis Cohen, A. M., M. D. Vol. X. Pneumotherapy, including Aerotherapy and Inhalation Methods and Therapy. By Dr. Paul Louis Tissier, Chief-of-Clinic in the Faculty of Medicine of the University of Paris. Illustrated. (Philadelphia: P. Blakiston's Son £ Co.. 1903.) The tenth volume of this system deals with the subject of " Pneumotherapy, including Aerotherapy and Inhalation Methods and Therapy." In general the plan of this book agrees with that of the previous ones of the system, except that in the second part — that part dealing with inhalation methods — the application of various drugs by this method has been discussed at considerable length. While this constitutes a departure from the strict letter of the title of the system, nevertheless the value of the book has been materially increased, thereby, this chapter being one of the best of the book. A large part of the book is taken up with a discussion of physiological questions. While much of this discussion is very interesting, the relation of some of it to the subject in hand is not very apparent, and not infrequently some of the best work on the topics discussed has been overlooked. Much space has been taken up with a description of the various kinds of complicated apparatus used for the application of condensed and rarefied air and combination of the two. On the other hand, the discussion of the therapeutic uses to which this apparatus is to be put occupies relatively a very small space and the conclusions are not always very clear. Some of the procedures are said to be beneficial for a remarkable number of conditions, the condensed air bath, for instance, being valuable in the treatment of many disorders — from heart-disease to toothache. As a multitude of remedies advised in a given disease raises skepticism in the student's mind as to the value of any, so a very extensive list of diseases in which a given procedure is said to be beneficial might tend to cause some undiscriminating readers to doubt its value in any. Some curious statements are made in places as to the nature of the diseases treated, not always in accord with generally accepted views. For instance, the author says: " I consider emphysema as an attenuated, benign form of pulmonary tuberculosis, fibrous in its development from the beginning." On the whole we cannot see that the author has made a very effectual plea for the more general employment of the procedures treated of in this book. A book one-fourth of the size could have contained all the matter of any importance which has a bearing on the subject treated, and, by careful editing and presenting the opinions and experiences of the author rather than those of a host of observers, it might have had much influence in bringing this somewhat neglected branch of therapeutics into greater repute among the medical profession. Manual of Medicine. By Thomas Kibkpatbick Monko, M. A., M. D., Professor of Medicine in St. Mungo's College. (Philadelphia and Neiv York: W. B. Saunders d Co.) The author makes no claim for originality in this text-book of medicine, except in the matter of size, stating that some of the English treatises are too small, others are too large for the average student even to attempt to master. This seems rather an inadequate reason, if one were needed, for the appearance of this book — as though the study of medicine were a matter of linear measure. A perusal of the book convinces one, however, that the average student, like the student of the multiplication table or catechism, will still have much to learn, even after he has mastered all of its pages. Possibly there is need for such a book. If so, the author has accomplished his purpose very well. Very few errors are apparent, and the author has chosen his material wisely, omitting a discussion of all debatable points and of newer work not definitely confirmed. This may make the book of more value for those students who desire bare facts, but certainly offers very little attraction to those who look for stimulation to thinking. The book is very comprehensive, treating not only of all conditions usually included in the text-books on medicine, but containing in addition a section on diseases of the skin, and also considering briefly those subjects usually treated of in text-books on physical diagnosis and clinical miscroscopy. It cannot be considered very satisfactory, however, to treat of the physical diagnosis of the chest (heart and lungs) in about thirty pages, and to condense a discussion on the urine, including methods of examination, into about thirteen pages. It is to be feared that such conciseness and omission of detail may induce in the student a similar attitude of mind in the application of his knowledge to practical purposes. The directions of the author also do not always guard against this possibility. For instance, the statement is made that in the practical study of the heart, as a rule, the outline of the relative cardiac dulness is not of much value and only the outline of absolute cardiac dulness need be carefully studied. 106 [No. 156. In order to reduce the size of the book the publishers have cut down the margins of the pages, and in other respects the book is not attractive. To those students desiring at a moderate price a small book covering a great field this book will probably appeal. A Manual of the Practice of Medicine, prepared especially for Students. By A. A. Stevens, A. M., M. D., Professor of Pathology, Woman's Medical College of Pennsylvania. Sixth revised edition, enlarged. Illustrated. (PhiladelpJiia, New York and London: W. B. Saunders <£ Co., 1903.) Most readers are familiar with the former editions of this small book. The good features of the former editions have been retained In the present sixth one and a considerable number of minor changes have been made to bring this book up to date. The selection of material has been made with care, and the work of editing has been well done. The paragraphs on treatment are very concise, but the directions are quite clear and in general the treatment advised has a rational basis. The make-up of the book is attractive, the typographical work being excellent, and the flexible binding used on former editions being retained. This book has in the past been largely used by students and practitioners for purposes of review and in preparing for examinations, ana it is probable that this will continue to be the main use made of it. The danger, however, that students will use such books as text-books and in place of more extensive reading is great and should be guarded against by teachers. When properly employed, however, books of this kind are of considerable value, and this is the most valuable one of its class that we have seen. Atlas of the External Diseases of the Eye. By Prof. Dk. O. Haab, of Ziirich. Second edition, thoroughly revised. Edited, with additions, by G. E. De Schweinitz, A. M., M. D., Professor of Ophthalmology in the University of Pennsylvania. With 98 colored lithographic illustrations on 48 plates, and 232 pages of text. (Philadelphia, New York, London: W. B. Saunders it Co., 1003.) It seems surprising that we have had for so many years works containing accurate pictures of morbid conditions of the inner structures of the eye without any accompanying illustrations of the external diseases of this organ. It is true that the external diseases of the eye, especially inflammations of the cornea, do not lend themselves easily to illustration, but there are many infections which can be portrayed with considerable suggestiveness and the pictures of these conditions will be found a substantial help by all who attempt to do any work in the field of ophthalmology. Haab's contribution is the best of its kind and the appearance of a second edition is an evidence not only of the need for such a work but that the earlier edition was weighed and found to contain material of high grade. For many years Zurich has been strong in ophthalmology and hardly a year passes without some fresh and valuable token that the science still flourishes there. Most of the first half of the work is taken up with practical descriptions of the external diseases of the eye and their treatment and of the usual methods of examination, matter to be found In all text-books on the eye. The plates are forty in number and they illustrate every disease which can be recognized with one's naked eye. The paintings are all from nature and accompanying each of them there is a history of the patient. Occasionally we find a condition somewhat idealized, but the painting is none the less suggestive and with very few exceptions the collection contains truthful reproductions of old and familiar scenes, and we have no hesitation in advising its purchase and in predicting for it a growing popularity. BOOKS RECEIVED. Mammalian Anatomy, with Special Reference to the Cat. By Alvin Davison, Ph. D. With over one hundred illustrations made by W. H. Reese, A. M., from the author's dissections. 1903. 8vo. 250 pages. P. Blakiston's Son & Company, Philadelphia. A Treatise on Orthopedic Surgery. By Royal Whitman, M. D. Second edition, revised and enlarged. Illustrated with five hundred and seven engravings. 1903. 8vo. 848 pages. Lea Brothers & Company., Philadelphia and New York. Functional Diagnosis of Kidney Disease. With Especial Reference to Renal Surgery Clinical Experimental Investigations. By Dr. Leopold Casper and Dr. Paul Friederich Richter. Translated by Dr. Robert C. Bryan and Dr. Henry L. Sanford. 1903. 12mo. 233 pages. P. Blakiston's Son & Company, Philadelphia. Clinical Treatises on the Pathology and Therapy of Disorders of Metabolism and Nutrition. By Prof. Carl von Noorden. Authorized American edition translated under the direction of Boardman Reed, M. D. Part IV. The Acid Autointoxication. By Prof. Dr. Carl von Noorden and Dr. Mohr. 1903. Svo. 80 pages. E. B. Treat & Company, New York. Infectious Diseases; Their Etiology, Diagnosis, and Treatment. By G. H. Roger. Translated by M. S. Gabriel. Illustrated with forty-three engravings. 1903. Svo. 874 pages. Lea Brothers & Company, New York and Philadelphia. Clinical Talks on Minor Surgery. By James G. Mumford, M. D. 1903. 16mo. 115 pages. The Old Corner Book Store, Boston. Elements of Surgical Diagnosis. By A. Pearce Gould, M. S. Lond., F. R. C. S. Eng. Third edition, revised and enlarged. 1903. IGmo. 607 pages. W. T. Keener & Company, Chicago. The Medical Epitome Series Normal Histology. A Manual for Students and Practitioners. By John R. Wathen, A. B., M. D. Series edited by V. C. Pedersen, A. M., M. D. Illustrated with one hundred and fourteen engravings. 1903. 12mo. 229 pages. Lea Brothers & Company, Philadelphia and New York. The Right to Life of the Unlorn Child. A controversy between Professor Hector Treul, M. D., Reverend R. van Oppenraay, D. D., S. J., Professor Th. M. Vlaming, M. D., 1903. 12mo. 125 pages. Joseph F. Wagner, New York. A Non-Surgical Treatise on Diseases of the Prostate Gland and Adnexa. By George Whitfield Overall, A. B., M. D. 1903. 12mo. 207 pages. Rowe Publishing Company, Chicago. Philadelphia Hospital Reports. Volume 5, 1902. Edited by Herman B. Allyn. M. D. 1903. Svo. 178 pages. Philadelphia. Transactions of the American Surgical Association. Volume the twenty-first. Edited by Richard H. Harte, M. D. 1903 Svo. 630 pages. Printed for the Association, Philadelphia. Medical and Surgical Reports of the Boston City Hospital. Fourteenth Series. Edited by Herbert L. Burrell, M. D.. W. T. Councilman, M. D., and Charles F. Withington, M. D. 1903. Svo. 178 pages. Published by the Trustees, Boston. A Text-Book of Practical Gynecology. For Practitioners and Students. By D. Tod Gilliam, M. D. Illustrated with 350 engravings, a colored frontispiece, and 7 full-page half-tone plates. 1903. Svo. 634 pages. P. A. Davis Company, Philadelphia. Ar.VRCH, 1904.] 107 The Lymphatics. General Anatomy of the Lymphatics, by G. Delaniere. Special Study of the Lymphatics in Differont Parts of the Body, l)y P. Poirier and B. Cuneo. Authorized English edition, translated and edited by Cecil H. Leaf. With 117 illustrations and diagrams. 1904. Svo. 301 pages. W. T. Keener & Company, Chicago. Atlas of the External Diseases of the Eye. Including a Brief Treatise on the Pathologj' and Treatment. By Prof. Dr. 0. Haab, of Zurich. Authorized translation from the German. Second edition, revised. Edited by G. E. de Schweinitz, A. M., M. D. With 98 colored lithographic illustrations on 48 plates. 1903. 12mo. 232 pages. W. B. Saunders & Company, Philadelphia, New York, London. The Anatomy of the Human Peritoneum and Abdominal Cavity. Considered from the Standpoint of Development and Comparative Anatomy. By George S. Huntington, M. A., M. D. Illustrated with 300 full-page plates containing 582 figures, many in colors. 1903. 4to. 292 pages. Lea Brothers & Company, Philadelphia and New York. Blood-Pressure in Stcrgery. An Experimental and Clinical Research. The Cartwright Prize Essay for 1903. By George W. Crile, A. M., M. D. 1903. Svo. 422 pages. J. B. Lippincott Company, Philadelphia and London. A Pocket Book of Clinical Methods. By Charles H. Melland, M. D., Lond., M. R. C. P. 1903. 16mo. 88 pages. John Wright & Company, Bristol. Simpkin, Marshall. Hamilton, Kent & Company, Ltd., London. The Practical Care of the Baby. By Theron Wendell Kilmer, M. D. With sixty-eight illustrations. 1903. 12mo. 158 pages. F. A. Davis Company, Philadelphia. The Self-Cure of Consumption Without Medicine. With a Chapter on the Prevention of Consumption and Other Diseases. By Charles H. Stanley Davis, M. D., Ph. D. 1904. 12mo. 176 pages. E. B. Treat & Company, New York. The Blues (Splanchnic Neurasthenia). Causes and Cure. By Albert Abrams, A.M., M. D. (Heidelberg), F. R. M. S. Illustrated. 1904. Svo. 140 pages. E. B. Treat & Company, New York. Third Biennial Report of the Board of Control of State Institutions of loica. For the biennial period ending June 30, 1903. Svo. 1085 pages. Des Moines. Practical Medicine Series of Year Books. Comprising Ten Volumes on the Year's Progress in Medicine and Surgery. Issued monthly, under the general editorial charge of Gustavus P Head, M. D. Volume III. The Eye, Ear, Nose and Throat. Edited by Casey A. Wood, C. M., M. D.. D. C. C. Albert H. An drews, M. D.. Gustavus P. Head, M. D. December, 1903. 12mo. 332 pages. The Year Book Publishers, Chicago. Diseases of the Nervous System. A Text-Book for Students and Practitioners of Medicine. By H. Oppenheim, M. D. Translated and edited by Edward A. Mayer, A. M., M. D. Second American edition, revised and enlarged. With three hundred and forty-three illustrations. 1904. 8vo. 953 pages. J. B Lippincott Company, Philadelphia and London. The Complete Medical Pocket-Formulary and Physician's VadeMecum. Containing upwards of 2500 prescriptions, collected from the practice of physicians and surgeons of experience, American and foreign, arranged for ready reference under an alphabetical list of diseases. By J. C. Wilson, A. M., M. D. Third revised edition. 1903. Svo. 268 pages. J. B. Lippincott Company. International Clinics. A Quarterly of Illustrated Clinical Lectures and Especially Prepared Original Articles on Treatment, Medicine, Surgery, Neurology, Pediatrics, Obstetrics, Gynecology, Orthopedics, Pathology, Dermatology, Ophthalmology, Otolo.gy, Rhinology, Laryngology, Hygiene, and Other Topics of Interest to Students and Practitioners. Edited by A. O. J. Kelly, M.D. Volume IV. Thirteenth Series, 1904. Svo. 321 pages. J. B. Lippincott Company, Philadelphia. Clinical Pathology of the Blood. A Treatise on the General Principles and Special Applications of Hematology. By James Ewing, A. M., M. D. Second edition, revised and enlarged. Illustrated with forty-three engravings, and eighteen colored plates drawn by the author. 1903. Svo. 495 pages. Lea Brothers & Company, New York and Philadelphia. Diseases of the Eye. By L. Webster Fox, A. M., M. D. With five colored plates and two hundred and ninety-six illustrations in the text. 1904. Svo. 584 pages. D. Appleton & Company, New York and London. Social Diseases and Marriage. Social Prophylaxis. By Prince A. Morrow, A. M., M. D. 1904. Svo. 390 pages. Lea Brothers & Company, New York and Philadelphia. The Treatment of Fractures. With Notes upon a Few Common Dislocations. By Charles Locke Scudder, M. D. Fourth edition, thoroughly revised, with 688 illustrations. 1903. Svo. 534 pages. W. B. Saunders & Company, Philadelphia, New York, London. Lectures on Diseases of the Nervous System. Second Series. Subjective Sensations of Sight and Sound, Abiotrophy, and Other Lectures. By Sir William R. Gowers, M. D., F. R. C. P., F. R. S. 1904. Svo. 250 pages. P. Blackiston's Son and Company, Philadelphia. Biographic Clinics. Volume II. The Origin of the III Health of George Eliot, George Henry Lewes, Wagner, Parkman, Jane Welch Carlyle, Spencer, Whittier, Margaret Fuller Ossoli, and Nietzsche. By George M. Gould, M. D. 1904. 12mo. 392 pages. P. Blakiston's Son & Company, Philadelphia. The Practical Medicine Series of Year Books. Comprising Ten Volumes on the Year's Progress in Medicine and Surgery. Issued monthly, under the general editorial charge of Gustavus P. Head, M. D. Volume II. General Surgery. Edited by John B. Murphy, M. D. November, 1903. 12mo. 556 pages. The Year Book Publishers, Chicago. The Physiognomy of Mental Diseases and Degeneracy. By James Shaw. 1903. 12mo. S3 pages. John Wright & Company, Bristol. Simpkon, Marshall, Hamilton, Kent & Co., Ltd., London. A Text-Book of Legal Medicine and Toxicology. Edited by Frederick Peterson, M. D., and Walter S. Haines, M. D. Volume II. 1904. Svo. 825 pages. W. B. Saunders & Company, Philadelphia, New York, London. A Handbook of Ophthalmic Science and Practice. By Henry E. Juler, F. R. C. S. With Illustrations. Third edition, revised and enlarged. 1904. Svo. 733 pages. Lea Brothers & Company, Philadelphia. Infant-Feeding in its Relation to Health and Disease. By Louis Fischer, M. D. 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D., . . . .122 Complications Arising from Freeing the Ureters in the More Radical Operations for Carcinoma Cervicis Uteri, with Special Reference PAGE to Post-Operative Ureteral Necrosis. By John A. Sampson, M. D., 123 The Silver Bolt as a Means of Fixing Ununited Fractures of Certain Long Bones. By Stephen H. Watts, M. D., 135 Exhibition of Four Appendices Vermiformes Showing Unusual Pathological Conditions (from the Service of Dr. Kelly). By 0. F. BuRNAM, M. D. 136 Notes on New Books, 141 VACCINE AND VACCINATION.^ By George Dock, M. D., Ann Arbor, Mich. I intend to limit myself to a narrow part of the subject, and especially to the practical as distinguished from the scientific or theoretic side. When we think of vaccination we must remember that if we are not wholly ignorant of the specific germs, we are still unable to make them serve as an index to the purity or qualitjof material, and we should also remember that we have no methods of dosage, such as make the application of diphtheria antitoxin and tuberculin fairly controllable. We recognize the effects of vaccine by the local results or by the immunity produced. For the former we have a more or less characteristic set of changes, ending in a peculiar and permanent scar. The immunity is not so easy to recognize in single cases, because we cannot tell how effective natural immunity might have been, and we rarely have more than the crudest notion of the degree of danger in a given case. When variolation was practiced the conditions were somewhat different, but with only casual exposure we are obliged to fall back, as proofs, on experiences with large numbers of people, where various de ' Read before the Johns Hopkins Hospital Medical Society, January 4, 1904. grees of thoroughness of vaccination and various degrees of danger of infection can be considered as neutralized by force of niunbers. The Material Used. In the earliest days of vaccination the so-called lymph from vesicles on human beings was used. In Jenner's memorable experiment on James Phipps he used the virus from a cowpox vesicle on the hand of a dairy-maid, but later he inoculated from a vesicle on the nipple of a cow. After a few transfers this stock died out, as the former had done, but soon after the publication of Jenner's first work several new strains were obtained. Many of these were kept on by inoculating from arm to arm, or indirectly, and so were spread all over the world. It is interesting to remember that in America the virus was introduced by Waterhouse in Boston and Hosack in New York, the Southern States being early supplied by Waterhouse through the interest of President Jefferson. Some of the early vaccine was kept up for a long time. Drake tells us that he could see no change in course or phenomena in that used in the West in the forty-four years following its introduction in 1803. According to Kaposi, the 110 [No. 157. material in the Vienna Vaccine Institute was descended from some sent by Jenner to De Carro in 1803, and retained its efficiency in the late SO's. But it did not always keep so well. L. PfeiSer mentions some that he saw a few years ago, of the same origin, so degenerated that it gave only a minimal areola and the scab dropped ofE on the 13th day. Even in the first few years after Jenner's announcement the degeneration of virus was often observed, and the search for new cow-pox virus was made. It became more lively in the 20's, stimulated by the revival of small-pox in many countries, often affecting vaccinated persons. Partly from the incomplete protection thus shown, partly from the imperfect development of the vaccine lesions, it was believed that the material in use was not as potent as it had been in the beginning. But as a result of the lessened prevalence of smallpox, natural cow-pox was much less frequent than in Jenner's time. Eewards were offered in some countries for the discovery of cow-pox. Eetro-vaccination, or the inociilation of the cow with human virus, was used for the purpose of reviving the stock. About the same time, that is in the end of the first third of the nineteenth century, the value of revaccination became known, though it took many years to be fairly appreciated, and it is still ignored in some parts of the world. Experiments for the production of cow-pox, by inoculating animals with small-pox virus, had been made by some in the early part of the century, and these were repeated, and in the hands of Ceeley and especially of Badcock, of Brighton, were successful. Badcock himself vaccinated over 13,000 persons with the virus, and furnished material to many physicians and apothecaries. It is an interesting fact that Dr. W. E. Coale, of Boston, " suspecting the efficiency of the virus then in use," obtained some of Badcoclr's material. In 18-52, Badcock sent him some " crusts from a variolated cow, a glass charged with the same material, and some points charged from a vesicle on a child's arm," caused by some of the primary lymph. Badcock sent Dr. Coale some more material in 1855, though this was not direct from the cow. Drs. Adams, of Waltham, and Putnam, of Boston, repeated Ceeley's experiments successfully, according to a letter by Dr. Coale, dated April 6, 1852, in the Boston Daily Advertiser. Other experiments made from the time of Badcock down to a recent period, by various investigators, have demonstrated the possibility of obtaining vaccine virus by variolating cows, and although the results were opposed by Chauveau and his colleagues, their scientific and economic value is now universally recognized, while the occasional propagation of small-pox by vaccination from such animals is explained by obvious errors in technic. But the great bulk of material used for vaccinating, down to the 70's, was humanized virus, inoculated either from arm to arm or indirectly. In large cities it was not difficult to keep up the succession, though the chief localities for that, foundling asylums, had certain important disadvantages. In the country and in small towns the supply often failed, or gave poor results. The methods used for keeping and inocu lating vaccine in this period, other than by operating from arm to arm, are of some interest. One of the earliest methods of preservation was by drying the lymph, obtained by pimcturing a vesicle, on a piece of glass. This was tied together with another glass and the two kept dry until wanted. Another was to soak threads in the virus, dry them and keep them in bottles. Or the virus was dried on elongated glass stoppers and the stoppers fixed in bottles, or it was dried on lancets, quills, or even thorns. On account of the rusting of steel instruments, with damage to the latter if not to the virus, silver or gilt lancets were used. Needles were used sometimes, and a Dr. Carl, in Prague, invented a forked silver needle. Small glass tubes,, such as barometer tubes, were also used, sealed at the ends by fusing. The use of crusts or scabs came comparatively late. The Eahly Technic. There were many modifications of the method of inoculating, though the details were for the most part derived from the earlier small-pox inoculations. Jenner first used short incisions, or punctures. When threads were used, they werecut in short lengths, placed in shallow incisions, and kept there by adhesive plaster. From the fact that some operators renewed the threads on the third day we may assume that the method was not always successfid. Sometimes the dried material, on threads, glass or instruments, was softened by soaking in blood, or by exposing to the vapor of boiling water, or soaking in water, or even saliva. More complicated methods of getting an inoculating surface were sometimes followed. Cross-scratching seems to have been a later invention. Fly-blisters were used at an early period, even a skin-trepan was invented, and as late as 1902 a cautery-hammer was devised, for raising a blister, in the cavity of which vaccine was to be inoculated. At various times since the invention of the hj-podermic syringe, that instrument has been used for injecting vaccine virus into the skin or subcutaneous tissue. Although it seems to serve the purpose, it has no great advantage, and some disadvantages. One of the common details of vaccinating developed from the use of humanized virus, viz., the practice of making multiple lesions. It was thought that the taking of part of the lymph lessened the effect on the vaccinifer, and so several vesicles were produced, one at least being untouched. Although the protection afforded by one good vesicle has always been recognized, there is some reason for believing that protection is in proportion to the area of typical scar. Bovine Vieus. The growing realization of the inconveniences of humanized virus gradually led to the development of another method, but there were other reasons besides the technical ones. In the 60's the fear of transmitting syphilis by vaccination became intensified, and although investigation showed that the risk was slight, considering the large number of people vaccinated, it also proved that the danger was real. April, 1904.] Ill The possibility of transmitting tuberculosis was also suggested by the work of Villemin, and was for a time much exaggerated. So attention was directed more and more to the use of bovine virus, that is, material raised purposely on the animal. In this way it was thought that the danger of setting up syphilis and tuberculosis could be avoided, and although the fear of transmitting inflammatory diseases was not absent, it did not retard the movement. In fact, then as now, there were some who thought that severe local reactions were desirable. The use of bovine vaccine goes back directly to Negri, who cultivated virus on animals, in Naples, from 1843. It is said that the same method was begun in Naples early in the century, but prohibited by law. Negri's method and material were introduced in Paris in 1864, by Lanoix, who, however, adopted cow-pox virus from the celebrated spontaneous case discovered at Beaugency, France, in 1866. The method spread rapidly. It was introduced in Brussels in 1865, by Warlomont. and in Berlin, in the same year, by Pissin, and soon afterwards in Vienna. In 1870, Dr. Henry A. Martin, of Boston, an indefatigable investigator and cultivator of vaccine, imported some of the Paris material, just before the strain died out during the siege. For some time after bovine virus came into use, the method of preservation was chiefly that of coating ivory slips with virus obtained by puncturing vesicles, the bases of which were compressed by forceps. Scabs were also used. On the continent of Europe a popular method consisted in vaccinating directly from the calf, the animal being taken to the domicile or to a central location, as was most convenient. The Use of Pulp. At first the material used was the liquid part of the contents of the vesicle, as was necessarily the case in using human virus before the scab stage, but in the 80's the so-called pulp came into use. The reason for the change was complex, and had reference partly to the greater tenacity of the liquid part of the bovine vesicle as compared with that of the human one, and its greater tendency to coagulate. The pulp is the whole vesicle, made up of the cells of the skin in the lesion, leucocytes, red-blood corpuscles, fibrin, fat, specific and nonspecific micro-organisms, and debris. Many objections have been made to the use of pulp vaccine, and from time to time tliese are brought forward in articles, but the arguments advanced are misleading, to say the least. Thus, it is said that pulp contains more pus and more bacteria than the liquid part obtained either by puncture of the vesicle or by tearing off the top of the vesicle and permitting liquid to exude from the base. But at the time the pulp is taken there is no pus in the ordinary sense, and it has never been demonstrated that the whole pulp contains more bacteria, bulk for bulk, than does the liquid part. Careful observations are needed in this connection, biit at the present time it should be borne in mind that the best vaccine in every respect, that is, the virus that causes least accidental infections and gives the best protec tion, is pulp vaccine. By this I mean the virus used over most of Western Europe and in England, and notably in Germany, where the statistics on all the points concerned arc most complete. Many methods of treating the pulp have been experimented with. It is not necessary for my purpose to discuss these, and I shall consider only the method now almost universally used, describing it in some detail from the beginning. Calves are used, generally from 3 to 6 months old, sometimes younger or older. Females are usually preferred on account of the greater cleanliness of bedding, though some operators use young bulls, which they inoculate on the scrotum. The animals are examined with reference to soundness, and are sometimes tested with tuberculin, though this is not necessary, as they are usually killed soon after the operation and can then be examined for disease, before the vaccine is distributed. After being under observation a few days the calves are thoroughly cleaned. Just before the operation, the animal selected having been fastened on a suitable table, the abdomen is shaved and washed with soap and warm water. In some institutions sublimate, carbolic acid or other antiseptic is used. A final washing is done with large quantities of sterlized water and the skin dried with sterilized towels. The operators,- in sterilized clothing, observe the usual aseptic precautions. A series of incisions is made in the skin of the abdomen, about an inch apart, extending as far forwards as the navel and laterally to the inner sides of the thighs. Sometimes the anterior abdomen, and even the side and back of the body have been used, but the thicker skin in these parts interferes with the best results. If more than slight bleeding follows the incisions it is checked by pressure with sterilized towels. The " seed " vaccine is then spread over the prepared surface with a spatula and allowed to dry. The seed is of various kinds. Sometimes it is bovine virus, selected with care from well-developed vesicles and of tested bacterial purity. Sometimes it is selected humanized vaccine, sometimes material derived more or less remotely from human variola. Often the makers either do not know, or are unwilling to state, the source and nature of the seed, and often misrepresentation has occurred. It is clear that in order to make an accurate study of the effects of vaccination the history of the material used is essential. . Dressings of various kinds have been used to protect the site of operation, but usually they are not considered necessary. The animals are kept in clean stalls, and carefully observed until the time for removal of the material, between the fourth and sixth days. The vesicles are then of fairly good size, but should not show evidences of suppuration. The calf is again fastened on the table, the abdomen thoroughly scrubbed with soap and warm water, rubbed by hand, and finally washed with sterilized water and dried. This removes the superficial dried epidermic scabs, and does not break the vesicles. For the removal of the pulp the common method is lo scrape each row of vesicles with a large curette, though it is said that some still use the forceps to clamp the bases. The 112 [No. 157. pulp is then made homogeneous by grinding, mixed with 50 per cent glycerine, and kept for several weeks to " ripen." Up to the early 80's pulp was used according to the earlier methods, but after that great activity was displayed in treating pulp with various antiseptics, the details reminding one of the complicated antiseptic dressings used in general surgery at the same period, but since 1891 the use of glycerinated lymph has been general. The addition of glycerine to vaccine virus is much older. Cheyne employed it as early as 1850 to keep lymph fluid; Mueller in 1866 to increase the bulk; Warlomont patented a method in 1883, and there are dozens of references to its use before him. But Copeman, by a series of careful investigations, showed that glycerinated pulp lost some of the bacteria it originally contained, and that they might even disappear completely at a time when the specific virus was still unimpaired in strength, and since then the method has been adopted by the leading vaccine institutions with little or no modification. Drying the pulp or lymph has a similar action on the bacteria, but glycerine has other advantages, one of the most important being the facility with which tests can be made on the glycerinated pulp, rendered fairly imiform by mixing in special apparatus. The tenacity of life of the specific germs has long been known to vary much, even under conditions apparently similar. In the glycerine preparations this is also true, but the real state is easy to fix by experiment in any specimen. It has been shown that glycerinated vaccine may be effective as long as a year after removal. Though the usual dilution is slight, from half to several times the weight of pulp being added in 50 per cent sterilized glycerine, dilutions of 1 to 2000 will give good results if carefully used. By the present method one calf will furnish from several hundred to several thousand portions of vaccine, three to four thousand being not unusual, and perfect vaccination has been obtained from calves giving as much as 15,000 portions. Copeman has summarized the advantages of glycerinated vaccine, and I quote from him the following : " 1. Great increase in quantity can be obtained without any consequent deterioration in quality, the percentage of insertion success following on its use being equal to that obtained with perfectly active fresh lymph. " 2. It does not dry up rapidly, as does unglycerinated lymph, thus simplifying the process of vaccination. " 3. It does not coagulate, so that it never becomes necessary to discard a tube on this account. " 4. It can be produced absolutely free from the various streptococci and staphylococci which are usually to be found in untreated calf lymph, and which are, under certain circumstances, liable to occasion suppuration. " 5. The streptococcus of erysipelas is rapidly killed out by the germicidal action of the glycerine. The danger of ' late ' erysipelas is diminished by reason of there being no necessity to open the mature vesicle for the purpose of obtaining lymph. " 6. The bacteriological purity and clinical activity of large quantities of the lymph can be readily tested prior to distribution." But no one who knows the subject claims perfection for glycerinated virus. Many efforts to improve on it have been made, by using other germicides, and many more will doubtless be made, until something still more satisfactory can bi; discovered. In the meantime it is necessary for all who have to use vaccine to know just what can be expected with the present methods. The Vaccine Lesions. Let us now examine some of the peculiarities of the vaccine lesions. From the beginning it has been recognized that the vaccine pock presents peculiarities by which it can be distinguished from all other skin lesions, and especially from smallpox, varioloid and chicken-pox; and by which one can form some opinion as to the quality of the change produced in the organism by vaccination. In his first publication, Jenner gave some pictures that have always been accepted as of the greatest value. All of Jenner's contemporaries admitted the fidelity of the illustrations, and Cuff, who colored them, and who made others for later writers, insisted on their accuracy after he had seen many hundreds of lesions. I show lantern slides of these plates, viz. : The original cow-pox vesicle on the hand of Sarah Nelmes; a vesicle, the second remove from horsepox ; a vesicle in a late stage, the second remove from a vesicle on a cow, casually derived from horse-pox; a vesicle on the 9th day, from virus taken from the subject of the preceding. While these figures are very instructive, Jenner was justly criticised because he did not give a complete description, with illustrations, of the whole course of the disease. He made good the deficiency in 1801, when he published a set of illustrations by Cuff, which I also show. In the meantime Aikin, in England, and Ballhorn and Stromeyer, in Germany, had published illustrations, and these were followed by many others more or less perfectly executed. Waterhouse had an illustration made showing the appearance of the vesicle in the negro, an important aid in the development of vaccination in America. I show next a copy of Sacco's illustration of cow-pox on the udder of a cow (after Rayer). Pfeiffer is probably right in thinking this was an inoculated cow-pox, not spontaneous, this belief being based on the distribution of the lesions. The vesicles are larger than those in trade vaccination. The next slides, Eayer's own pictures of the vaccine vesicle, are also of interest, on account of the general accuracy of Eayer's illustrations of skin lesions, and the influence the writer exerted upon medicine. I show also his pictures of atypical vaccination. Not less interesting are John D. Fisher's pictures, taken as they were from what were considered typical vesicles by men who remembered the earliest days of vaccination. The next series is that of Kirtland, made in 1802, and interesting because it shows the course of inoculated variola with that of vaccination at corresponding dates, but as it was not published until 1896 it did not affect the development of vaccination. Aiiolhor valuable pictui-e, historically, is that of Bousquet, showing the effects of recent virus from the cow-pox case of. April, 1904.] 113 1836, at Passy, compared with the old vims then used in Paris. Variations in the details and course of the vesicle have always been recognized as likely to occur, even with perfectly good virus, but on the other hand, marked departures in size, shape and course have always been considered as throwing the gravest doubt on the quality and also on the consequent immunity. Jenner insisted on the necessity of repeating vaccination until a perfect result was obtained. Recently, some doubt has been thrown on the essential nature of the areola, especially by makers of vaccine, and it might readily be supposed that this will not form after the use of virus of great bacterial purity. But I do not think we can abandon even this part of the local phenomena of vaccinia. In countries where most pains are taken to get good vaccine, and where its results are carefully followed and recorded, the areola is usually well-developed. I show some slides taken from cases inoculated by myself with American glycerinated virus of fair bacterial purity, but rather weak specific power, with welldeveloped areola. Incidentally, let me call attention to the method of inoculation, by single incisions, of which I shall speak later. The next and last picture I consider of great importance. It is from a photograph, and shows two lesions. These have dark roundish scabs with irregular surfaces, measuring 6 by 8 and 7 by 8 mm. respectively. Around each scab is a ring-shaped vesicle, from li/o to 3 mm. wide. There is no distinct areola, but an imusally deep-looking narrow zone of redness and swelling, very unsymmetrically placed, strongly suggesting local infection. This photograph has been widely reproduced in advertisements as a representation of typical vaccine lesions. It differs radically from anything hitherto accepted as a tj-pical lesion, and I shall have to speak of it later. It may serve to introduce the next division of my subject. Some Aspects of American Vaccine Virus. I must say at the outset that I do not intend to speak of all makes or makers of vaccine in the United States, but only of certain characteristics that I have found among a few rather conspicuous firms. It might be supposed that makers of vaccine virus would not sell inferior preparations. Experience shows that this is not so. Dr. Rosenau, of the U. S. Public Health and Marine Hospital Service, who has examined virus for a long period, has shown that practically all the vaccine virus sold in this coimtry has an unnecessarily large bacterial contamination, and although his observations show that improvements have taken place since he began his work, the results are still far from satisfactory. Eosenau charitably attributes the poor quality of the vaccine in part to over-confidence in the germicidal power of glycerine on the part of the makers. This, however, while charitable, is not altogether just. The makers had access to the literature, from which the actual capacity of glycerine to purify vaccine could have been obtained. Besides, the makers, particularly those I have in mind, made the most positive statements of purity, not only in advertisements, where such words as " aseptic " might have had a Pickwickian sense, but also in private correspondence, at the very time the virus, according to Eosenau's examinations, was very bad. It must be remembered that high bacterial contamination does not necessarily indicate dangerous infective possibility, but on the other hand it is believed by many that such an excess has a relation with the frequent secondary infections that occur from such virus. Then, too, the remarkable development of tetanus following vaccination, of two years ago, has been ascribed by MacFarland, long connected with the production of vaccine, partly at least to contaminated virus. Another explanation for the impurity of the virus is that sudden calls for large quantities compel the makers to put on the market " imripe " vaccine. In tlie present unregulated state of vaccination such demands are unavoidable. Systematic vaccination would do away with it. As it is now it would seem that policy, if not honesty, would lead the makers to declare the imperfection of the virus, just as some honest boards of health, unable to furnish pure water to cities, notify citizens when the contamination reaches a dangerous degree. Or, to take a more commercial comparison, large demand does not excuse a butcher who for a similar reason sells spoiled meat. The purity of American vaccine is not always as perfect as it should be; how is it about the specific power, or the capacity to confer immunity against small-pox? Much of it ii-' seriously lacking in specific power. Some makers not only admit, but advertise as a point of excellence, that their vaccine does not produce an eruption. While they do not state in advertisements that scars are not left, I have heard the scientific manager of one large firm assert before a medical society that a scar is not necessary. Not only is there no proof of this, but, on the contrary, all the evidence we have goes to show that a certain scar, not too large, not too deep, and quite different from the scar following a slough or a phlegmon, is an essential part of the result of efficient vaccination. Another manager admitted to me that his firm aimed at getting the mildest possible result from vaccination. This they did, as my observations show, by reducing the specific action, for bacterial contamination was quite marked in many points and tubes I saw in use. Weak specific action has an important bearing on the practical use of vaccination. With the best vaccine we expect to j^roduce immunity lasting for several years, if not, as was once hoped, for a lifetime. Though small-pox, even fatal small-pox, may occur in some persons so vaccinated, yet the general resistance will be high. With less effective virus the immunity is shorter, from a few weeks to a few months, and on the whole very imperfect. At first glance it may seem that vaccine giving protection for even a month would be good enough, but more careful examination seriously alters the matter. If for no other reason, the production of a wound every few weeks would be not only dangerous, but would be more intolerable than the fear of small-pox itself. ."Moreover, vaccine that gives an abortive vesicle, indicating short duration of immunity, is often very slow in taking, up 114 [No. 157. to a month in one make, by the admission of one of the managers of the firm. But such vaccine would be useless in the face of actual danger, as has occurred so often in the last five years, and as is likely to occur, suddenly, many times in future before our laws are perfected. Along with indifference to the production of pure and efficient vaccine, some of the makers of that material exert a positive influence for harm as extensive as it is insidious. In the advertising pages of scores of journals, and in countless circulars, not only are the advantages of the wares set forth in the usual language of advertisements, but questions of technic, of pathology and treatment are stated with impressive assurance. The photograph I showed illustrates some of these features. It is said to have been taken on the 8th day, but instead of showing the smooth umbilicated vesicle characteristic of that time, it shows a poorly developed vesicle surrounding a large dense scab. This is not the scab from drying of the contents of the vesicle, but is the result of necrosis of the skin, caused by extensive and deep scraping, part of the technic recommended by the firm. This method, if not original with makers of vaccine, owes its present vogue, I think, to the writings and pictures published by such firms, and to the demonstrations made by representatives of the firms, sometimes men of no medical training whatever. It is based upon a method formerly much used by physicians, and still recommended in some text-books, but according to the original method the denudation is very superficial, the epidermis is regenerated within a few hours, and the vaccine lesion goes on undisturbed by a necrotic mass over its place of inoculation. But the early scab is undesirable for other reasons than the very good one just mentioned. It favors accidental infection by rubbing with the nails or clothing, owing to its irritating qualities; it furnishes a good nidus for germs either originally in the skin, or introduced at the operation or later, and especially for those of tetanus. Many vaccine wounds have been so severe that boards of health have found it necessary to protest against them, and the Board of Health of Chicago has taken the pains to print a diagram one-«ighth inch square as the largest abrasion compatible with safety. It would be much better to prohibit such an operation entirely, as has been the law in Germany for several years. As my own photographs show, clean superficial incisions will permit the virus to take, if it is potent, and it is obvious that if such incisions do not heal by primary union, there is at least but little irritating and septic material in them. The history of the photograph with the hard scab also illustrates other aspects of the vaccine trade, viz., the possibility of lack of special knowledge of vaccinia on the part of the makers, and the differences of interest of the so-called biologic department and the counting-room. The gentleman in charge of the former was not aware of the difference between a depression caused by an early scab, and the characteristic umbilication of the genuine vesicle. In a letter replying to my criticism of the picture he wrote: " I saw these vaccinations just before they were photographed, and, in my opinion, they are very nearly typical for the age of the lesions." He also asserted that his firm had never sent out any other pictures of vaccine lesions, and quoted employees of the publication department to prove the statement, though I was able to show him a jiicture sent out as a circular by his firm, in which a group of abortive conoid al vesicles was reproduced as an illustration of the successful use of the virus. I mention this experience as an evidence of the need of some better arrangements for the production of vaccine virus than we now possess, an arrangement by which the material would become less a commodity to be turned out according to the inclinations of those who know nothing and care little for any other than its selling qualities, and more the subject of careful elaboration and well-directed effort at improvement. Copeman makes the interesting statement that in the vaccine institutions he visited in Europe researches were being made tending to improve the quality of vaccine. Medical literature bears witness to the scientific activity of these institutions, but in this country the only originality exhibited is limited to details of packing. It is too often forgotten that vaccination is a public rather than a private benefit. Its real object is not merely to prevent sickness or death in individuals, but to prevent epidemics with all their numerous and widespread consequences. This is the reason why some countries have adopted general vaccination, and the reason why in this country, without a wellplanned regulation, measures are adopted in times of danger that aim at compulsory and general vaccination, but for various reasons often fail. If people voluntarily adopt general vaccination, they are not likely to continue the practice unless the operation is reasonably mild and safe, and the protection fairly certain. As more or less compulsory vaccination is likely to be necessary for a long time to come, it would seem essential that the power compelling the operation should guarantee the purity of material and the safety of the operation. For this, either public manufacture or public inspection are necessary. Inspection as carried out for the last two years under the Public Health and Marine Hospital Service has done some good, but as the results are published without names much of the value of the examinations is lost, and no test of specific activity is attempted. It is often said that such control is impossible under our system of government, but this objection is more theoretical than real. If the general government can furnish pure seed to farmers, and the separate States regulate the sale of oleomargarine", the inspection of oil, salt, etc., or the sale of alcoholics and tobacco, vaccine could easily be put imder public control, provided, of coui-se, that the wishes of the people were not thwarted by the unseen but powerful influence of lobbies supported by those who prefer to keep the industry in their own hands. The details of such public control are beyond the scope of this / paper, which aims rather at exciting an interest in the prac tice of vaccination and its accurate and careful study. ApfiiL, 1004.] JOENS HOPKINS HOSPITAL BULLETIN. 115 CONCERNINC THE SINUS FRONTALES IX MAN WITH OBSERVATIONS UPON THEM IN SOME OTHER MAMMALIAN SKULLS. r>Y ADEUti-K r Watts Lek, M. D. Assistaiil ill A iinloiiii/. Univcrsilij of California. {From the Htarxt Avatomical LdhuKilorii of the University of California.) A review uf the literature suggests the necessity ol' u more eompleto descrijjtion of the sinus froiitales with some revision of the nomenclature according to their developmental characteristics, as well as a complete study of their architecture. The writer accordingly took Dr. Flint's suggestion Id make a series of metallic injections of these cavities in order to reveal in positive form the normal negative outlines of the sinuses. Since students rarely obtain a stereoscopic concept of the pneumatic spaces coiili'iliutiiig so markedly to the shape of the human cranium, an employment of the method by classes engaged in routine dissections is iirged. In this laboratory it is found that students gain a much clearer idea 01 the cavities when they are studied by means of lead casts. As will be seen by reference to the illustrations, two kinds of technique were utilized in gathering data for this paper, namelv, chiselling and casting. The chisel calls for time and some delicacy of manipulation to get good results, but casting i--' simple, rapid, and seems by far the best method, inasmuch as the lead mold positively expresses the negative sinus. Following is an outline of the casting method : When students have completed the dissections of the external face and cranium, a sagittal section of the head is made corresponding to the median line. While one or the other sinus frequently overlaps the median plane, the septum between them is commonly complete; accordingly it occasionally happens that tlie sections open only one sinus, and a pour-hole into the other must be provided by drilling through the intact septum. To prevent the metal escaping from the sinus by way of the infrrndibulum ethmoidale, the hiatus semilunaris is exposed and plugged with moist clay. In a melting pot o\cr a circular gas burner, lead is raised to a temperature of l)risk oxidation, as metal of a lower temperature often solidifies before reaching the utmost limits of the cavity. With these precautions the metal is directed into the sinus with a pouring ladle. It must, however, be poured slowly and in a thin stream, for should it enter rapidly and in a large mass, air is often retained in the sinus in quantities sufficient to ruin tlie cast. After allowing the lead to cool thoroughly the material is returned to the student for further dissection. Under the supervision of an instructor, he carefully removes the molds. They are then marked with the body number, making it possible at any time to obtain collateral information concerning the individual by consulting the records in tiie preparation room. The casts have rough surfaces due to generation of gas by the molted lead coming in cnnlnct with organic tissue in tlie cavities. Iiii'llierniiii'e, l!ie metal con tracts slightly while cooling, but in the main the molds apjjroximate quite exactly the sinuses in which they are made. This study is based upon examination of twenty-one adult male subjects, in age ranging ivom twenty-live to sixty years. The molds of all the sinuses changed from their normal state by pathological processes were rejected. The cavities are said to be generally smaller in the female than in the male. Owen ' has observed that the sinuses of Europeans are larger than in some other tribes. He states that they are imperfectly developed among the native Australians, and in consequence this deficiency engenders a want of resonance to the voice. In opposition to this, Macalister states that the sinuses are very large in Australian crania,' and Hilton finds them quite extensive in the skull of an African aborigine." The latter, however, made but a single observation, and it is possible, of course, that his specimen might have been an unusual one. Sufficient attention has not been called either tn the importance of symmetry in the architecture of living forms, to its significance, or to the means by which it becomes one of the most striking characteristics of all the higher forms of organic life. It is suggestive, however, that all structures in the body are at some period in the life-history of the organism either comj>letely or partially symmetrical — that is to say, form either complete mirror changes of each other, or may be divided by a median plane into halves which arc enanteomorpbic. In this connection it is noteworthy, therefore, that the sinus frontales vary in respect to symmetry more than any other paired structures in the human body. This is noted not only with reference to the deflection of the septum sinuum frontalium but also in other characteristics of sinuses ill the same skull. ']"ho sinuses form two cavities in the os I'rordale. situated doi-sad 1)1' the arcus superciliaris and ('cphalad (it the erliita, displacing the spongy bone between the inner and mitei- tables. They communicate with the meatus nasi nieilius by means (d' an osseous tube, the infundibulum ethmoidale, and are lined with a continuation of the nasal mucous membrane. Their 'Owen. Ours: Circle of Sciences, p. 167. Quoted by Humpliry. A Treatise on the Human Slveleton, etc. G. M. Humphry. Macmillan & Co., London, 1858. = A Text Book of Human Anatomy, etc. A. Macalister. P. Blakiston Son & Co. ' Hilton On the Cranium, p. 13. Quoted liy Himiphrey. A Treatise on the Human Slioleton, etc. G. M. Humphry. Macmilliui & Co., London. 1858. IIG [No. 157. position divides tlu.Mii iiiln twu |iarts. tlir pars frdiilMlis, tliu portion of the sinus in the S(|u;una, and the pars orhilalis, the ]iortion in tiie jiurs orhitalis ossis frontalis. J'xith frontal parts are slinwn in Vijx. .J, /'. /<'. I), and /'. /•'. >'. Tiie orl)itai parts are sliown in the same figure, 1'. (). I>. and /'. 0. S. Between the partes frontales is a perforate (ir imperforate partition of bone, leaning to one side or the other, the septum sinnuni frontalium (Fig. 5, s.s.f.). The frontal and orbital parts of the cavity are separated from each other in varying degrees by a partition of bone called the septum interpartes (Fig. .), S.I. (I.). Tlie cavities are also suljdivided hv lionv the median line and eiieroaehes upon tlii' territury nf the other. This uiieipial deM'lopment is responsii^le for the deth^ction of the .sei)lum siiiiium rrontaliuni. The two cavities always show a niarke(l ililference in outline and capacity, as is readily seen \iim inspection of tlie casts represented in Fig. 5.

The sinus frontalis may be absent throughout life. This condition was found once in the skull of an old adult and the usual superciliary eminences were entirely wanting of both sides.' I'he extremes in size are pictured in Figs. 3 and 4, the former showing the largest, the hitter the smallest casts in the series.

FiiaiiE 1. — Human Sinus Fionlalis. In tliis case the arcus superciliaris on each side was equally developed, notwithstanding the difference in the size of the sinuses. The median septum appro.ximates the mid-line more clearly than is usually the case.

a — Summit of Bulla ethnioidalis dextra. Its fellow is opposite occupying a slifihlly lower level.

h — Septum interiiartes.

c — A strip of the outer (able of the skull and a portion of

diploe above the septum sinuum frontalium. The latter is intact and very thin. This septum more nearly approximates the median line than is usually the case.

d — Linear elevation of the dorsal wall indicating a poorly developed septum lateralis.

e — Septum lateralis.

f — Pars orbitalis sin.

g — Pars orbitalis dex.

trabecultE called septa lateralos when in the pars frontalis (Fig. 5, s. 1. «.), and septa dorsales when in the pars orbitalis (Fig. 5, ,s-. d. .s.). The lateral limits of the sinuses are ordinarily di.stant from each other about seven centimeters. They reach c(!phalad into the squama about three centimeters, and the diameter of a sinus from the most ventral jioint of the pars frontalis to the most dorsal one of the jiars oi-bitalis is about two and a half centimeters. These figures of course represent the average of the twenty-one specimens used for this study. The pars frontalis of one sinus usually overlaps

Contrary to the statement of Sappcy," examination of the arcus sujierciliaris develops no jirecise information concerning the size of the sinus beyond. The arcus may be larger or snuiller than (he sinus. In the majority of cases, it is quite triu! (hat a large superciliary prominence indicates a large

' A series of sagittal sections found this os frontale of an unusual construction; it was thin throughout, the diploe included between the outer and inner tables was reduced to a thin line.

"Traite d'Anatomie Descriptive, Ph. C. Sappey, Vol. I, p. 264. Paris. 1888.

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cavity behind it and also tlie reverse, Init tlie presence of an arciis is no guarantee of a sinus in tlie siiuaina ossis frontalis. One old individual of the series posse.ssed strongly fashioned eminences above the orbits, but luul sinuses extending only into the orbital roots. Casts i}!' these apprai- in Fig. -I.

Between the sinuses is the .septum simiuin frontalium. Proportionate to their extent into the s(|iuuiia. this septum is contracted in breadth and increased in length. It seldom n])|irii\imMt('s the median line, a fact due to the uneipial size

thirteen, the left one in threi', and the remaining four were aljoiit (•i|iial.

Since in the process of their evolution the sinus frontales extend into lioth the squama and j)ars orbitalis ossis frontalis, it may \ir convenient to cla.ssify them according to their position; any pair uuiy consist of partes orbitales, or partes frontales, but the latter condition is much more common. If the sinus of one side presents both parts well developed, its mate is usuallv apprnximatelv the same in form, iinwever, when

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Figure 2. — Nearly all of the bone dorsad of the sinuses is removed. The left sinus is considerably the largest.

a — Pars orbitalis sin.

6 — Long, tortuous and thin septum interpartes sin. Its fellow is more ventrally placed, is shorter, thicker and stands in one plane.

c — Septum lateralis sin.

d — Pars frontalis sin.

e — A strip of the inner table of the skull and a trace of diploc corresponding to the septum sinuuni frontalium, although (he latter is very thin. In this specimen the septum is intact and is in its characteristic, deflected position, but the medial chamber

of the right sinus has caused an vmusual ilivision of the septum, one arm being continuous with the medial walls of the cavities and the other arm ending by a free, caudal border in the pars frontalis dex.

/. — Bulla ethmoidalis sin.

g. — Septum dorsalis sin. It is longer and thinner than usual. Opposite is seen another septum dorsalis stretching between the dorsal and medial walls of the pars orbitalis dex. and has a free, falciform, cephalic bor<ler.

/(. — Linear elevation of ventral wall and is all that remains of a one-time septum lateralis.

of the cavities. AVhen the two sinu.ses communicate the septum may be perforated at any ]ioint in its extent. Usually, however, if not intact, the opening cuts through its caudal e.xtremity. Out of twenty pairs the right sinus was largest in

one sinus shows a capacious pars frontalis with only a slight orbital extension, the opposite cavity as a nde will be purely frontal in location.

The pars' frontalis is, at times, no more than a slight,

118

[No. 157.

cephalic dilation of the infundibiilum cthinoidale, reaching not further than tlie caudal level of the glabella (Fig. 8, A). Wliile again it will be seen passing cephalad to the caudal circumference of the tuber frontale, stretching laterad to the Imea temporalis, or even, according to Hajek/ excavating the

° Nebenholen der Nase. M. Hajek. Leipzig, nnd Wien.

])rocessus zygamaticus and running dorsad lo the sutura sphenofrontalis.

Out of ninclecn cases wliere it appeared on both sides the pars frontalis was largest in (hirteen. This frontal jwrtion of tli(! sinus (Fig. 1, g). wliether large or small, is commonly a single chamber, but it consists frequently of a series of unequally-sized pockets, partially sejiaratcd from each otlier

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Fkhire 3. — A Wood's metal cast of a large sinus (natural size I.

P. O. D.— Pars Orbitalis Dex.

P. F. D.— Pars Frontalis Dex.

P. O. S.— Pars Orbitalis Sin.

P. F. S.— Pars Frontalis Sin.

s. 1. d.— Septum interpartes dex.

8. s. f. — Remains of septum sinuum frontalium.

s. i. 8. — Septum interpartes sin.

a. — Metal prolongation Into the cephalic end of the infundi bulum ethmoidale.

FiGUKi; 4.— Lead casts of a small sinus and representing an instance where the sinuses were i)urcly orliilal in development (natural size).

P. O. D.— Pars Orhilalis Dex.

P. O. S.— Pars Orbitalis Sin,

a. — Metal prolongation into the cephalic end of the infundibulum ethmoidale.

FiGUHE 5. — Casts of an average pair of sinuses, showing a natural perforation of the septum sinuum frontalium (natural size).

P. 0. D.— Pars Orbitalis Dex.

P. F. D. — Pars Frontalis Dex.

P. 0. S.— Pars Orbitalis Sin.

P. P. S. — Pars Frontalis Sin.

s. i. d. — Septum interpartes dex.

s. s. f.— Soi)lum sinuum frontalium.

s. 1. 8. — Soi)lum lateralis sin.

s. d. s. — Sopliim dorsalis sin.

o. — Melal prolongation into Ihe cephalic end of (he iufundibulum ethmoidale.

Apdti.. 1901.

.JOHNS HOPKINS HOSPITAL BULLETIN.

II

by bony septa. These septa laterales (Pig. 1, e) are hung from the cephalic junction of the ventral and dorsal walls of the sinus and, before extendinij far into llie sinus, often end in free, falciform borders. Occasionally they are so long that the several chambers are continuous with each other by very small openings. The septa, however, do not always span the intermural space but exist as low lineal elevations, in the majority of instances on the ventral wall (Fig. ?, //, and Fig. 1. (/.). It is the rule lor flic septa laterales to

thin that light passes through it almost unobstructed, while those of a smaller sinus may be short and thick.

The type of sinus represented by the pars orlntalis alone often exists on one or both sides. This, however, is much less common than the purely frontal type, or a combination of the two. The pars orbitalis is represented at times by a simple, slight, dorsal extension of the pars frontalis, while at others it reaches out over almost the entire orbital roof. In the series, the pars orlntalis existed bilaterally in trn crania.

FiGT'RF. G. — A and B are casts from different subjects (natural size), dorsal view. They illustrate the variation in position of the partes orbitales. P. O. of A shows a left orbital extension proceeding from the lateral portion of the pars frontalis, while P. O. of B is a pars orbitalis dex., resembling an outstretched wing, passing from the medial portion of the pars frontalis. A long septum interpartes partially separated the masses of metal representing the two divisions of the sinus.

FiouKE 7. — A and B are casts from the left sinuses of different

subjects (natural size), ventral view-. A shows no lateral septum, while B, although a smaller sinus, is nearly bisected with an interval created by a long septum lateralis, indicatin.g that these structures have no direct bearing of the size of the sinus.

Figure 8. — A and B are casts from a middle-aged adult (natural size), ventral view, showing one sinus as a simple dilatation of the cephalic end of the infundibulum ethmoidale. The casts A and B are joined by a mass of metal filling an opening in the middle third of the septum sinuum frontalium.

increa.se in number with an increase in the lateral extefit of the sinus, but the amplitude of the latter, however, bears no definite relation to the presence of the septa. A large cavity may exist without them (Fig. 7, A), while a comparatively small one may possess a number. The capacity of a sinus, moreover, does not seem to influence the form of the septa. In a large cavity the one existing iiartition is often found so

where that of one side showed no marked size difference with its fellow. Out of twenty-six single sinuses, however, presenting a combination of orbital and frontal parts, the latter was most voluminous in twenty-two.

The pars orl)italis (Fig. 2, d) u.sually passes dorsad from the medial portion of the pars frontalis (Fig. G, B. P. ().), nevertheless it might be an extension from the lateral part of

120

[No. 1.57.

till.' riMiital (li\ i>iiiii (if the sinus ( Fi^'. 'i, l- /'• <>) At times both parts communicati' with cadi otlicr \ci-v rrccly, but thcv usually are divided by a se|ituiu reaelijiig UKMlially from the lateral limit of the sinus. This septum interpartes (Vi'J.. 2, b) may exist in one sinus and be absent on the opiiosile side, or, as is usually the case, be present in both. In construction it often varies from a long, thin partition to a short, thick one. Ijike the frontal division, the pars orbitalis may consist of one or many chambers, but its pockets arc seldom as large, since the septa forming them are, as a rule, rarely so deep as the septa lateralcs. The septa dorsales, subdividing the orbital portions of the sinus, are usually, however, short anil thick. (Generally speaking, they arise from I he kitci-al and dor.sal limits of the ])ars orbitalis, although (hey may sometimes pass laterally from the median wall.

The sinus frontalis of the ox excavates the froulal, parietal and ocri|iital bones, making a very large ehamber ln'tween the

^

Fif;i:RE 9. — IJolail of an illustration from Ellenberg and Baum,' showing the immonso sinus frontalis of the ox, which exoavales llie fronlal. paricial anrl oe(i|)ital bones, as well as the horn.

iniuu- and outer tables wliieb nuiy or may not communicate with its neighbiii' on the opposite side. Tlie two tables of the cranium are iml reinfoi-ccd by compleli' bridges spanning the sinu.s, except around the peripheral portinns of the cavity, where thick trabecular divide it into small po(k<'ls, not comparable in size, however, in size to simihir structures in the hinnan skull. The sinus extends up inio IIh' Ihumi which near its base is also trabc<-nlate(l. Dorsad of the luirn there is a system of it.ral>ec-uhi; admirably situated Uw I be reinforcement of this part of the skull against strains or shocks impart<!d through the horns. These also form with the outer table of the skull an eminence for the abtachnumt of the large cervical muscles. That the presence of the sinus in this animal affords some protection against traumatism, is shown by a s]X!cimen witth an extensively healed fracture of the outer table over the sinus, while the inner table remains intact. II does not seem possible to subdivide tlie sinus frontalis in th(>

' Handbuch der Verglelchenden Anatomie der Hausthiere. EUenberg u. Baum, p. 102, Berlin, 1900.

ox's skull into distinct porlions, unless they arc namc(l ai'bitrai'ilv fi'om the bones in- regions in which they occur.

'I'bc fi-dnlal sinus in the pig's skull (Fig. 10) excavates the fronlal and a portion of the parietal bone, it does not, however, extend into the (.cci|iital bone as is the case with the ox. This sinus is usually separated from its neighbor by a complete bonv .septum sonu'wliat more regularly jilaced than .septmu sinuuni fronlalinin in the human <-rani\nn. although the partition in the ])ig umy have usually a considerable lateral deflection. This sinus is often subdivided into a pars medialis and a ])ars lati'i'alis by a septum intcr]iarlcs which extends anteriorly to a greater or less extent. 'Fhcse two ])arts. however, do not corres]iond respectively to the pars frontalis and

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FicaiKE 10. — A preparation of an adult pig's skull viewed slightly in perspective. The area shaded with diagonal lines represents a portion of bone removed to exhibit the sinus which excavates a position in the frontal and parietal bones. Here the cavity is differentiated into a pars medialis (a) and a pars lateralis (?;) by a long sei)t\im interpartes (c).

jiars orbitalis of the sinus frontalis in the human cranixiiu. The pars medialis is inchuled between the uunlian and lateral ]iartition and ciu'rcsponds to the ])ars frontalis, while the pars lateralis is located between the orbit aiul the septum inter])artes corresponding to the jiars orliitalis of the human sinus ficiidalis. The two |ioriions of the sinus communicate anteriorly. iVs in the human and other sjiecimens, the sinus is stdxlivided around its jicrijihery by a series of small trabeculne irilo small pockets. These, however, cannot lend a gr(>at deal of additional strenglh in reinforcing the vault of the cranium, but the sejitum interpartes (Fig. 10. r) reaching from the outer to the inner table and extending forward through the broader part of the sinus contributes a great deal to its struc

April, 1904.]

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tural strength. The sinus frontalis in the sheep is limited to the ventral and lateral portions of the ossis frontalis. Its depth in the maximum is from 0.7 to 1.5 centimeters. Like the sinus in the pig's skull, it is subdivided into two portions by a septum interpartes and the trabeculse around the periphery of the sinus are much more developed, exaggerating the sacculation of the sinus to even a greater degree than is shown in Fig. 11.

In the dog the frontal sinus (Fig. 13) shows an irregularly spherical or ovoid cavity in the frontal bone, usually completely separated from its mate by the septum. Jfo trabeculfe bridging the tables are found in this skull and those around the periphery of the sinus are only developed to the extent of slight ridges, thus causing a slight sacculation of the periphery

jrCyr.U.

ox.

FiGUBE 11. — A preparation of an adult sheep's skull, where the sinus frontalis is confined to the frontal bone.

a — Pars medialis.

6 — Pars lateralis.

c — Septum interpartes.

The latter in this animal has the additional function of lending support to the osseous tube O. C, which transmits into the superciliary vessels and nerve.

of the sinus. In the skull of the cat (Fig. 13) the sinuses are limited to the frontal bone and are completely separated from each other by the septum sinuum frontalium. This cavity can often be divided into the pars frontalis and the pars orbitalis by a septum interpartes, the orbital portion extending lateralward out into the orbital process of the frontal bone. With the exception of this septum, there are no trabeculae save those indicated by mere ridges to interrupt further the regular outline of the sinus. In monkeys there is no sinus frontalis present, notwithstanding the well-developed arcus superciliaris. There are, however, a large number of dilated bony cells which occupy a similar position to the sinus

frontalis as it is found in other animals. These rarefied bone cells take the place of the sinus and probably communicate with each other and the nasal meatus, although injections to prove tMs point were not made. In horned animals trabeculae are arranged so as to provide not only for the strength of the sinus and the protection of the cerebrum, but also as a reinforcement against stress applied to the skull through the horns. Xo gradual increase or decrease in complexity can be followed through the animal series, the sinus seeming to adapt itself in each species toward the architecture of the skull to the end that it affords at the same time lightness and strength. It has been suggested that the frontal sinuses are being

^^-/^

FiGUBE 12. — A preparation of an adult male dog's skull, and shows the sinus entirely within the frontal bone.

eliminated from the vertebrate skeleton by a process of evolution, owing to their occasional absence in otherwise normal human crania, their irregularity in form, extent and capacity, as well as their extreme asymmetry. But a comparison of the sinuses in a series of mammals shows no diminution in their size corresponding to the position of the species in the animal scale. Moreover, the extreme modification presented by the sinuses in monkeys also seems to argue against the plausibility of the suggestion.

Inspection of a comparative table of the relation of brain weight to body weight in the series of mammals compiled by Leurent and Gretiolet reveals the following facts :

For example, in the horse and pig the ratio of brain weight to body weight is respectively 1 to 583 and 1 to 481, that is to say, the proportion is much smaller in the pig than in the horse and yet the former has the largest frontal sinus. It appears from these two instances, which can also be amplified

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[No. 157.

by others in the tabic, that there is no distinct relation between brain weight in its relation to body weight and the sinus frontalis. This also appears to be the case in reference to the relation between the cranial capacity and the size of

Fi^. IS.

FiQTiBE 13. — A preparation ot an adult female cat's skull with the sinuses situated In the frontal bones.

the skull, for monkeys, which next to man have the highest relative cranial capacity, possess only a modified frontal sinus as the tissue beneath the well-developed superciliary arches consists simply of dilated pneumatic cells.

J^i

^.JV.

X.VU:L. fecit

Figure 14. — A preparation of an adult male monkey's skull (species unknown). No sinus exists in the usual form. The arcus superciliaris sin. has been cut and shows the sinus, consisting of dilated pneumatic spaces.

A MODIFIED ISrOCHT'S STAIN.

By T. W. Hastings, M. D. Instructor in Clinical Pathology, Cornell University Medical School.

The numerous methods of blood staining and the many staining fluids described during the last seven years have had as their objects to be attained the doing away with separate fixation and the development of the malarial " chromatinstaining" material.

The stains described by Eomanowsky, Ziemann, Nocht (1), Jenner (2), Goldhorn (3), Leishman (6), Michaelis (7), Eeuter (8), Willebrand (9), Wright (10), and SchegoleflE (11) possess at least one of these qualities, and Leishman's and Wright's possess both of them. None of these methods, however, gives constantly and without fail the clear, intense staining obtained by employing Nocht's principle of mixing the three solutions of eosin, alkalinized-methylene-blue, and methylene blue. Nocht (12) pointed out that the essential staining element of the Eomanowsky and Ziemann methods is a new staining material,' which he designated as "red from methylene blue" (Michaelis' (13) " methylen-azur," or " azur-blau "), which is formed in all alkaline-methylene-blue solutions.

While using Nocht's methods according to the directions given by Lazier (4) and by Ewing (5), the possibility of preparing a Nocht's solution with methylic alcohol suggested itself — a combination of Nochf s and Jenner's methods.

After several trials such a solution was obtained, but little or no differentiation of leucocyte granules and no "chromatinstaining " were obtained until Leishman's publication suggested the method of differentiation by diluting the staining fluid with distilled water.

The stain-powder is made as follows from the dry, powdered water-soluble yellow eosin and the dry, powdered Ehrlich's rectified methylene blue (or medicinal methylene blue) :

A. Eosin solution 1% aqueous.

B. Alkaline-methylene-blue solution.. 1%

C. Methylene blue solution 1% aqueous.

B (Nocht, 14) is freshly prepared by adding to a warm 1% solution of dry, powdered sodium carbonate (Na^Coj) 1% of methylene blue powder; heating this mixture over a water-bath for 15 minutes; adding 30 cc. of water for each 100 cc. of original fluid to replace loss by evaporation; and heating a second time over water-bath for 15 minutes (to make up one lot of stain 200 cc. of this solution B should be prepared). This warm alkaline-methylene-blue solution is poured off from the gummy residue, partially neutralized with 5-6 cc. of 12y2% acetic acid, and mixed with solutions A and C, as follows:

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123

Distilled water 1000 cc.

Eosin sol. A 100 cc.

Alkaline-methylene-blue sol. B 200 cc.

Methylene-blue sol. C 70-80 cc.

If 70 cc. of solution C is not a sufBcient quantity to produce a fine precipitate, this solution (C) is added until the precipitation is obtained (70-80 cc. in toto).

This mixture of three solutions is allowed to stand i/^ to 1 hour, filtered through one filter, the residue allowed to dry in the air for 24-36 hours, and this dry residue is dissolved in Merck's pure methylic-alcohol.

From the quantities given above one obtains usually 0.7 to 0.9 gramme of dry, brittle residue, and 0.3 gramme of this dry residue in 100 cc. of methylic-alcohol results in the satisfactory staining solution. The residue is soluble with difficulty and must be rubbed well in a mortar with pestle to obtain solution.

To use the stain no previous fixation is required. The dried blood smears are flooded with the staining-solution for 1 minute; the solution is then diluted with distilled water (5-7 drops for %-inch cover-slip) and this diluted stain allowed to act for 5 minutes ; the specimen is washed thoroughly with distilled water, care being taken to clean off with the fingers the negative side of the glass upon which a precipitate collects ; blotted with filter-paper; mounted in balsam.

The colors of nuclear material, granules, plates, red cells, malarial parasites, are similar to those found in specimens stained by Nocht's method.

Bottles of the staining fluid two years old retain their fixing and staining properties, provided the stain is always poured from the bottle and pipettes are not used, for slight changes in reaction of the fluid destroy the staining properties. Stained specimens do not fade, but are found well

stained after a period of two years. Specimens several weeks old may not stain well; specimens several months old never stain well ; and leukemic specimens rarely stain well after six to eight weeks.

The chromatin material of the malarial parasite stains clearly. The stippling of Schiiffner (15) and of Ruge (16) is well shown. All the leucocyte granulations are well differentiated.

The granular-basophilic and polychromatophilic changes in the red cells are well shown. The blood plates stain clearly.

References.

1. Nocht: Cent. f. Bakt., Bd. 25, p. 764 (1899). Cent. f.

Bakt., Bd. 26, No. 1.

2. Jenner : Lancet, Vol. I, p. 370, 1899.

3. Goldhorn: N. Y. Univ. Bull, of Med. Sciences, Vol. I,

No. 2 (1901).

4. Lazier : Johns Hop. Hosp. Reports, Bd. 24, p. 839 (1898).

5. Ewing: Jour. Exp. Med., Vol. V, No. 5 (1901).

6. Leishman : Br. Med. Jour., 1901, Vol. II, p. 757.

7. Michaelis : Deut. Med. Woch., July 27, 1899.

8. Renter: Miinch. Med. Woch., July 30, 1901. Cent. f.

Bakt., Vol. XXX, No. 6, 1901 (Aug. 26).

9. Willebrand: Deut. Med. Woch., Jan. 24, 1901.

10. Wright : Jour. Med. Research, Jan., 1903.

11. Schegoleff: Medicinskoie Obozrenie, Vol. LVIII, No. 2,

1902.

12. Nocht: Cent. f. Bakt., Bd. 25, p. 764 (1899).

13. Michaelis: Cent. f. Bakt., No. 29, p. 763, 1901. Ein fuhring in die Farbstoffchemie Berlin, 1902, p. 43.

14. Nocht : Cent, f . Bakt., Bd. 26, p. 17, 1899.

15. Schiiffner : Deut. Arch, f . klin. Med., Bd. LXIV, p. 428

(1899).

16. Ruge: Zeit. f. Hvg. u. Infectionskrank., Bd. 33, 1900.

COMPLICATIONS ARISING FROM FREEING THE URETERS IN THE MORE RADICAL OPERATIONS FOR CARCINOMA CERVICIS UTERI, WITH SPECIAL REFERENCE TO POST-OPERATIVE URETERAL NECROSIS.

By John A. Sampson, M. D., Resident Gynecologist, The Johns Hophins Hospital; Instructor in Oynecology, Johns Hopkins University.

Associated with the advance in all forms of surgery, there arises a new series of complications which must be recognized, remedied and finally avoided. The most serious complication which has been associated with the advance in the operative treatment of carcinoma cervicis uteri has been that of injury to the ureter. Since the opening of the Johns Hopkins Hospital in August, 1889, until January 1, 1904, there have been admitted to the gjTiecological department of this hospital 10,961 patients. Of these, 8590 have undergone an operation of some sort. There have been 4669 major operations, which term includes all coeliotomies, both abdominal and vaginal.

and all operations on the kidney. There have been 31 instances of accidental injury to the ureter, only one of which occurred in a minor operation, a ligation of the ureter in repairing a vesico-vaginal fistula. Of these 31 cases, 19 occurred in hysterectomy for carcinoma of the cervix. Accidental injury to the ureter as a complication associated especially with hysterectomy for carcinoma cervicis uteri becomes very evident when one considers that there have been 19 instances of injury to the ureters in 156 hysterectomies for cancer of the cervix, as compared with only 11 cases in 4513 other major gynecological operations. These injuries have

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[No. 157.

been of various kinds, as ligating, clamping, cauterizing, cutting, and interfering with the blood-supply of the ureter so that necrosis occurred with a resulting uretero-vaginal fistula. Some of these injuries were recognized at the time and repaired, while others were not discovered until afterwards. The cases of accidental ligation and clamping of the ureter have been published.'

All who are interested in the operative treatment of carcinoma cervicis uteri recognize that hysterectomy alone effects a cure in but a very small percentage of the cases. The comparison of statistics is very unsatisfactory and misleading. Over a year ago all our cases were reviewed, and we found that only about 12 per cent were free from recurrence at the end of five j'ears, and about 23 per cent at the end of three years. In addition, there had been a primary mortality of 14. + per cent. If 14. + per cent die as a result of the operation, and about 88 per cent of the cases recur within five years after the operation, it is little wonder that cancer of the cervix is looked upon by many as an incurable disease, especially when, in addition, it is considered that in about three-fifths of the patients admitted to this hospital with this disease, the growth had extended beyond operative treatment.

I have studied the relation between the ureters and carcinoma cervicis uteri and these results ^ have been published. In this article the work of Kundrat' was reviewed, who studied the parametrium in 80 of AVertheim's cases. He showed that the parametrium was involved in 44 of these cases, and that apparently in 22 of these 44 cases the parametrium had been able to stop the further extension of the disease, as shown by a study of the pelvic lymphatics beyond the parametriiim, thus emphasizing the importance of a wide excision of the parametrium. Kundrat also showed that only by the microscope can one diagnose the presence or absence of cancer in the parametrium, as has been emphasized by both Wertheim * and myself.'

A study of the relation between the ureters and the cervix shows that this varies in different cases and may be altered by physiological and pathological conditions, and also by various steps in gynecological operations. At the point where they enter the parametrium they may be 2 to 3 cm. distant from the cervix, while where the ureters enter the bladder the distance may be less than 5 mm., depending on the position of the uterus in the pelvis, it therefore may take but a very slight involvement of the parametrium by cancer for the growth to reach or extend beyond the ureters.

In carcinoma cervicis uteri this relation is altered in the following ways, as has been described in the above-mentioned article : '

1. By the distention of the cervix by the growth, thus bringing the cervix nearer the ureters.

2. By the direct invasion of the parametrium by the growth, and as this is apt to occur in the lower part of the parametrium, it does not need to go far in order to reach or extend beyond the ureters.

3. By metastases to the structures of the parametrium; as, a. The large parametrial lymph nodes, especially the one

sometimes found where the uterine artery crosses the ureter.

b. The minute parametrial lymph nodes, scattered throughout the parametrium, and which may be involved by carcinoma without increasing in size.

c. The (intravascular?) lymph nodes, also minute, which apparently protrude into the lymph channels like sponges and are apparently different in structure from the other minute lymph nodes, but like them may be involved by cancer without increasing in size, so that their presence can only be diagnosed with the microscope.

d. Other structures of the parametrium, as nerve sheaths, lymph channels, etc.

It becomes very evident that the ureter passes through tissiie which should be removed ; as shown by :

1. The large percentage of recurrences after hysterectomy for this disease.

2. The renal insufficiency resulting from the extension of the disease, thus compressing the ureters.

3. The accidental injury to the ureters in the operative treatment of the disease.

4. The anatomical relation between the cervix and the ureter under normal conditions shows that this relation is changed by the position of the uterus in the pelvis and the size of the cervix, and that in the lower portion of the parametrium it takes but very little involvement of this tissue by the cancer for the growth to reach or extend beyond the ureters.

5. The study of the parametrium by Kundrat in 80 operable cases showed that it was involved in over half the cases, and that in half the cases in which it was involved, it had apparently checked the further advance of the growth, as shown by a study of the pelvic lymphatics beyond the parametrium.

6. The study of the cases in which the ureters have been resected shows how easily the growth can reach or extend beyond the ureter, either by direct extension or by metastases, and that the diagnosis of cancer about or near the ureters can be definitely made only with the microscope, as shoven by me in the article ' previously referred to.

Two ways of removing all the tissue from pelvic wall to pelvic wall present themselves:

1. To dissect the ureters free from this tissue.

2. To remove the tissue with the lower ends of the ureters and implant the renal ends of the ureters into the bladder.

The object of this paper is to consider the effect of freeing the lower ends of the ureters in these operations, and whether or not it is justifiable, and if so how it should best be done. In order to determine the above, the subject must be viewed from the results of anatomical, experimental and clinical studies.

What Takes Place when the Ureters are Freed in the

Cervicis Uteri.

If one will catheterize both ureters with silk bougies and, after grasping the cervix with traction forceps, make a bi

April, 1904.]

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manual pelvic examination, the relation between the cervix and the ureters may be determined, for the catheterized ureters can be easily palpated. While making the examination, if another person will displace the uterus by means of traction forceps, as pulling it down, pushing it up in the pelvic cavity and displacing it to the right or left side of the pelvis, a very good idea may be obtained of what effect these positions of the uterus have upon the ureters, which one can readily feel in the bimanual examination. Under normal conditions, the ureters are only slightly affected by these positions, unless extreme, and one can see that the distance of the ureters from the cervix is dependent mainly on the position of the uterus in the pelvis; i. e., when the uterus is in the right side of the pelvis, the left ureter bears nearly the same relation to the left side of the pelvis as the right does to the right side of the pelvis. On the other hand, the uterus is nearer the right ureter than the left, the distance depending on the degree of displacement. I studied these relations still more satisfactorily in the pelvis of a multipara, only a few hours after death. Catheters were inserted in the ureters from above and the bladder was opened and the catheters withdrawn until the ends appeared just at the ureteral orifice in the bladder. A bimanual examination was now made with one hand in the pelvis and the other in the vagina. The uterus was displaced by pulling it up in the pelvis, drawing it down and displacing it to the right and left side. While extreme displacement in either direction also displaced the ureters, one could see that the relation between the ureters and the cervix was mainly dependent on the position of the uterus in the pelvis, and that under normal conditions any displacement of a freely movable uterus, unless extreme, changed but very little the relation of the ureters to the sides of the pelvis and other fixed pelvic structures.

The pelvic portion of the ureter is surrounded by a sheath (described in previous articles ^ ^""^ ®), which is adherent to the peritoneum in that part of the pelvic portion of the ureter which lies just under the peritoneum and situated above the parametrium (when the uterus is in anteposition ; for in the retroposition the uterus may lie posterior to the ureters for their entire pelvic portion). The sheath of the lower pelvic portion of the ureter is firmly connected with the tissue along or through which the ureter passes and from which the sheath is derived and the isolation of this portion of the ureter with its sheath is very difficult. On the other hand, the sheath may be split open and the ureter easily shelled out. In freeing the ureters they are usually shelled out from this sheath and thus all vessels coming to that portion of the ureters are injured, and in addition there is danger of injuring their outer perimuscular fibrous coats, in which are situated the larger ureteral vessels. At the close of the operation the ureters lie in the pelvis as loose cords, deprived of their sheaths, and exposed to the danger of ureteral necrosis or ureteral obstruction.

In considering the effect of freeing the pelvic portion of the ureter, a knowledge of the efficiency of the blood-supply of the ureter is most important, and such Icnowledge can only

be gained from anatomical, experimental, and clinical studies. A result of sucli studies has been published in a previous article."

The Blood-Supply of the Ureter.

The ureter is nourished by a periureteral arterial plexus, the main trunks of which run in a longitudinal direction from the kidney to the bladder in the outer loose perimuscular fibrous coat of the ureter. From these longitudinal vessels small branches arise, some of which anastomose with each other, thus forming the mesh-work of the plexus. These smaller branches are, for the most part, more deeply imbedded in the outer coat of the ureter than the main trunks which in places may be but loosely imited to the ureter. Small arteries arise from this plexus, penetrate the walls of the ureter, and thus supply the inner coats of the ureter. I do not know whether or not there is a free anastomosis between the deeper ureteral arteries. In sections of the ureter cut from specimens injected with Prussian-blue the free anastomosis of the capillaries can be demonstrated easily. On the other hand, I have never been able to determine whether or not there was any anastomosis between the small arteries found within the muscular coats. These vessels are not very numerous and are very small, as shown in Fig. II, and one would not suppose that they could nourish the ureter for any distance unless the plexus remained intact. This plexus is nourished mainly by the ureteral arteries which arise from branches of large vessels along the course of the ureter, as the aorta, renal, ovarian, iliac, uterine, and other arteries. The ureteral arteries are not the same in all cases, as a branch from one artery, as, for instance, the ovarian, present in one case, may be absent in another, and its place be taken by a branch from another artery, as the aorta, a ureteral branch of which may not be present in the first instance or both may be present in the latter case (see Fig I). This plexus may receive additional nourishment from small branches arising from the plexus of vessels which supply the tissue about the ureter, and may anastomose with the branches of other vessels supplying these parts.

An idea of the efficiency of this plexus may be gained from the following experiments which I made. In five instances the arteries of the ureter for its entire length were injected by inserting a canula into the renal artery through the incised aorta, using an aqueous solution of Prussian-blue in two instances and a 15 per cent solution of gelatine colored with ultramarine-blue in the other three. Fig. I was drawn from one of these specimens. The internal iliac artery was injected in the opposite side of one of the above cases, and as a result the arteries of the ureter were injected for its entire length. I have injected the internal iliac artery in another instance, the ovarian in one, and the abdominal aorta in two, first clamping the renal, iliac, and lumbar arteries in the latter two cases so that the coloring material could not enter these vessels. This latter group of cases was not quite as satisfactory as the first six cases referred to, as the work was done after the organs had been removed; nevertheless,

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they all demonstrated the free anastomosis of the arteries of the ureter, giving rise to a periureteral arterial plexus, and showed that it is possible to inject the entire plexus from such arteries as the renal and internal iliac, and also probably from any one artery which furnishes a ureteral artery. Through this plexus there is established an arterial communication between the kidney and the bladder, because when one injects the renal artery alone with ultramarine-blue, the particles of which will not enter the capillaries, in addition to the injection of the ureteral arterial plexus, both the bladder and the uterus are partially injected. The anastomosis of the renal with the ovarian and the latter with the uterine also aids in bringing this about.

From a knowledge of the blood-supply of the ureter it would seem that many liberties could be taken with the ureter without causing necrosis; as, for instance, the ureter could be dissected free, from the bladder to the kidney, severing all vessels coming to the ureter between these organs, and yet necrosis would not occur if the periureteral arterial plexus remained intact.

On the other hand, one would suppose that the destruction of this plexus for only a short distance would lead to necrosis of the ureter, for even if there existed a free anastomosis of the deeper arteries of the ureter, on account of their size and small number, one would think that they would not be capable of maintaining the nourishment of the ureter for any great distance.

Experiments on Dogs Demonstrating the Efficiency OF THE Blood-Supply of the Ureter.

In the article ' previously referred to, I gave the results of some of my experiments and referred to the work of Monari, who showed that many liberties could be taken with the ureter of a dog, as it could be freed from the tissue surrounding it and if replaced in this tissue necrosis would not occiir. On the other hand, if the ureter was freed, but for a short distance and gauze was placed about it, necrosis was very apt to occur.

There is an arterial plexus about the ureter of a dog very similar to that found in man. It receives branches from the vessels near it and presents variations much as are found in human beings. The main trunks of this plexus tend to arrange themselves in two relatively large branches, one on each side of the ureter, which are loosely bound to the ureter. The smaller branches arising from the trunks anastomose with each other, thus forming the mesh-work of the plexus, and are more closely united to the ureter than the larger vessels, as is also the case in man. On this account it is quite easy to injure the large trunks but not the smaller branches (see Figs. Ill, IV and V). The following experiments were done:

I. In seven dogs, the ureter was isolated for nearly its entire length and an attempt was made to strip off the periureteral arterial plexus with my finger nails. The dogs were killed in from one to four weeks and ureteral necrosis occurred in only two ca-ses. In four of these cases tlic de

scending aorta was injected with a 15 per cent solution of gelatine colored with ultramarine-blue, and very satisfactory injections of the ureter were obtained. It could be seen in these specimens that in trying to strip off the arterial plexus I had removed only portions of the main arterial trunks and the large veins, while most of the smaller branches, which are imbedded more deeply in the outer coat of the ureter and form the mesh-work of the plexus, were uninjured and were able in five instances to maintain the arterial plexus, and thus the blood-supply of the ureter. In addition newlyformed vessels come to the ureter from the surrounding tissue, and also new vessels go out from the ureteral plexus into the surrounding tissue (see Fig. III).

II. In three cases the ureter was isolated for about 4 cm. and in order to completely destroy the plexus, the ureter was scraped on all sides with a very sharp knife, for a distance of 2 cm. Necrosis occurred in all three cases.

III. In three dogs a ureter was isolated for nearly its entire length, and then the larger vessels of the plexus were torn off by the finger nails and mouse-tooth forceps, as in the first experiments. Both uterine vessels were tied, thus ligating the ureteral arteries which complete the lower end of the plexus and arise from the uterine. Necrosis occurred in each instance.

IV. An attempt was made to simulate the condition sometimes found after the more radical operations for cancer of the uterus. In six dogs the ureter was isolated for about its lower one-third, and the tissue about it, including portions of the larger vessels of the plexus, was torn off as above. Both uterine arteries were tied and necrosis occurred in five of the six cases.

V. In two dogs the above was done, except the uterine artery on only one side was tied. Necrosis occurred in one case.

VI. In twenty-five \iretero-vesical implantations in dogs, there was but one failure, which occurred in one of nine cases where organisms had been introduced into the bladder, in order to see the results of implanting the ureter in the presence of infection. In three of these nine cases the kidney became infected and in each instance there was a marked stricture of the ureter at the seat of the implantation.

VII. In another dog the ureter was freed and stripped, as in previous operations. A small rubber tube 8 cm. long was split, and by springing it apart the ureter was placed within its hunen. Necrosis of the ureter occurred for a length of 7.5 cm.

VIII. A dog's ureter was scraped with a sharp knife until a fistula was formed. The ureter was replaced in the abdominal cavity and 53 days afterwards the dog was killed. The kidney was found to be normal, the ureter patent, and there was no evidence of there having been any trouble except for tlie adhesions about the ureter.

It is evident that in a dog the ureter may not only be freed for its entire length, but its larger vessels may, in part, be destroyed by stripping them off; yet necrosis will not necessarily occur, for the plexus may be maintained by the

April, 1904.]

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smaller branches which are more adherent to the ureter and are very difficult to remove, and also by such portions of the large branches as have not been destroyed. On the other hand, when the ureter is scraped with a sharp knife, thiis destroying the smaller branches as well as the larger, necrosis will occur, even though the distance be very short. Again, when the ureter is freed but a short distance and the plexus interfered with, and in addition the arteries supplying the lower end of the ureter are ligated, then necrosis is very apt to occur, for the portion of the ureter stripped and also that below the injury, must receive most of its blood-supply from the blood-vessels in the plexus above the injury, and the stripping may interfere with the blood reaching these parts through the injury to the plexus.

In injury to the ureteral plexus, veins are destroyed as well as arteries, but as there is a verj' free anastomosis between the veins of the ureter, one would expect much less trouble from injury to the veins. Nevertheless, it must embarrass the circulation to a degree, varying with the extent of the injury. Infections, exudates, and foreign material, as gauze, must all be considered as accessory etiological factors in the causation of ureteral necrosis.

So far, the results of the study of the blood-supply of the ureter in man and experiments on animals tally. The next thing to be considered is what may be learned from clinical experience.

Clinical Cases Demonstrating Some of the Injurious Results Arising from Freeing the Ureters in the More Eadical Operations for Carcinoma Cervicis Uteri.

Clinical cases showing the efficacy of the blood-supply of the ureter have been referred to in £1 previous article. In this article attention was called to the fact that many liberties could be taken with the ureter. The human ureter has been dissected free for its entire length and yet necrosis has not occurred, and even when its outer coat is injured the ureter may be preserved. On the other hand, if the periureteral arterial plexus is injured sufficiently necrosis will occur.

There have been six instances of ureteral necrosis in 1.56 hysterectomies for cancer of the cervix in this hospital, and not a single instance of such a complication following the many times that the ureter has been accidentally exposed in other gynecological operations. I have abstracted the main points in these six cases.

Case I.— Mrs. M. W. Age 46. Gyn. No. 5991. Gyu. Path. No. 2301.

Diagnosis : Squamous cell carcinoma cervicis uteri.

Prognosis bad, for sections through the edge of excision of the growth showed that it probably had not been all removed.

Operation: Hystero-salpingo-oophorectomy, combined abdominal and vaginal, with preliminary catheterization of the ureters with silk catheters.

Steps in the Operation Interfering with the Blood-Supply of the Ureters.

1. The right ureter was found to be surrounded by the growth and with difficulty was dissected free from it.

2. Uterine arteries were tied.

3. Pelvis drained through the vagina with gauze, which probably came in contact with the right ureter.

Nature of the Ureteral Injury.

Eight uretero-vaginal fistula, appearing on the ninth day when the pelvic packs were removed. Otherwise, convalescence was uneventful.

Result: Six weeks later an attempt was made to turn the uretero-vaginal fistula into the bladder, by a plastic operation through the vagina. Operation was imsuccessful. The fistula persisted imtil death two month later, apparently from renal infection.

Case II.— Mrs. S. R. Age 24. Gya. No. 8788. Gyn. Path. No. 4994.

Diagnosis : Squamous cell carcinoma cervicis uteri.

Prognosis bad, for from a microscopical study of the specimen the growth had apparently not been all removed.

Operation: V, 30, 1901. Hystero-salpingo-oophorectomy, combined abdominal and vaginal, with preliminary catheterization of the ureters, with silk catheters.

Steps in the Operation Interfering with the Blood-Supply of the Ureters.

I. Both ureters were dissected free from the carcinomatous cervix to which they were adherent. The right ureter was the more adherent. The ureters thus stood out like two cords from above the middle of their pelvic position to their insertion into the bladder.

II. Both internal iliac arteries were tied.

III. Gauze drains were placed through the vagina, which probably came in contact with the ureters.

Nature of the Ureteral Injury.

Eight uretero-vaginal fistula, manifesting itself by a discharge of urine from the vagina on the tenth day.

Result: Patient died a year later from recurrence of the growth. Fistula persisted off and on until shortly before death.

Case III.— Mrs. A. M. Age 64. Gyn. No. 9256. Gyn. Path. No. 5757.

Diagnosis : Squamous cell carcinoma cervicis uteri.

Prognosis bad, for the growth had extended out to the edge of excision.

Operation : Hystero-salpingo-oophorectomy, combined abdominal and vaginal, preliminary catheterization of the ureters.

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Steps in the Operation Interfering with the Blood-Supply of the Ureters.

I. Both ureters were dissected free from about the middle of their pelvic portion to their entrance into the bladder.

II. The left internal iliac artery was ligated. On the right side the uterine artery was ligated at its origin.

III. The pelvis was drained through the vagina with gauze, which probably came in contact with the ureters.

Nature of the Ureteral Injimj.

Bilateral uretero-vaginal fistula; bilateral renal infection.

Convalescence : Uneventful until the tenth day, when urine appeared in the vagina and none was present in the bladder. A month later urine came from both vagina and bladder, and the presence of purulent urine in the bladder, with chills and fever, the temperature reaching 103° suggested renal infection. Six weeks after the operation, the vaginal leakage ceased. Cystoscopic examination made at that time showed that there was a stricture of the left ureter, for a catheter could be forced but 3 cm. into the ureteral orifice, while on the right side a catheter was passed 5 cm. into the ureter, passing three strictures, and purulent urine escaped from the catheter, thus indicating renal infection.

Result: A letter received from her physician a short time ago, 18 months after the operation, stated that at present there was no evidence of a return of the growth and that the patient was apparently in good health.

Case IV.— Mrs. N. B. Age 64. Gyn. Nos. 9493, 9534, 9881 and 10,168. Gyn. Path. No. 5758.

Diagnosis : Squamous cell carcinoma cervicis uteri.

Prognosis bad, for sections showed that the growth had extended out to the edge of excision.

Operation : Hystero-salpingo-oophorectomy, abdominal with Downes cautery clamp. Preliminary catheterization of the ureters.

Steps in the Operation Interfering with the Blood-Supply of the Ureters.

I. The left iireter was dissected free for its lower pelvic portion as the left broad ligament was involved by the growth.

II. Cautery clamps, which are apt to burn further than would appear, and by destroying surrounding tissue interfere with secondary collateral circulation, were used.

III. Pelvic drains of gauze, which probably came in contact with the left ureter.

Nature of the Ureteral Injury.

Left uretero-vaginal fistula. On the fifteenth day a large amount of watery vaginal discharge was noticed, and later a diagnosis of left ureteral fistula was made. Cystoscopic examination made four weeks after the operation showed that a portion of the urine came from the ureter into the bladder and a portion through the fistula. Leakage from fistula

stopped five weeks after the operation, or three weeks after the appearance of the fistula. The patient was readmitted September 5, 1903, three and a half months later. A diagnosis of bilateral renal infection made. Urine from both kidneys was turbid. Repeated washing out of both kidneys through renal catheters with silver nitrate, 1-3000, improved her general condition and she left the hospital much improved after remaining here two months. At this time there was no evidence of a return of the growth.

Patient returned January 5, 1903, after two months' absence. She felt better for the first few weeks but afterwards began to have pain in her left groin and large quantities of pus in her urine. Irregular nodular masses could be felt in the lower part of the i)elvis. The cancer had returned.

Result: Return of carcinoma. Bilateral renal infection.

Case V.— Mrs. C. H. Age 49. Gyn. No. 10,084. Gyn. Path. No. 6384.

Diagnosis: Squamous cell carcinoma cervicis uteri. Local growth all removed, but metastases were found in the lymph nodes of the parametrium.

Operation : Hystero-salpingo-oophorectomy, abdominal. Preliminary catheterization of the ureters.

Steps in the Operation Interfering with the Blood-Supply of the Ureters.

I. Both ureters were dissected free from their entrance into the parametrium to the bladder.

II. The uterine arteries were ligated and cut lateral to the ureters.

III. The pelvis was drained through the vagina with gauze, taking care that it should not come in contact with the ureters.

Convalescence: Patient did badly; died on the sixth day. Pulse rapid, temperature rose to 103.3° on the sixth day, but fell to 100.3° in the next eight hours, and just before death rose to 101.4°. Patient was drowsy, although the amount of urine excreted was over 1 liter a day after the first 48 hours.

Autopsy was negative. Cause of death not found. The ureters were carefully examined for any evidence of necrosis and in the right ureter, about 2 cm. above its entrance into the bladder, there was found a slight aneurysmal dilatation. Fig. XXII is a drawing made from a longitudinal section of the ureter at this place, showing that local necrosis has occurred and that the ureter is about to rupture at this point, thus giving rise to a ureteral fistula.

Result: Death as result of operation; cause not determined. Ureteral necrosis.

Case VI.— Mrs. A. M. Age 48. Gyn. No. 10,633. Gyn. Pajth. No. 6860.

Diagnosis : Squamous cell carcinoma cervicis uteri. Lymph node removed from the division of the loft common iliac into

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the internal and external branches was found to be carcinomatous.

Operation : VII, 25, 1903. Abdominal hystero-salpingooophorocystectomy. Freeing the lymphatics from the pelvic vessels and removing with them the uterus and growth, together with all the parametrium. The ureters were dissected free from their parametria! sheath by splitting it open lengthwise from its outer side. Preliminary catheterization of the ureters.

Steps in the Operation Interfering iviih the Blood-Supply of the Ureters.

I. Both ureters were dissected free from their parametria! sheath for a distance of 4 cm.

II. Both uterine arteries were tied at their origin.

III. Gauze drainage: (a) Through vagina, but gauze did not come in contact with the ureters; (b) sides of the pelvis lateral to the ureters were drained extraperitoneally through incision made just above Poupart's ligament on both sides. Possibly the lateral extraperitoneal drains came in contact with the ureter.

Nature of the Ureteral Injury.

Convalescence was imeventful until the thirteenth day, when urine appeared in the vagina. Flank drains were started in two days and removed in four days. Pelvic drains through vagina were all removed by the seventh day.

The patient left the hospital four weeks after the operation, with a severe cystitis, all the urine from the left kidney coming through the vagina.

Patient was readmitted two weeks later. Apparently all the urine from the left kidney came through the vagina.

Cystoscopic examination: Bladder apparently normal. Urine cultures showed a growth of colon bacillus. About one-half of the urine came through the vagina. IX, 15, 1903, 53 days after the first operation, the left ureter was resected and reimplanted in the bladder, through an incision parallel to Poupart's ligament, extraperitoneally. Cocain in the form of Schleich's solution was used as a local anesthetic. There was no evidence of leakage until the eighth day, when apparently about half of the urine came through the inguinal incision. Firm pads were placed over this incision and a tight bandage was put in; the leakage ceased but the amount of urine passed through the bladder did not increase. The patient did not have any untoward symptoms. A week later the amount of urine excreted each day had gradually increased, but did not reach the amount passed before the leakage had occurred. As no urine appeared at the site of the inguinal incision, a probable diagnosis was made of occlusion of the ureter. This was apparently confirmed by cystoscopic examination. The end of the ureter could be seen in the bladder, but repeated examinations over long periods of time failed to show any evidence of urine coming from the ureter, and repeated attempts at catheterizing the ureter failed. The catheter could be passed in about 1 cm.

and then met an obstruction. The most probable diagnosis was that a second ureteral fistula had resulted from ureteral necrosis, and as it had time to become imbedded in scar tissue before forming, firm pressure had favored an occlusion of the ureter with a resulting cure of the fistula, but at the same time destruction of the kidney without any localizing or constitutional symptoms.

Pathological Changes Caused by Freeing the Ureters.

In the consideration of the above the ureter is not the only part concerned, but of still greater importance is the integrity of the kidney, whose function is dependent on an intact ureter, and also the effect of the escape of urine sterile or infected into the retroperitoneal tissue or into the general peritoneal cavity, should a ureteral fistula form as the result of the injury.

Conclusions based on anatomical studies, animal experimentation and the review of cases reported in the literature, justify one in saying that many liberties may be taken with the ureter, but that injury to its outer perimuscular fibrous coat, in which is situated the periureteral arterial plexus, is likely to cause ureteral necrosis.

The basis of this work is formed for the most part from experiments on dogs, but in a few instances I have been able to study the ureters of patients who have died after operations in which the ureters have been freed. The blood-supply of a dog's ureter is very similar to that of the human being, so experiments may be done simulating the various steps in operations involving the ureter, and the results of these experiments may be studied at different stages in the process of ureteral necrosis. The final results of these experiments, i. e., whether necrosis occurred or not, have already been referred to in this article. I shall now describe the pathological changes taking place in the ureter itself as a result of interfering with its blood-supply, and also the changes in the other parts and organs affected by the injury.

One must consider two classes of cases; first, those in which necrosis does not occur; secondly, those in which it does take place.

I. Changes which Take Place when Xecrosis Does NOT Occur.

These changes manifest themselves in disturbances in the circulation of the ureter and thus an impairment of its function; and secondly, in the results of adhesions forming about the ureter with the chance of causing a stricture of the ureter.

A. Circulatory Disturbances, not Sufficient to cause Ureteral

Necrosis.

1. Arterial. — The first effect of injuring the outer coat of the ureter is a diminished blood-supply to that part of the ureter, but this may soon be compensated for by a hypertrophy of the smaller vessels of the plexus which have not been injured and necrosis may thus be avoided. Later on, as adhesions form newly-formed vessels arise in the adhesions, some

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extending from the surrounding tissue to the ureter and others from the ureter into the surrounding tissue. See Figs. Ill, IV, and V.

2. Venous. — In freeing the ureter, veins are injured as well as arteries, and as there is a very free anastomosis of the deep ureteral veins, these may become greatly engorged, as shown in Fig. VI, from a patient dying on the fifth day from intestinal obstruction, following a radical operation for cancer of the uterus in which the ureter had been freed, with but very little injury to the ureteral vascular plexus.

The only effect of these circulatory disturbances of the ureter which can be appreciated is that the ureter becomes swollen — compare Figs. IV and V— and this may embarrass the kidney by ofiPering resistance to the escape of urine from that organ.

The ureter may be kinked or the adhesions may form a stricture giving rise to partial or complete ureteral obstruction, just as intestinal obstruction may occur. I have seen such conditions result from experimental work on dogs, and Fig. VII represents a hydro-ureter as a result of adhesions formed around a freed ureter, the patient' dying on the ninth day from renal infection of the opposite kidney.

II. Ureteral Necrosis.

Two distinct classes of cases must be considered ; first, those in which a fistula does not form ; secondly, those in which the ureter ruptures and there follows an escape of urine into the surrounding tissue.

1. Ureteral Necrosis in which a Rupture Does not Occur.

The first change which manifests itself is an extravasation of blood into the ureteral tissue between the epithelium lining the lumen and the muscular coats. This condition is associated with necrosis of the part and is probably dependent on the necrosis; in other words, the condition is that of a hemorrhagic infarction. See Fig. VIII. This may be localized or may involve the ureter for several centimeters, depending on the extent of the injury. As the condition progresses the infarcted area becomes more distinct, the center failing to take the hematoxylin stain, while about the periphery can be seen a deeply stained border caused by the fragmentation of nuclei and the proliferation of cells outside of these. Fig. IX. This condition causes a swelling of the ureteral tissue with a resulting narrowing of the ureteral lumen, so that at the junction of the necrotic and living portion of the ureter a stricture develops (Fig. X), giving rise to a hydro-ureter above (Fig. XI), while below the necrotic area the ureter becomes swollen and here one can see the compensatory hypertrophy of the smaller ureteral arteries. Compare Figs. XII and XIII. While this condition has been going on the ureter has become imbedded in adhesions which protect the ureter and help prevent a rupture, Figs. IX, X, and XIV. Later on, at the end of two or three weeks, newly

formed vessels begin to penetrate the necrotic portion of the ureter and convert it into fibrous tissue (Fig. XIV) or the central necrotic portion may slough with a complete loss of the mucosa and muscular coats. Fig. XV. The extent of the process depends on the extent of the injury; the inner coats are affected first, and the outer fibrous coat becomes hypertrophied and very resistant (Fig. IX) and soon newly formed vessels enter it from the surrounding tissue with which the ureter may come in contact (Figs. XIV and XV). These newly-formed vessels maintain the nourishment of the outer ureteral coats but the inner coats have already become necrotic, and while vessels may invade it, the mucosa and muscular tissue have already been destroyed and the ureter may be converted into a fibrous cord.

The effect on the kidney is that of a progressing ureteral stricture (See Figs. XVI, XVII, XVIII, XIX) with corresponding hydro-ureter, hydro-nephrosis, anjd destruction of renal tissue. In some cases when the injury is light the kidney may continue to function with a persistent ureteral stricture, while in others, the kidney may be thrown out of function by destruction of the ureter. Added to these changes is the danger of ascending renal infection.

2. Ureteral Necrosis Leading to a Ureteral Fistula.

Why does a fistula occur in some cases and not in others? The first portions of the ureter affected are the inner coats, and the outer perimuscular fibrous coat is the last part affected; while necrosis is occurring in the inner coats of the ureter, the outer coat is becoming imbedded in adhesions. If the necrosis is very extensive or there is anything to prevent the formation of adhesions, which splint and protect the ureter, or if the adhesions are insufficient, then a fistula is likely to form. When the injury is verj' extensive, then the ureter for a long distance may be destroyed and exist as a friable necrotic tube, which, unless firmly imbedded in adhesions, will permit of an extravasation of urine. On the other hand, if the necrosis is more localized and the necrotic area is not well protected by adhesions, then an aneurysmal dilatation will occur at this place, which is likely to rupture and give rise to a ureteral fistula. In Fig. XXII this aneurysmal dilatation due to localized necrosis is shown. The specimen was obtained from a patient who died six days after the operation, the cause of death not being determined at autopsy. It is impossible to state whether in this specimen the early condition of the process was that of a hemorrhagic infarction or that of an ulceration. Judging from experimental work, it probably began as an infarcted area.

The effect of the formation of a fistula depends upon whether it becomes encapsulated or finds an outlet, and also of the greatest importance, whether or not the urine becomes infected. When the opening is small there may be an extravasation of urine and a final healing of the fistula. I scraped a dog's ureter with a sharp knife imtil a fistula appeared. It was dropped back into the peritoneal cavity discharging urine from the fistula, yet when the dog was killed 53 days later, the only trace of the injury was that the ureter was imbedded

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in adliesions at this place. On the other hand, the injury may be more extensive, with loss of iiroteral tissue, and if the urine becomes encapsulated, as shown in Fig. XX, the ultimate result is throwing the kidney out of function by destruction of the ureter. The extravasated urine may become infected and escape into the peritoneal cavity, giving rise to general peritonitis, as occurred in one dog; or may lead to renal infection; or, as shown in Fig. XXI, the urine may become encapsulated, then infected, and by direct extension up along the ureter a paranephritic abscess may be formed. Another possibility is that the urine may find an outlet, and the formation of a uretero-vaginal fistula is the usual indicwtion of post-operative ureteral necrosis.

Etiological Factors in the Causation of Ureteral Necrosis. These may be:

1. Injury to the periureteral arterial plexus. 8. Injury or ligation of the ureteral arteries themselves, or arteries which furnish these vessels.

3. Anything interfering with the formation of adhesions about the ureter, which splint and protect the ureter, and through which vessels may come to the ureter ; as,

(a) An infection.

(b) An exudate.

(c) Foreign bodies, as gauze, etc., separating the ureter from the surrounding tissue.

(d) Necrosis of the tissue with which the ureter comes in contact, as might result from the use of the cautery.

4. Stricture of the ureter below the injured area, thus distending the weakened ureter.

When the uterine artery is tied at its origin, the ureteral vessels derived either directly or indirectly from this artery are destroyed; furthermore, if the ureter is dissected free, ureteral arteries coming from other vessels to that portion of the ureter are also destroyed, as from the vaginal, middle and inferior vesical arteries. By the above procedure the bloodsupply of the lower 4-6 cm. of the ureter has been destroyed, except that coming from above through the periureteral arterial plexus, which we know is snflScient to prevent necrosis. If the ureter is handled roughly in shelling it out from its sheath, or from adherent cancerous tissue, there is danger of ureteral necrosis, for the smaller blood-vessels within the ureteral wall are too small and few in number (even if they do anastomose with each other?) to nourish the ureter but for a very short distance. It can readily be seen that an exudate or infection about the injured ureter would increase the liability of necrosis, as would also gauze, necrosis of the surrounding tissue, and anything interfering with the function of the ureter. To the above must be added the possibility of general lowered resistance.

Diagnosis of Ureteral Necrosis.

There are two distinct classes of cases which must be considered, one in which necrosis occurs but a fistula does not

form, and a second in which the well-known tell-tale fistula arises.

In the first class of cases we are dealing with the gradual formation of a ureteral stricture, which may be temporary or permanent, and which may even lead to occlusion of the ureter. In the absence of infection, and if the patient recovers, this will probably never be diagnosticated unless a cystoscopic examination is made and the ureters are catheterized. Even if the patient dies, the injury could easily be overlooked. If renal infection occurs the diagnosis may be very difficult. I have had two patients die from ascending renal infection following these operations, one on the ninth and the other on the seventeenth day.' In one case, the ureters had been resected but not in the other. Both patients were free from pain and there were no symptoms referable to renal infection except the fever and constitutional symptoms associated with it. Even should urine escape, unless it manifests itself by escaping through the vagina or abdominal incision, its diagnosis would be very difficult, for it might become encapsulated, the kidney finally cease to function and the results would be similar to those cases in which the ureter became occluded. Should the urine form a mass which could be palpated in bimanual examination, then a diagnosis might be made; or should the injury lead to a hydronephroitic mass which could be palpated, then some injury to the ureter would be suspected. The most important aid in diagnosing these injuries is keeping an accurate account of the amount of urine obtained from the bladder, which should be measured every 4 to 6 hours. A sudden diminution in this amount, especially if associated with any constitutional disturbances, suggests that there may be some ureteral injury, and if marked enough would warrant a cystoscopic examination and catheterization of the ureters. One must remember that the ureter may become completely occluded or a renal or pararenal infection may take place without a single localizing symptom. While localized pain helps in such a diagnosis, the absence of such pain does not exclude such conditions. The appearance of urine through the vagina or abdominal incision makes clear the diagnosis of a ureteral or vesical fistula. I shall not go into the differential diagnosis between the two. The earliest day at which a ureteral fistula appeared in our cases was the ninth, and the latest the fifteenth. Wertheim ° reports a case in which the escape of urine did not appear until after three weeks.

Prognosis of Ureteral Necrosis.

In those cases in wliich a fistula does not form, the ureter may recover with but little or no interference with its function. On the other hand, the injury may be sufficient to cause a temporary or permanent stricture, or even complete occlusion with corresponding renal insufficiency (Figs. XVI, XVII, XVIII and XIX). Associated with these changes is the danger of renal infection. Even when the ureter ruptures and an extravasation of urine occurs, the ureter may recover if the opening is small, as shown by this experiment. I scraped a dog's ureter at one place until an opening in the

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ureter was made, and yet when the dog was killed, 53 days later, the ureter was pervious, and the same repair may take place in women, as shown by the spontaneous healing of those cases in which a fistula develops. When an extravasation of iirine occurs and the ureteral injury is too extensive to heal, then undoubtedly the urine may be absorbed, the ureter occluded, and the kidney functionally destroyed. Of great danger in these cases is the chance for infection with the formation of a localized abscess or the possibility of an ascending renal infection. This infected urine may become localized or may spread, causing a general peritoneal infection, as occurred in one dog, or an ascending para-ureteral infection with the formation of a paranephritic abscess (Figs. XXI and XXIV).

Prognosis When a Uretero-Vaginal Fistula Forms.

This fistula may heaJ spontaneously, as two of our six cases did, one of which was double, thus making three fistulas. In Case No. Ill the leakage ceased 33 days after its appearance, and in Case No. IV, 31 days; but in both instances ureteral stricture resulted with renal infection, as sliown by catheterizing the ureters and making cultures from the urine from each kidney.

The fistula may persist for a long time. In Case I it persisted until death two months after its appearance, apparently from renal infection ; while in Case II it persisted until " shortly before death," from a recurrence of the grovrth one year after the operation. The greai; danger associated with a ureteral fistula is that of ascending renal infection. This occurred in at least three of the five cases in which a fistula developed, i. e., Cases I, III and IV, Case I probably dying as a result of renal infection.

Treatment of Ureteral Necrosis.

Unless a uretero-vaginal fistula forms the diagnosis is very difficult. Should the necrosis be bilateral and a fistula not form, then renal insufficiency might develop from partial or complete occlusion of the ureters. Catheteriziug the ureters might not only make the diagnosis, but possibly temporarily relieve the condition. In some cases an exploratory laparotomy might be necessary in order to form a ureteral fistula or implant the ureters into the bladder should the condition of the patient permit it. If an extravasation of urine occurred and was diagnosed, it should be opened and drained.

What shall he done with the ureitero-vaginal fistula? Some will heal spontaneously, but with stricture, and in many instances an ascending renal infection. Nephrectomy will cure not only the fistula but also the renal infection of that ,side. A surgeon can argue justly that an infected kidney with a strictured ureter is an organ dangerous to life and should be removed. There is one great drawback to nephrectomy in these cases, and that is the danger of renal insufficiency. For in the original operation both ureters had been freed, and while a fistula may have formed only in one, there is abundant opportunity for renal insufficiency of the other

kidney resulting from partial or complete obstruction of its ureter, as a result of its having been freed at the previous operation. Nevertheless, one may find in the literature such cases cured by nephrectomy, and Wertheini' reports two such cases in a paper previously referred to in this article. Should one contemplate such treatment, the sufficiency of the other organ ought to be determined first.

Plastic operations, such as turning the fistula into the bladder through the vagina, will undoubtedly relieve some cases, but the renal infection and the stricture, botli of which are probably present, especially the latter, are not likely to be relieved by such an operation, for the stricture is in most cases responsible for the maintenance of the renal infection.

Eesection of the ureter and reimplantation into the bladder seem to me to offer the best chance of maintaining the renal sufficiency, relieving the stricture and curing the renal infection if present. This should be done extraperitoneally and the wound freely drained at the close of the operation. I realize that such an operation is very difficult, for the ureter is imbedded in scar tissue and there is great danger of ureteral necrosis occurring from dissecting the ureter from this tissue. Nevertheless, it saves a kidney, which is especially desirable when the other organ is likely to be insufficient. I did this in one case. No. VI, and ureteral necrosis probably occurred, but the patient was cured by a probable occlusion of the ureter, as has been described. Fortunately, the other kidney had escaped and was sufficient.

The Avoidance of Ureteral Necrosis.

Anatomical, experimental and clinical experience have taught lis that many liberties may be taken with the ureter without causing necrosis. On the other hand, an injury to its outer loose perimuscular fibrous coat, which contains the periureteral arterial plexus, is likely to cause ureteral necrosis. This plexus may be injured by cutting off its blood-supply by the ligation of ureteral arteries or the larger vessels from which these arteries arise, as the uterine, anterior branch of the internal iliac, or the internal iliac artery itself. This injury alone probably never results in ureteral necrosis, for if the plexus itself is uninjured the ureter may be nourished from the renal artery alone. I liave injected the entire ureter and portions of the bladder and uterus by injecting the renal artery alone, using a granular injection mass which could not pass through the capillaries, thus demonstrating that the entire injection was arterial and that an arterial communication existed between the bladder and the kidney through the ureteral arteries. Nevertheless, in all operations tliere sho\dd be as little injury to the blood-supply of the part as possible. Consequently, in these operations the ligation of the uterine artery alone is sufficient and attended with less danger than the ligation of the internal iliac artery or its anterior branch.

The most important etiological factor in the causation of injury to the periureteral arterial plexus is the actual injury to the plexus arising from handling the ureter roughly after it has been freed from the sheatli which protects the ureter

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and its plexus. When the ureter has been isolated and all vessels cominji: to that part have been cut off by freeing the ureter, that portion of the ureter freed must be nourished by vessels coming from above through the plexus, and if the plexus is injured in dissecting the ureter free, necrosis may occur.

Clinical experience and a study of the parametrium shows that the tissue about the ureters should be removed in these operations. Anatomical, experimental, and clinical studies demand that the periureteral arterial plexus must be preserved.

Two ways of preserving the periureteral arterial plexus present themselves: First, to dissect the ureter with its sheath free, thus preserving the arterial plexus; secondly, to resect the lower ends of the ureters and implant the renal ends of the ureters into the bladder. The dissection of the pelvic ureteral sheath free from its surrounding structures is difficult, for it is derived from these, as shown in a previous article ; ' likewise, the sheath frequently becomes involved in the extension of the growth, and while this procedure may be possible in the early cases it is attended with the danger of leaving disease behind in the more advanced ones, and unfortunately a positive diagnosis of cancer in the parametrium can only be made by the use of the microscope. On the other hand the ureter may be shelled out from this sheath and if great care is taken necrosis will not occur but if the plexus is sufficiently injured necrosis will take place, and of great importance a new sheath may be derived from the surrounding tissue.

The removal of all the tissue from pelvic wall to pelvic wall with the lower ends of the ureters offers the greatest •chance for a cure, and at the same time the ureteral sheath and periureteral arterial plexus may be preserved, for the portion of the ureter which is above the parametrium lies "beneath the peritoneum, and this peritoneal flap may be "brought down and, with the ureteral sheath, sutured to the bladder. The suturing of the sheath and the peritoneum to the bladder relieves the tension of the implantation, and the periureteral arterial plexus is preserved and also the ureteral sheath. Against this procedure are the uncertainties of the uretero-vesic^l implantation and the danger of ascending renal infection. Careful work should minimize the chance of failure in the uretero-vesical implantation, and possibly the formation of a vesico-vaginal fistula at the close of the operation will lessen the danger of ascending renal infection, as discussed in previous articles.^- ^ ^"'^

Other accessory etiological factors in the causation of ureteral necrosis must be considered and avoided if possible. The presence of an exudate or infection will endanger the vitality of the injured periureteral arterial plexus, and on this account the area must be drained. On the other hand, the presence of gauze placed between the injured ureter and the surrounding tissue is a foreign body which deprives the ureter of any nourishment and support (splinting) which it may receive from this tissue with which it should come in contact. When the area is drained care must be taken not to have the ilrain come in comtaet with the ureter. The condition

of the tissue which the ureter rests upon after freeing is most important, for if the vitality of this tissue is preserved the ureter will become adherent to it and will be nourished by it. On the other hand, if the vitality of this tissue is interfered with, then the ureter will not only be deprived of this nourishment but will lie in contact with necrotic tissue, which will predispose the ureter to necrosis. The following conditions interfere with the nourishment of this tissue:

1. The ligation of large vessels, as the internal iliac or its anterior branch, which are unnecessary.

2. The use of the cautery or cautery clamp, destroying this tissue.

3. Unnecessary mass ligatures.

4. Exudates and infection.

An avoidance of the above will greatly aid the preservation of the blood-supply of the ureter, no matter what the nature of injury or operation involving it.

Conclusions.

I. The ureter passes through tissue which should be removed in every instance of hysterectomy for carcinoma cervicis uteri; as shown by:

1. The large percentage of recurrences after liysterectomy for this disease ; 88 per cent of the cases operated upon in this hospital, after a period of five years, showing recurrences (cases reviewed in October, 1902).

2. The renal insufficiency resulting from a compression of the ureters by the extension of the disease.

3. The accidental injury to the ureters in the operative treatment of the disease; 19 in 156 hysterectomies for carcinoma cervicis uteri, as compared with 11 instances of accidental ureteral injury in 4513 other major gynecological operations in this hospital.

4. The proximity of the cervix to the ureters and the relation between the two may be greatly altered under physiological conditions, by steps in operations and by pathological processes.

5. Kundrat has shown that the parametrium was involved in 44 of 80 operable cases, and that in half of these cases the parametrium was able to check the further progress of the disease.

6. A study of the parametrium, in those cases in wdiich the ureters have been resected shows that it takes but very little involvement by direct extension or metastases for the growth to reach or extend beyond the ureters and that the presence of this growth can be diagnosed only with the microscope, as I have emphasized in a previous article."

II. The pelvic portion of tlie ureter lies in a sheath which protects the ureter and its periureteral arterial plexus and is derived from the tissue through which the ureter passes, and on this account the isolation of the ureter with the sheath is very difficult. On the other hand, the sheath may be split open and the ureter easily shelled out.

III. The effect of freeing the ureter irom its sheath manifests itself in the opportunity for partial or complete ureteral obstruction resultinsc from the kinking or imbedding of the

134

[No. 157.

ureter in adhesions (Fig. VII) and also in circulatory disturbances resulting from injury to the blood-supply of the ureter, which vary according to the severity of these disturbances and may present the following conditions :

1. Injuries to the larger branches of the ureteral plexus, where the smaller branches are able to enlarge and maintain the nourishment of the ureter, thus preventing necrosis (Figs. Ill, IV and V).

2. Venous congestion due to injury of the larger veins, causing distension of the deeper ureteral veins which anastomose freely with each other (Fig. VI).

3. Necrosis of the ureter which may or may not give rise to an extravasation of urine, depending on the extent of the injury and whether or not the ureter becomes imbedded in adhesions.

IV. Necrosis of the ureter apparently begins as a hemorrhagic infarct and the inner coats of the ureter are the parts first affected, while the outer perimuscular fibrous coat is the part last affected. In the early stages hemorrhage with necrosis is noticed first in the tissue beneath the epithelium (Fig. VIII). The size of the area involved and also the extent of the process depends on the severity of the circulatory disturbances. Later on the tissues in the infarcted area fail to take the hematoxylin stain, while about the periphery of this area is a deeply staining border, due to fragmentation of nuclei, and proliferation of cells outside of these (Figs. IX and X). The outer fibrous ureteral coat becomes greatly thickened (Fig. IX) unless it also becomes necrotic.

V. Rupture of the ureter may not occur because the necrosis was not extensive enough, and also the ureter may become imbedded in adhesions which splint it and help nourish the outer ureteral coat by means of vessels coming in from the surrounding tissue (Figs. XIV and XV). The effect of necrosis is a stricture due to swelling caused by the necrotic tissue. This stricture may be temporary or permanent, depending on the severity of the process, or the necrosis of the ureter may be so extensive as to cause complete occlusion of the ureter with loss of function of the kidney (Figs. XVI, XVII, XVIII and XIX).

VI. Rupture of the ureter may occur, leading to an extravasation of urine, which may become encapsulated (Fig. XX), if infected lead to renal or pararenal infections (Fig. XXI) or other localized or diffuse infectious processes. When the urine finds an outlet through the vagina or abdominal incision a ureteral fistula is formed which w the usual manifestation of ureteral necrosis. The ureteral rupture is due to the extent of the necrosis, especially if the outer ureteral coat is involved, and the failure of the ureter to become imbedded in adhesions due to gauze, exudates, infection, or sloughing of surrounding tissue.

VII. Ureteral fistulse may heal spontaneously, but probably always with a stricture and frequently with renal infection, which may cause the death of the individual. Frequently they persist over long periods of time with all the dis

comforts and dangers associated with this condition. In some eases they may close, with occlusion of the ureter and a loss of function of the kidney.

VIII. The most important etiological factor in the causation of ureteral necrosis is injury to the periureteral arterial plexus, arising from tearing or otherwise injuring the plexus, as may occur in dissecting the ureter free. Other etiological factors must be considered, as the ligation of vessels supplying the plexus, exudates, infection, destruction of tissue about the ureter, as would result from the use of the cautery, foreign bodies against the ureter (as gauze), pressure on the ureter, stricture below the injury, and lowered general resistance.

IX. Dissecting the ureter free from its sheath in these operations is attended with danger of interfering with the fimction of the ureter and of causing ureteral necrosis, and should be avoided when possible and if done great care should be taken not to injure the periureteral aiierial plexus.

References.

1. Sampson : Ligation and Clamping the Ureter as Compli cations of Surgical Operations. American Medicine, 1902, IV, 693-700.

2. The Relation Between Carcinoma Cervicis Uteri

and the Ureters, and its Significance in the More Radical Operations for that Disease. Johns Hopkins Hospital Bulletin, 1904, XV, 72-84.

3. KuNDRAT : Ueber die Ausbreitung des Carcinoms im para metranen Gewebe bei Krebs des Collum Uteri. Archiv fiir Gynaekologie, 1903, LXIX, 355-409.

4. Wertheim : Zur Frage der Radikal Operation beim

Uterus Krebs. Archiv fiir Gynaskologie, 1900, LXI, H. 3, S. 662.

5. Sampson: The Importance of a More Radical Operation

in Carcinoma Cervicis Uteri, as Suggested by Pathological Findings in the Parametrium. Johns Hopkins Hospital Bulletin, 1902, XIII, 299-307.

6. The Efficiency of the Periureteral Arterial Plexus

and the Importance of Its Preservation in the More Radical Operations for Carcinoma Cervicis Uteri. Johns Hopkins Hospital Bulletin, 1904, XV, 39-46.

7. Ascending Renal Infection; with Special Reference to the Reflux of Urine from the Bladder into the Ureters as an Etiological Factor in its Causation and Maintenance. Johns Hopkins Hospital Bulletin, 1903, XIV, 334-352.

8. Wertheim: Ein ncucr Beitrag zur Frage der Radikal

Operation beim Uterus Krebs. Archiv fiir Gyneekologie, 1902, LXV, 1-39.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL. 1904.

PLATE XVII.

brauches of the aoiMa. renal, ovarian, internal iliac, uterine, and vaginal arteries, marlced. A, K, (>, I, TJ, and V.

rterus drawn upwards and to the risht. I ho tube and Dvary have been rt'inoved.

Contracted bladder, drawn downwards and to the ri^bt.

Ovario-Uenal Anast. Anastomosis between (he subperiloneal branches of the nretero-sul)peritoneal arteries, arising from the renal and ovarian arteries.

• * Anastomosis between the uterine and ovarian arteries, cut away

by the removal of the tube and ovary.

Rr. r. linineh from the periureteral arterial [)l("xus. supplying the tissue about tbc un'l^r.

Anas. Br. I*. Anastomosis lietween the sul)peritoii('al branch of the aortic uretero-subperitoneal artery, and a branch arising from the plexus.

Sup. Ves. Anas. Anastomosis of the superior vesical artery of one ^ide with the superior vesical artery of the other side.

^'^'> 1%9'^f.f- "

IU:. I. TmO rKiarUKTEKAL AlETKKlAL PLEXUS FHOM A Wo.MAX 21 YKARS

Or.D, X 4/5. Left Urkter.

The left rt-nal and right internal iliac arteries were injected with a 15 per cent solutirm of gelatine, colored wilb ult raniiirine blue. The organs were removed and hardened in 10 per cent formalin. The drawing was made from the dissected hardened specimen.

The periureteral arterial plexus in this instance is derived from

.P^yi- Ureteral arfericl PUxus

ex

f

r.iV

V f

c.

fe:^^i0V

"Ureteral SheQ.th. Fig. II. — Cross Section op Uheter, Showing

THE PEnlUKETEEAL ARTERIAL Pi.ESfS, AND

THE Ureteral Sheath, in a Woman, 21 Years Old, x 5. Right Ureter.

The left renal and the right internal iliac arteries were injected with a 15 per cent solution of gelatine, colored with ultramarine blue. The organs were removed and hardened in 10 per cent formalin. The drawing was made from a cross section of the right ureter taken about li) em. above the uterus. Same case as one from which Fig. I was made.

For the sake of clearness, onl.v the ureteral arteries are drawn, as injected. The capillaries and the veins were not injected. The periureteral arterial plexus, situated within the ureteral sheath, can iie seen cut across as well as the small arteries in the walls of the ureter. This sheath is apparently derived from the pelvic connective tissue and serves as a protection to the ureter and its periureteral arterial plexus. The arteries in the ureteral walls are small in size and number and on this account, even should the.v communicate freely with each other, would not be able to nourish the ureter for any great distance if the periureteral arterial plexus was destroyed.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL, 1904.

PLATE XVIII.

St,^ Mer. Ar

CornpenSdtotj hyJ>etT7Ofi/iy o-f tfii SfiialUrbr ancftes Of tAc uretcyal bU'XUS uy\d fA« f-erm ufion oiiitw vessels iron TAc/>/ctus c^Uncf /n^ oaf info /At sur~ Toixndino tissue

Vesicul Crti

<ty fcr/rted veSSeis ^O'HQ to Thf Ureter

formtd altoui the

Mreler

Fig. III. — Restoration of thk Blood Supply of

THE UUETEK FOLLOWING INJDRY TO ITS PERIURETERAL Arterial Plexus. Dog No. 1, X 1.

Portions of the arterial plexus of the lower two-thirds of the left ureter were torn off with forceps, injuring the main trunks of the pelvis.

The dof: was killed at the end of two weeks and the descending aorta was injected with 15 per cent gelatine, colored with ultramarine blue.

The ureter of the dog is nourished by a periureteral arterial plexus similar to that found in human beings, the main trunks being more loosely attached to the ureter than its smaller branches and are therefore more easily injured.

Following injury the ureter becomes imbedded in adhesions and there is a hypertrophy of the smaller branches which have escaped injury and likewise new vessels arise from the ureter and from the newly-formed adhesions about the ureter.

\ pie x us

Coo^ VSm«;/ hraneAft of ir/ep-tal

Co.f

%>:-

Fig. IV. — Cross Section oif a Hog's Ukktkii. Showing the Relation

Between the Main Trunks ok the I'kku'iieteuai. Ahteriai. Plexus

AND Their Smaller Branches. Dog. No. 9, x 8.

The left ureter of a dos was freed for nearly its entire leii;;lii and portions of the arterial [liexiis were slriiiped oIT. The dos was killed at the end of two weeks and the deseendInK aorta was injected with IT) per cent t'elatlne. colored with ullramarlne blue.

This illnstratinn Is from the unin.1nred iH'eter and shows (hat the main trunks of the plexus are bni loosely attached to the ureter, while the smaller branches are more deeply Iniliedded In the outer perimuscuiar Hbrous coat of the ureter, and on Ibis account It Is difficult to Injure them. Note the small size and number of the deeper ureteral arteries, for ultramarine blue being granular docs not enter the capillaries.

Pig. v. — Cross Section of a I)o(!'s IhiETER, Showing the Compensatoet

IIvrERTBorHV of the Smaller liRAS-ciiKs of the Arterial Plexus

Following 1n.iurv to Its T.aihier Trunks. Dog No. !•, x S.

From same dog as illu.stralcd iu Fig. IV. Cross section of injured ureter. The main trunks of the arterial plexus, shown in Fig. IV, have been stripped oH from the ureter, bul Ihe smaller braucbes. also shown in Fig. IV. being imbedded in (be outer perimuscuiar librous coat of the ureter, escaped injury and have liccouu> hypertrophied, thus maintaining the nourishment of the ureter. The ureter itself has become thickened.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL, 1904.

PLATE XIX.

Quttr //erOnusciiUt- ^ibteus coat

Throw 6oSeU Vein

M y<:/yo-U,rc'?er

^l^.^-^

Fin. VI. — Ciioss Section of a Uueteu wiiii-h has been Freed in tiii: MiiKE Uadicai, Operation for Carcinoma Cervicis Uteri, Showim; THE Passive Conge.stion Due to lN.riiHV of the Larger Vein.s. Gvx. No. 10.4n4. Gyn. Path. No. 671.5, X 6.

Patient died on tlie otli day from intestinal olistrviction. The lower portion of the ureters had been freed in the operation and this specimen was obtained from the freed portion of the right ureter.

There is a free anastomosis of the deeper ureteral veins and when the outer main trunks are injured these deeper veins becnine engorged, as shown in the drawing, probably interfering somewhat with the function of the ureter, and thus possibly the passage of urine from the kidney to the bladder.

IJ&moryna'jtL W(// oe^imji^JV Necros^JS

Fig. VII. — IIvniioi-RicTEu Kksiji.ting from Freeing tub Ureters in the More Kahicai, Oi'Erations for i,Ain,iN2^' _ Cervicis Uteri, thus Depriving the Ureter of its Sheath and Rendering it Liable to Partial or Complete Ureteral Obstruction from it.s Becoming

iMBEDOKn IN AlMIESIONS. (lYN. No. 10,4:i2, X 6.

Patient died on the ninth day from ascending renal infecliuu of the right kidney. The left ureter, where it had been freed, was imbedded in adhesions, giving rise to a hydroureter abuve.

\ lumen tf Utttter

•.-^3^

",<K- V?'

^'

Fig. VIH. — Cross Section op Dog's Ureter. Showing Beuinxixg

Necrosis as the Result of In.tukv to the Peru retehal

Arterial Plexus. Dog No. 22, X 8.

The left ureter of a dog was freed for 4 cm. and then the periureteral arterial ple.xus was removed aud the ureter scraped on all sides for a distance of 2 cm., thus not only destroying the main trunks of the arterial plexus, hut also injuring the smaller branches which are more adherent to the ureter t see Fig. IV). Tlie dog was killed in two days.

The necrossis manifests itself as a necrosis with hemorrhage into the tissues just beneath the epithelium.

Fig. IX. — Cross Section of a Dog's Ureter, Showing Necrosis of all

THE Ureteral Coats Except the Outer Perimuscular

Fibrous Coat. Dog No. 5, X 8.

The lower portion of the ureter was freed and portions of the arterial Iilexus were removed with forceps.

The dog was killed at the end of one week aud the descending aorta was injected with 1.5 iier cent gelatine, colored with ultramarine blue. The ureter had become necrotic for a distance of 2 cm. This represents a section through the necrotic area, showing that the outer librous coats had escaped. The inner coats ijresent the picture of a hemorrhagic infarction, the epithelium has disappeared and the central portion fails to take the hematoxylin stain, while about this is a deeply staining border caused by the fragmentation of nuclei and proliferation of cells.

islthJeel Vretei

Str:tturt,

>rtuicu(ii V Cobi

Wec>-cs/s ojurtte^

I'lO. X. — Longitudinal Section of a Dog's Ureter at the Junction of A Necrotic with an Intact Portion. Dog No. 5, X 8,

One can sec how the necrosis begins in the inner coats of tlie ureter and leads to swelling with stricture, causing hydroureter above, and below preseuliug (he picture sliowu in Fig. Xll. Compare this drawiiu' with the one shown in Fig. Xlll, whicli is the normal ureter from the eame dog.

Hyam -urcfet

p^s

V\>;. XI.

-C'Ross Section of Hydroureter Caused by Stricture Below, Due to Ure'i'ehal Necrosis. Dog No. .">. X 8.

Same dog as shown In Figs. IV and V. Section laken above the stricture siunvu in Fig teiision of the lu'oter caused by the necrosis below.

X, showing the dis

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL, 1904.

PLATE XX.

ThieXnttJ /toytrrt"S<iaf/,-6yoi<f

-* rSuy

Fig. XII. — Cross Section of TTitiOTioit Bklow Necrotic Portion'. Show i.Nc Distention ani* Hypertrophy of Deeper

T'reteuai. Vessels. Dog No. 5, X 8.

Section taken just below necrotic area sbow'n in Fij^. X The ureter is much swolleu aiul tlie deeper ureteral arteries are hypertrophied and distended, due to injur.v of the arterial plexus. Comiiare with Fig. XIII. which represents a cross section nf ttic normal ureter from the same dog.

Fig. XIII. — Cro.ss Section of Dog's Uheteh. Showing Nokmae Arterial Hlooii Supplv. Doc No. 5, X 8

Normal ureter from same doy as illustrations shown in Figs. IX, X, XI and XII. with which compare, noticing the difference in the size of the deeper bluod-ves.sets and of the diameter of the ureter in the injured and intact ureter.

New/y -foym^d vesseh a/.s/rrj ie/«.ee^

Lumen o{ Ut-ei^r

Nucoja

/;"•>

>

i

>.-./: '.

Thickenetl />er('"MS- / ,

Ne>w«

' ^^^

Fin. XIV. — Ciioss Sectio.n of Duc'.s nuKTKii, Showing Nr.ciio.sis ok

I.NNKIl C'OAT.S, WITH NKWLY FORJIEn VeSSKI.S LWAWNG

THE Nechotic Tis.sme. 1)00 No. 7, X S.

LarRcr vessels of ureteral plexus were stripped fvuni tlie lefl iiri'ler and boll) ulei-Ine arteries were li^ated.

iioy was Itllied in tliree weelis and doseondin^ aorta was injected willi ].'► i»er cent ;;ela1ine. colored witli ultrairiai'ine lilne. Itesnlt : ureteral necrosis wllli stricture and li.vdroureler and iijdroneplirosis (see Fig. XIX). Tlie ouler fibrous coat of llie ureter lias lived and newiylormed vessels can be seen entering: It from the surroundiUK tissue, tor the ureter became adberenl (o Ilie rectum.

Nfci-oto: inner Qccisof ThicVeneJ JjeriTnus

\'

^

o/ inner- ur-iteyal Coa^S

-Sectio.n T.vkio.v .Tust Above the One Shown in Fio I See also Fki. XIX.)

XIV.

Shows the preserval ion of the fuller pi'rininseiilar tibrous coat, and als(> the KlouLAliiUi; of liie inner ones wliidi had liecouie necrotic.

THE JOHNS HOPKINS HOSPITAL BULLETIN. APRIL, 1904.

PLATE XXI.

S«

,ti»'t ox

'if'

tl'/l

Striclu re

m

I,

Portion

S/r.Afe

i~^

r«i.

1^

Fig. XVI. — SEMi-i>i.\i:i!AMMATie Rr.r KESENTATION OF THE EFFECT OF I'BETERAL NECROSIS OX

THE Ureter and Kidxev. Dog No. 19, x 1.

The left ureter was stripped from its surrounding tissue for a distance of 4 cm. and scraped with a sharp knife. Tlie dog was killed in four da.vs and necrosis of the inner and portions of all the ureteral coats had occurred, causing swelling of the ureter with stricture formation and beginning hydroureter ahove. The necrotic portion is represented hy the shaded lines and this portion of the ureter has become imbedded in adhesions.

Fig. XVII. — As ix Fig. XVI. Dog No. 17. X 1.

The periureteral arterial plexus was in.iured by stripping portions of it off lor the lower one-half of the ureter : the vesical arteries were tied, which complete the lower end of the ureteral plexus. The dog was killed at the end of one week. One sees a later stage of the effect of the necrosis shown in Fig. XVI. J'lie ureter has become almost occluded with hydroureter above and beginning hydronephrosis, and also the ureter is more tortuous. Sections IX, X. .KI and XII. while from another case, represent very well the changes shown In this drawing.

Fig. XVIII.— As ix Figs. XVI axd

XVII. Later Coxditiox.

Dog No. 1G. x 1.

The periureteral "arterial plexus was injured liy stripping portions of it away from the lower part of the left ureter, and the vessels were tied which complete the lower end of the ureteral plexus ou both sides. The dog was killed at the 1 nd of three weeks. One sees a later stage of the effects of ne( rosis shown in the previous illusI ration. The hydrouretor and hydronephrosis is more marked, as well as the lortuosity of the ureter.

THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL, 1904.

PLATE XXII.

5e<^t

'c.

"f

Pelvis

P«lv<s'

Ivy

(a injluiniuufory

1 1 ssue YtSf >icfinf

ifdiiuialion \ _ Siy^cfurA Thiiey uyehral Cools ^ Tnfectton ascencf- \ Para-ar€ifyatT7)^/clivi^ S^l Ureter net imbeddeJ i:t ui^/ammai'oty tissue^ aCCoiifif'tnQ /o>- t'fs fxfrenif dilatatton Fig. XIX, — Si'ECIMEN FROM WHICH Il.I.ISTRATIONS XIV AND XV WKUK Made. Doo No. 7, x 8. The ureter has. become greatl.v (lisleiKled and very tortuous, the pelvis of the kidney hits become markedly distended, with lo.ss of kidney tissue. The ueei'otie ureter has become adlierent to the rectum and is splinted and nourished by it. The inner coats of ureter are necrotic and in places are separating, as a slough from tlie outer fibrous coal (see Fig. XV). Tlie ureter was occluded and the kidney thrown fut of function. An extravasation uf urine did not occur, due to I he fact tiial the outer fibi-ous coal did not I)ecome r.eerollc and was nuurisiied tjy tiie surrounding tissue. FlQ. XX. — SE.MI-DIAGIU..MMATIC REPKESE.\TATIO.N OF THE EFFECT OF Ureteral Necrosis where AN E.\TRAVAS.\TI0N OF URINE Occurred which Became Excaps ulated. Dog No. 8, XI. E.^periment similar to the oue illustrated iu Fig. XIX. In the former instance the ureter became imiiedded In adhesions and an extravasatit>n of urine did not occur. in lliis instance tlie necrosis was so exienslve and the adhesions were so slight that a rupture was not prevented. The urine became encaiisulated, the reclum forming the mesial wall of the sac and the Ihickened peritoneum the rest of Ihe sac. Ilydroureler and iiydroni'piirosls resuili'd from tliis and pnihaliiy Ihe urine would evenlu ally have been absorbed, the ureter occluded, and the kidney ceased to function. Pig. XXI. —Semi-diagrammatic Kepresext-itiox of an Ascending Taraureteral a.nd Pararenal Infection, FROM AN Extravasation op Urine. Dog No. 26, X 1. Same cases as represented in Fig. XXIV. The ureter ruptured, the urine escaped, then became encapsulated and infected. THE JOHNS HOPKINS HOSPITAL BULLETIN, APRIL, 1904. PLATE XXIII. necrotic Ureteral Well a6ouf to ru/>ftiri ^'Vl//an]^ofary Tissue Fig. XXIII. — Ciioss Skctiox of Ukkter wheue .X.scexdixg Re.xal Infection H.\s OccfEiiED Following the Fiikeing oe the Ureters in THE Moke Radical Operations i-or Carcinoma Cervicis Uteri. Gyn. No. 10,432, x 4. Same case as one represented in Fig. VII. but opposite ureter. The e.vstitis had extended through the bladder wall and had involved the ureter and extended up it : this might cause necrosis. Fig. XXII. — Localized Necrosis ok Ureter Aboit to Rupture, Following Freeing of the Ureter in the More Radical Operations for Carcinoma Certici-s Uteri. Gyn. No. 10,084, x 4. Ureters had been freed. I'atient died on the 6th day. Cause of death was not determined. Longitudinal section of right ureter. It is impossible to say whether this began as a localized ulceration or hemorrhagic infarction ; judging by animal experimentation it was the latter. ^ ^^ 1 » V Su^i"""^ '"s ri.55^ lu I post i. SS.;< H. A\>sctss KS^ Fig. XXIV. — Snows the Relation of ax Asce.ndixg Paraureteral Infection to the Ureter. Dog. No. 26, x 8. Left ureter of a dog was scraped on all sides for a distance of 2 cm., thus injuring not only the larger vessels of the arterial plexus 1)ut also the smaller branches. The dig was killed in six days and necrosis with rupture was found. The urine became encap sulated, then infected, and an ascending paraureteral infection occurred, also giving rise to a pararenal infection (see Fig. XXI). AlMfll., I!l(l| JOHNS HOPKINS HOSPITAL lUILLETlN. 135 THE SILVER BOLT AS A MEANS OF FIXING UNUNITED EUACTIJIIES OF OERTAIN LONG BONES. By Stki'hen 11. Watts, .M. I)., Assisliiiil llf'sidcid Sunjcdii. Tlw Juliiis llnjiliiiis lliispHtd. Doubtless L'vrryiiiii'. wliu has Iku! iiuicli lo <li) w illi ununited fracturos, resiJizrs Imw unsatisractx)ry tlioy arc to ileal witli. and how uncertain arc the mccliauical uhmiis cin|il(i_veil Iti fix them. A'unicrous niethoils luive lieen recninnicnilcd ; silvciwire, nails, screws, plates, hooks, ivory pegs, ixmy rings and other more complicated apparatus. Mast of these molhods will not hold the I'ragments in good apposition it they tend lo become displaced. About two years ago I was present ai an "jicration for ununited fracture of the shaft of the feunir. The fragments had been mortised together and wired, the wound in the soft parts then being closed. As the plaster cast was about to be applied, a snap was heard and the wire was found to be broken. The wiring had to be repeated. At that time it occurred to tnc that a silver bolt, substituted for the wire, would not only hold the fragments much more securely, but in much better apposition. I had some bolts made and a few months ago we used one of them in a case of ununited fracture of the shaft of .the femur, near the junction of its middle and upper thirds. The patient, a num 32 years of age, was brought to the hospital on June 24, 1903, with the history of having been injured in a stone quarry some hours previously. On examination he was foimd to have a very bad compound, comminuted fracture of both bones of the right lower leg and a compound fracture of tlic left femur, the skin opening over the site of fracture being cpiite small. This wound was thoroughly cleaned and a plaster cast applied. An attempt was made to save the right leg also, but five da.ys later it became necessary to amputate it just above the knee. The fractured left femur was treated in plaster until August 7, 1903, when, no union being present, and considerable overriding of tlic IVagmeuts being discovered, the easts were discontinued and lUick's extension applied. The small wnund in 1he soft ])arts hail healed some time before. On A\igust 21. 190:!, two nmnllis after the injnrx. no union having taken place, the limb was operated upon. 1'he ends of the fragments, which overlajiped several centimeters, lay in a definite sac filled with clear fluid; evidently an early stage in the formation of a false Joint. The sac was excised, the bones mortised step-wise, care l.ieing taken to ]U'cs(Tve as much peri osteum as jjossible, and the silver bolt inserlcd in an anteroposterior direction as shown in the aceom|ianyiug diagram. The nut was S('rewc(l down and the projecting portion of the bolt cut off. The fragments were thus held lirmly in excellent position. The skin wound was sutured with silvei- wire, a very small drain nf rubber tissue being placed down to the site of the fracture. In this ca.se the mortise was so uuule that the projecting portion of the lower fragment lay anterior to, and thus rested upon, the projecting portion of the upper fragment. This arrangement is of some importance, as it removes from tlie bolt a large ])art of the weight of the log and coiuiteracts tlie tendency of the u]i|icr fi'agment to become flexed. At ilie first dressing, which was nuide aboiit two weeks after the o]KM'ation, the wound was found to be very clean and the fragments of bone in good pasition. The skin suture and di-ain were reuuned and Ihe cast reapplied. After Ibis, new casts wci'c applied al intei'vals of 3-4 weeks, the 13 B .JOHNS HOPKINS HOSPITAL BULLETIN. (Nu. 157. woiiud having been I'ouiid peri'ectly healed at tlio time of the second dressing. On Dec. 4, 1903, about three montlis after the operation, it was interesting -to note that, whereas a few degrc&s of lateral motion was possible at the site of fracture, no motion was possible in an antero-posterior direction, namely, in the direction of the shaft of the bolt. On January 10, 1904, the fracture was found to be perfectly solid, no further retentive apparatus being necessary. The patient was very persistent in his efforts to limber up the knee and succeeded wonderfully well. In a very short time he was able to walk on crutches. When he left the hospital his only encumbrance was a poorly-fitting artificial leg on the opposite side. The skiagram, which was taken about five months after the operation, shows the bolt in situ. In the above case we usril a bult whose shaft was 1 5-8 inches long by 3-32 inch in diameter aiul whose head was 1-4 inch square by 3-32 inch in thickness. This is a very convenient size and can be used for any part of the shaft of tlie femur or humerus. For the latter a slightly smaller Ijolt would be preferable. They can be made by almost any jeweler or instrument maker. This method is liy no moans perfect, but was used for want of a better one. It seems chiefly applicable to fractures of the shaft of the femur or liumerus and certain obliijue fractures of (be tibia. Its grciwl advantage is that it apposes the fragments better and holds them thus more securely than perhaps any other method with which I am acquainted. It has many disadvantages in common with most otlier mechanical methods of the same general nature. Some of these are: 1. Tliat a foreign body is left in the bone, which may ]irovc a source of irritation and require removal at some subsequent period. With carefid techni(iue, I believe this would practically never be necessary. Wo find that buried silver sutures, even in infected wounds, rarely cause trouble. 3. 'J'hat the limb is considerably shortened. Tlie shortening, however, is usually a minf)r consideration as compared with a good useful member, and, as a matter of fact, in a large number of cases of ununited fracture, there is some overriding of the fragments which cannot be overcome, and of which advantage may be taken to secure good apposition. 3. Tliat the bone is weakened by the introduction of tlic bolt. If iliis be true, the same objection might be rai.sod to many of the methods now used, in which a foreign body is left in the bone. Most likely there is some compensatory enlargement of the bone at this point. EXHIBITION OF FOUR APPENDICES VERMIFORMES SHOWING UNUSUAL PATHOLOGICAL CONDITIONS (FROM THE SERVICE OF DR. KELLY).' By C. F. Buenam, M. D., Assistant Resident in Gynecology, The Johns Hopl-ins Hospital. During the past summer four especially interesting appendices have been received at the pathological laboratory of the gynecological department of the hospital. The rarity of the conditions presented is sufficient to make the specimens interesting in themselv&s, but this interest is greatly added to by a consideration of the clinical facts obtained by inquiry from and observation of the patients from whom the specimens were obtained. 1 propose, therefore, to give a resume of the clinical and pathological findings of each case and then to add such conchisioiis or suggestions as these facts seem to warrant. The group of cases includes one of actinomycosis, one of carcinoma and two of tuberculosis. Two of the cases occurred in tlie service of the hospital and two were private patients of Dr. Thomas S. Cullen, to whom, and to Dr. Kelly, I desire here to express my thanks for pci-niissioii to report the series. Case 1. — Primary .\ctinomycosis of .Appcmlix. (riyn.-Pntli. No. 6961.) fatherine P., bl., fct. 38. Service of Dr. Kelly. ClinicaTw Histohy : Past History. — Always well and strong. Has spent most of life on a farm in North Carolina. 'Presented to (lie .lolius Hopkins Hospital Mi-cllcal Society, November 2, 1903. Menstrual History. — Eegular, q. m. Duration 4 days. Last period just ended on admission. Marital History. — Two Para, 3 and 2 years. A miscarriage in September, 1902. Present Hlness. — Its onset was in December, 1902, with intense colicky pain in the right lower part of the abdomen. Previous to this there had been no diarrhea or blood in the stools or any symptoms indicating disease of the intestines. This pain lasted a few weeks, but at the end of a week the patient noted at the site of McBurney's point a " swelling the size of a hen's egg." From this point the swelling continued gradually spreading until at the time of her admission to the hopjiitnl. l\1iiy 27, 1903, almost the entire abdomen below the iiiiihilii-iis wiis involved. A week prior to her admission a small simis had opened in the vicinity of the umbilicus and was discharging a purulent-like material. Patient had night sweats and had lost in weight and in strength. Physical Eraminaiion. — On admission patient was noted to be a fairly well-nourished midatto woman. The lungs and heart on pliysical examination were normal. No enlargement of the superficial lymph glands was present. Above the umbilicus the abdomen looked normal and on palpation was soft April, 1904.] 137 and not tender. The lower part of the abdomen was protuberant and around the umbilicus red-looking. On palpation it was densely hard and gave the same impression as an intramural abscess. Owing to the thickness and rigidity of the abdominal wall the pelvic examination was found to be quite indefinite. The temperature was irregularly remittent, higher in the afternoon than in the morning. In the beginning it rarely went to 103°. The leucocj'te count made at this time was 12,000. Treatment and Course. — On May 29 a median incision made from umbilicus to symphysis opened a large cavity lying anterior to the recti muscles and containing a necrotic material. The wall, composed of subcutaneous fat and muscle, presented a homogeneous, semi-translucent appearance, being similar to that seen in an omentum infiltrated with carcinoma. Microscopic examination showed in the tissue from the wall the ray-fungus. Healing hardly took place at all, although the temperature went to normal. About the middle of June the patient began to take potassium iodide by mouth and an ointment of the same was applied locally. On June 27 the median incision was again opened and parallel incisions were made along the recti muscles. These incisions were connected b}' cross-incisions. It was noted that the muscles and all the tissues down to the peritoneum were infiltrated. From this time the induration began to disappear and the incisions to heal, and at the time of death the abdominal wall was almost normal. Improvement continued until July 24, when a pain began in the right lower thoracic region. This onset of pain was accompanied by fever. On August 9, after a chill, the temperature, which had been of an intermittent type, rose to 106°. The leucoc}i;es then coimted numbered 5800. The liver dulness was greatly increased and marked tenderness was present over it. A few days before death, August 27, rales, dulness on percussion and other signs of limg involvement, set in. The sputum examined for the ray-fungus did not show it. Findings at Autopsy. — The abdominal wall, save for scar tissue, was almost normal. The omentum was adherent to the line of incisions along the abdominal wall. A few adhesions were present between the sigmoid and the uterus. The superior surface of the liver was adherent to the diaphragm and in freeing it an abscess in the right lobe of the liver 8 cm. in diameter was entered. A number of smaller abscesses were present in the substance of the liver. An area of softening and necrosis was present in the spleen. Besides these lesions the abdominal viscera were normal save in the region of the ileo-cecal-appendical junction. The lungs were studded with yellowish opaque areas. The pleural cavities contained fiuid encysted between layers of adhesions. The brain was not examined, ilicroscopical examination of these various lesions showed that they were those of actinomycosis. The appendix lay behind the cecum and ileum. It was not so much a retrocecal appendix as a retro-ileac appendix. It was so densely buried in adhesions as to be discovered witli difficult)', and only came clearly to light after dissecting back these adhesions. In doing this several small abscesses were discovered in the adhesions between the ileum and appendix and between the cecum and appendix. The appendix measured about 4.5 cm. in length and 1.3 cm. at base in cross diameter and 1 cm. near apex in cross diameter. On opening the cecum it was found that the appendix pouted into it in an interesting way. On cross-sectioning, the lumen was found greatly narrowed even quite near the cecum. A section at the jiinction of the inner and middle thirds shows a complete obliteration of the lumen on microscopical examination. The cecal mucosa and wall seemed fairly normal. A section through the appendix quite near its cecal end and passing through one of the small abscesses described, showed a narrow lumen. A surface epithelium, mostly absent (apparently by manipxilation) ; normal-looking crypts of Lieberkiihn; a fairly normal interglandular substance, save that an unusual number of small round cells were present; a thickened submucosa, composed of a dense fibrous tissue containing very few nuclei and in which the blood-vessels ran longitudinally; an absence of the lymph follicles; between the submucosa and the circiilar muscle a small abscess not observed macroscopically containing pus cells and the fungus; a normal-appearing circular muscle coat; and a longitudinal muscle coat which, where present, seemed normal (it had been largely pulled off in the dissecting out of the appendix). The abscess noted macroscopically was in the adhesions but also extends into the muscle coat of the cecum a little way. It contained the rayfungus in addition to pus cells. A section through the appendix at the junction of the cecal and the middle thirds showed an obliterated lumen. In its place was a granulation tissue. At almost the middle point was a small abscess containing, in addition to pus cells, a giant cell. The fungus was not present. The mucosa was entirely gone. It may be added here that attempts in life were made to obtain a culture from the abdominal wall, but with negative results. The fungus, as it appeared in the tissue which had been hardened in formalin, cut in celloidin and stained with haematoxylin and eosin, showed the central network of threads but the clubs were not obtained. Considered from the history of its onset and from its clinical course in conjunction with the pathological findings described, it can be definitely concluded that we had to deal with a primary actinomycosis of the appendix which had extended to and involved the anterior abdominal wall and had later metastasized to the liver, lungs, etc. Among the points of interest clinically observed was the absence of leucocytosis with a high elevation of temperature. The count of 12,000 made on the patient's admission can be explained by a temporarj- secondary infection, as the abdominal wall abscess was in direct communication with the exterior. As to the treatment, the observer was impressed that a great deal of real benefit was derived from the potassium iodide, which was given in doses as high as 4 grams t. i. d. by mouth and by an ointment which was rubbed into the abdomen. In this case the treatment which is universally agreed to be the proper one, i. e., the complete removal of the infected area. 138 [No. 157. was, on account of its tremendous extent, impossible. It is possible that if in July, after the abdominal infiltration had greatly subsided and the metastases not yet appeared, we had removed the appendix with the adjacent cecum and ileum, the patient might have recovered. Without an operation actinomycosis of the abdominal wall and intestinal tract is always fatal. Grill's collection gives some idea of operative results: Out of 111 cases, 45 died, 22 recovered, 10 were bettered and the remainder were yet \inder treatment or had been lost sight of at the time of his publication. Those interested in the potassium iodide treatment will find it excellently considered in Prutz's paper and in tlie monograph on actinomycosis of Poncet and Berard. It would seem in our case that metastases had occurred through the blood. Bollinger was the first to show metastases by the honphatics; later, Ponfick demonstrated the occurrence by the blood. Hertz in 64 cases of intestinal actinomj'cosis finds that in all but two the infection had passed the mucosa without leaving a trace; in our case in part the mucosa and lumen of the appendix were both replaced by actinomycotic tissue. It does not seem indicated to go into the history of the disease in this paper, interesting as such a consideration is. Nor is there anything in the case which adds to our knowledge of the actinomyces itself or the mode of its entrance into and infection of man. These subjects are considered in some of the papers referred to in the literature cited at the end of this paper, that of Poncet and Berard cited above being very good. While a rare condition, actinomycosis primary in the appendix has been reported a number of times in the literature. This has been well shown by the monograph of Isemer, 1898, who collected 19 cases, and that of Spickenbaum, 1900, who collected 27 cases. Without attempting any further collection, I might add the cases of Ekehorn, 1900; Daske, 1902, Thevenot, 1902, and Letulle, 1903. Case II. — Primary Carcinoma of Appendix. (Gyn.-Path. No. 6974.) Mr. . set. 25. Private patient of Dr. Cullen. Clinical Account: Family History and Past History unimportant. Present Illness. — For two years patient has had recurrent attacks of pain in the right lower quadrant of the abdomen. These attacks have been increasing in frequency and severity. An attack was subsiding at the time of the operation, October 4, 1903. There were pain and tenderness at McBurney's point and the temperature was slightly above normal. At the operation the appendix was found adherent to the mesappendix at its tip. It was quite red and inflamed-appearing. No enlargement of the mesenteric glands was noted. The convalescence was rapid and at the present writing the patient is quite well. Pathological. — The appendix measures 6 cm. in length, 7.5 mm. in diameter at base, and 1.5 cm. in diameter at its tip. The cecal end looks almost normal, while the outer twothirds of the appendix appears inflamed and adhesions are present upon this part of its surface. On cross sectioning, an apparently normal lumen is seen at the cecal end, a wider one in the middle third, and no lumen in the outer third. The outer 1.5 cm. of the appendix shows in place of a lumen a yellowish core which contrasts with the paler surrounding ring of appendix. Sections were taken at various levels. That through the cecal end on microscopical examination shows a practically normal appendix. Section from the middle third presents a mucosa intact and fairly normal-appearing. The submucous, muscular, and peritoneal coats show acute inflammation as evidenced by a marked infiltration with polymorphonuclear leucoc^-tes, plasma cells, and exudate. Sections of the tip show that the yellow core observed macroscopically is a carcinoma which has filled the lumen, has entirely replaced the mucosa and submucosa, has invaded the circular muscle coat, and at one point at least has reached the longitudinal muscle coat. The muscular and peritoneal coats show products of acute inflammation similar to those observed in the middle third of the appendix. The carcinoma cells are arranged in little groups between which run bands of fibrous tissue. The majority of these groups are solid, as is seen in the cell nests of an epithelioma, but here and there a gland type is seen and one can follow the changes from the solid nest to an almost normal cr\pt of Lieberkiihn. The individual cells are polygonal in shape, larger than normal gland cells. The nuclei show considerable irregularity in staining and in size. This tumor can properly be considered as a primary adeno-carcinoma of the appendix. Several specimens similar to this and also some other forms, as the colloid, of primary carcinoma of the appendix, have been reported. Dr. E. Hurdon reported a case from this laboratory. Kelly, of Philadelphia, in 1900, reported two cases and collected from the literature eleven others. A. W'. Elting quite recently reporting three cases of his own, analyzed the entire literature, and after excluding a number of cases where insufficient pathological proof is given, found in addition to his own twenty other authentic cases. As this specimen and the clinical observations clearly suggest, it is probable that the number of such specimens will multiply rapidly with the spread of the practice of careful laboratory study of specimens obtained, not only by operation, but also by autopsy. For it seems credible that most carcinomata in the appendix would sooner or later lead to inflammatory conditions; in case the surgeon intervened soon enough to conditions similar to that in our specimen; if left alone, to those of abscess formation or of general peritonitis. The small primary neoplasm is completely obscured by the large secondary inflammatory process, unless recourse be had to microscopic examination. The inflammatory process present in this case is an acute one and in the specimen there remains little to suggest previous inflammatory changes. The neoplasm, from its extent and its activity as manifested by cellular changes, would seem to be less than two years old. The history points to attacks over a period of two years. The specimen affords no absolute data by which can be decided as to whether the original attacks antedated the appearance of the neoplasm or not. Apkil, 1904.] 139 From the appearance of the tumor, however, I am inclined to believe that the carcinoma developed in an appendix previously the site of inflammatory changes. To the advocate of early operation in appendicitis, either of these possibilities, i. e., the occurrence of carcinomata in inflammatory appendices or of inflammation of the appendix resulting from cancers, is welcome as no small support to his contention. Case III. — Primary Tuberculosis of the Appendix. (Gyn. Path. No. 6825. Miss , set. 28. Private patient of Dr. CuUen. Family History and Past History unimportant. No history of any tuberculosis. Present Illness. — For about a year the patient had had a dull pain in the right lower quadrant of the abdomen. There had been no acute attacks of pain. Xo diarrhea or blood had been noted in the stools. Physical Examination. — At the time of the operation there was no sign of tuberculosis in the lungs or elsewhere on physical examination. Her temperature was normal. At operation the appendix was found very red and had a peculiar " pock-marked " appearance. It was not adherent. The uterus was in retroposition. Otherwise the abdominal viscera seemed normal. The appendix was removed and the uterus suspended. The patient made a rapid, vmeventful recovery from the operation and is relieved of her symptoms. Pathological. — The appendix measures 5 cm. in length and 1 cm. in cross diameter. The caliber is pretty constant from end to end. On cross section at different levels the lumen is seen to be present save in the tip 1 cm. The mucosa is tliickened, about 2 mm. apparently. Sections were made at different levels. Microscopical. — The mucosa in some places is intact. In others is entirely replaced by caseous material. The submucosa is infiltrated with tubercular tissue, poorly staining epithelioid cells, areas of caseation, and in some places t3'pical tubercles with a giant cell in the center, surrounded by epithelioid cells can be seen. The circular muscle coat is in places invaded by the tubercular process, but it extends no further, the longitudinal muscle coat and the peritoneum showing no alteration. Tubercle bacilli were readily demonstrable in the sections. Case IV.- — Tuberculosis of the Appendix. (Gyn.-Path. No. 6769.) Mrs. H. , st. 37. Service of Dr. Kelly. Family History is entirely negative to tuberculosis. Past History. — For past thirteen years patient has been delicate, being subject to gastralgic attacks. She has had three children. She has had no trouble with menstruation. Present Illness. — Its onset was in the fall of 1902 with pain in the right lower quadrant of the abdomen. This pain had been continuously present from that time amtil her admission, June 6, 1903, to the hospital. It varied in intensity and was greatly aggravated during the menstrual periods. There was some history of a chronic cough during the past months. There had been no blood in the stools nor diarrhea. Physical Examination. — Some enlargement of the glands of the neck; indefinite signs of trouble at the apices; tenderness and muscle spasm in lower abdomen, especially on the right side; a temperature of 100°; a leucocyte count of 12,000; an unsatisfactory pehnc examination, were the imjiortant observations on her admission to the ward. Under ether, the uterus, tubes and ovaries felt normal on palpation, and a diagnosis of probable appendical abscess was made, as a mass could be felt in the region of the appendix. Treatment and Course. — An incision was made directly over the tumor, which was found to be composed of an adherent mass of omentum, appendix and cecum. No pus was present. The appendix was retrocecal, the lumen in its outer third was obliterated, in its middle third normal, at the cecal end very narrow. A fistulous opening existed between the middle third of the appendix and the cecum. The appendix was removed and the openings in the cecum were closed. No tuberculosis was present, macroscopically, on the tubes, ovaries, or elsewhere in the immediate region. The entire peritoneum was not examined, biit so far as seen it looked normal. The incision was drained. Convalescence was slow; the sinus caused by draining had not entirely closed at the time of her discharge from the hospital. She had an intermittent fever, unaccompanied by a loucocytosis. She had some cough, but no tubercle bacilli were demonstrated in the sputum. Pathological. — The appendix measured 7 cm. in length and ..5 cm. in diameter. Dense adhesions were present on its surface. The condition of the lumen is described above. The mucosa appeared normal. On microscopical examination the mucosa in a section from the middle third was mostly normal-appearing. In the submucosa on one side was a group of typical tubercles with giant cells in the center surrounded by epithelioid cells. The tuberculosis was mostly limited to the submucosa, but at one point extended almost out to the peritoneum. Remarl-s. — Of Cases III and IV it can be said : that Case IV is not a tuberculosis limited to the appendix and probably is not a primary tuberculosis of that organ; that Case III is a primary tuberculosis of the appendix so far as a clinical diagnosis of such a condition is possible. The only absolute way to determine it would be by autopsy. Some light might have been gained by the use of tuberculin after operation, but the patient was never in the hospital and the opportunity to do this was not present. As has been repeatedly suggested by those who have reported clinical cases resembling Case III, there is no reason why a primary tuberculosis of the appendix should not occur. So far as I know there is no case reported which meets the autopsy standard of proof. It would seem at autopsy that even cecal tuberciilosis, which is the commonest variety of intestinal tuberculosis, is rare as a primary or at least as a 140 [No. 157. solitary tubercular condition. Eisenhardt, who is extensively quoted, in 1000 autopsies on tubercular patients, found intestinal tuberculosis 563 times, but in every case there was lung involvement. In no case did he find the appendix alone involved of the intestinal tract. It is by no means to be considered, however, that the failure to find confirmation in autopsies is conclusive against the condition, for it is selfevident that patients who die of tuberculosis will almost certainly have extensive lesions, and therefore it will no longer be possible to locate the primary seat of the disease. On the other hand, the surgeon is not prepared to settle the question. We know well how after the removal of a large tubercular focus, as, for example, the fallopian tubes and uterus, the patient will improve greatly in health and apparently entirely recover, even when there is positive evidence that other parts of the body not removed are tubercular. It is evident that neither of the patients had extensive intestinal tuberculosis. It seems quite likely that in Case IV the disease in the intestine was limited to the cecum and appendix. The cecum was found somewhat thickened at the operation. Had a diagnosis been certainly made the question of excision of the cecum would have arisen. Both of these appendices belong to the typical tubercle ulcerative type, in contradistinction to the hyperplastic type as occurs in Crowder's ease. The nimiber of cases of primary tuberculosis, even from the clinical standard, published, is small. A much greater number of appendico-cecal cases have been reported. Among the appendical cases are those of Carl Beck, 2 cases; Karewski, 2 cases; Sonnenburg, 2 cases; Crowder, a case; Potel, a case; Mosher, a case; Josselind Jung, a case. These cases present the clinical aspects of ordinary inflammations of tlie appendix, mostly, as in our case, that of a chronic condition. The diagnosis in life would always be doubtful. The indication for a radical operation is greater than that of an ordinary appendicitis. The presence of these cases, as likewise those of primary cancer and primary' actinomycosis, make an additional danger in appendicitis to that usually considered and add support to the justification of early operation in all cases. From theoretical grounds and from comparative results of removal of tubercular foci elsewhere, the results should be good. As a matter of fact they are good, as we find by reading the publication of the results of operative treatment of cecal tuberculosis. It does not fall within the limits of this article to give these results, but I refer those desiring to know them to the excellent consideration of the subject by Professor Mikulicz in the Handbuch dor Pract. Chir. of Mikulicz, von Bergman, etc. Literature, Carcinoma of the Appendix. 1. Whipman: Lancet, London, 1901, Vol. I, pp. 319-821. 2. HuiiDON : Johns Hopkins Hos])it;il I'ullotiii, .Tainiarv and August, 1900, p. 175. 3. Kelly: Proc. Path. Soc. Pa., 1900, p. 109. 4. Giscard: Toulouse, Imp. St. Cyprian, 1900, 8, p. 51. 5. Elting : Tr. M. Soc. N. Y., Albany, 1903, p. 324-344. LiTERATUEE, ACTINOMYCOSIS OF THE APPENDIX. 1. Grill : Beitriig zur Klin. Chir., Bd. 13, S. 551, 1895. 2. Hertz: Sammelreferat, Centralblatt f. d. Grenzgeb. der Med. und Chir., 1900, S. 561. 3. Illicu: Beitrag zur Klinik der Actinomycose, Wein, 1892. 4. Prdtz: Mittheilungen aus der Grenzgeb. der Med. und Chir., 1899, Bd. IV. 5. Isemer: Inaug. Dis. Greifswald, 1898. 6. Spickenbaum : Inaug. Dis. Kiel, 1900. 7. PoNCET ET Berakd : " Traite Clinique de Actinomycose Humaine," Paris, 1898. 8. Daske: Inaug. Dis. Greifswald, 1902. 9. Ekehorn: Upsala Lakaref, Fohr, 1900, M. F. V. 455 459. 10. Thevenot: Gaz. d'Hop., Paris, 1902, Vol. LXXV, pp. 901-904. 11. PoNFiCK : Die Actinom3-cose des Menschen, Berlin, 1882. 12. Paetsch : Die Actinomycose des Menschen, Berlin, 1888. 13. HiNGLAis: L'actinomycose — Appendico-cecale, These de Lyon, 1897. 14. Letulle (M.) : " Eevue de Gj-necologie et de Chirurgie Abdominale," Tome VII, Xo. 4, 1903. Literature, Tuberculosis of the Appendix. 1. Crowder : Am. J. Med. Soc, Philadelphia, 1902, CXXIV, pp. 236-243. 2. Josselind Jung: Nederl. Tydschr. v. Geneesck., Amster dam, 1902, 15 Februari, No. 7. 3. Carl Beck: Volkmanns Sammelung Klin. Vortrage, 1898, pp. 1101-1144. 4. Karewski: Deutsch. Med. Woch., 1897, Mai 13. 5. Sonnenburg: Pathologic und Therapie der Perityphe litis, Berlin, 1895. 6. Fowler: Ueber Appendicitis, 1896, Berlin. 7. Mosher : Brook. Med. News, 1903, XVIII, 82. 8. Eisenhardt: Inaug. Dis. Munchen, 1891. 9. Potel (M.) : Lyon Med., 1900, XCV, 621-623. 10. ContATii: Beit, zur Klin. Chir., Bd. 21, S. 1, 1898. 11. Nothnagel: Handbuch der Spec. Path, und Therp., Bd. 17, 1898. 12. Von Mikulicz : Handbuch der Prak. Chirurg.. Vol. Ill, S. 356. Apkil, 1904.] 141 NOTES ON NEW BOOKS. American Year-Book of Medicine and Surgery for 1904. Being a Yearly Digest of Scientific Progress and Autlioritative Opinion in all branches of Medicine and Surgery, etc. Under the general editional charge of George M. Gould, M. D. Surgery. (Philadelphia, New York and London: W. B. Saunders and Co., IdOif.q The temptation, in noticing a book of this sort, is to dismiss it with some facile cynicism about " tabloid literature " and to extend our censure of pre-digested mental food until it includes Dr. Gould and his Year-Book. The merest glance through its pages, however, suffices to show that such an easy commonplace is not in this case pertinent. The book meets an actual demand, and the demand is not for superficial notices, which are primarily readable, but for accurate reviews which are primarily thorough. A good resume is never easily made, but in this volume this work is always well done; and the book, considering its almost encyclopedic scope, together with its physical limitations, is little short of excellent. It is comprehensive and it is terse; furthermore, it does not bulk unnecessarily, and the material is conveniently arranged. We cannot think of any principle of selection in choosing the articles for review which would meet all demands, but the Year-Book of Surgery for 1904 has certainly given due — some will think, undue — prominence to the American literature; and we doubt if American journals have contained as large a proportion of the medical articles of value as the references in Dr. Gould's book might suggest. Certainly some of the minor characters have a good many lines to speak in this volume, which is somewhat aggravating for busy men who have come to see the star performers. The Medical Annual. A Year-Book of Treatment and Practitioner's Index. (Bristol: John Wright & Co., 1904). The Medical Annual for 1904 keeps up the high reputation of the work. The list of contributors is excellent; two are especially well-known here. Mayo Robson, who writes on abdominal surgery, and Dr. Saundby, who discusses renal and urinary diseases. The volume opens with an excellent review of the work in Therapeutics for the past year. The extracts throughout are good, and it is pleasant to see that American literature receives full attention. The illustrations are a special feature of this volume, one set of plates showing the surgical anatomy of the ear and others the skin lesions of acute infections. Everywhere special attention is given to treatment. The work can be highly recommended and should be found very useful by the general practitioner. The Practical Medicine Series of Year-Books. Vol. II. General Surgery. Edited by John B. Mukphy, M. D. (Chicago: The Year-Book Publishers, November, 1903.) This small volume is composed of abstracts of articles which have appeared in the various foreign and domestic journals during the preceding year, and purports to give in this way a fair idea of surgical progress during that period. The general appearance of the book is unattractive, and the paper and print are poor. These are, however, a very fitting index to the character of the text. There are numerous typographical errors. The abstracts, while fairly well selected, are poorly executed, in fact in many instances the sentences are meaningless jumbles of words. On page 41 we find the following: " Is the average surgical patient actually less in danger from infection if the surgeon wears rubber gloves? First, as to the surgery. Theoretically, the hands need to be resterilized during the operation. Blood serum is, however, a very potent germicide, and this fact is overlooked by most of us." On page 118 this sentence occurs: "Transplantation of tumor cells through so many generations would seem to prove that the life of ordinary tissue cells may, under conditions not realized in one organism, be able to live much longer than the Individual to which they belong"; and again, on page 470, the following: " Another condition which leads to quite profuse hemorrhages can be readily recognized cystoscopically, and, besides, profuse hemorrhages are always encountered." The remarks interpolated by the editor are always concise, lucid and interesting. The book can be hardly recommended to students as an example of correct English construction. Social Diseases and Marriage. Social Prophylaxis. By Prince A. MoBROW, A. M., M. D., Emeritus Professor of Genito-Urinary Diseases in the University and Bellevue Hospital Medical College New York, etc. (Neto York and Philadelphia: Lea Brothers d Co., 190^.) This volume of nearly 400 pages ought to be read and carefully considered by every physician. It is a model of clear statement and frank advice. Its object is to point out the obstacles which venereal diseases ought to be to marriage and the danger to the health of a wife or an unborn child from them. If all conscientious physicians who are called upon to treat these disorders could be induced by reading the book to give to persons infected with gonorrhoea or syphilis who contemplate marriage the wise advice which reason and knowledge dictate, the number of innocent victims of venereal infection would be materially lessened. The author is not an extremist and writes with moderation, and hence his words should be heeded. The third section of the book on social prophylaxis will commend itself to all thinking people, laymen as well as physicians. The author evidently favors a legislative enactment to penalize the transmission of venereal disease to innocent persons, although he does not advocate it unreservedly. The true remedy after all is to educate the young man as to the dangers which he will encounter in an unchaste life, and the young woman that it is never safe to marry a licentious man. Modern Surgery, General and Operative. By John Chalmers Da Costa, M. D. Fourth edition, rewritten and enlarged, with 707 illustrations, some of them in colors. 1099 pages. (Philadelphia, New York, London: W. B. Saunders d Company, 1903.) " The work stands between the complete but cumbrous textbook and the incomplete but concentrated compend. . . The effort has been to present the subject in a form useful alike to the student and busy practitioner." Such, in brief, is the introduction the author gives to his work. It is an efficient one, protecting him on the one hand from the charge of incompleteness and on the other from that of unnecessary detail. Usefulness of course is the highest attribute to which such a production can lay claim. The large number of text-books of surgery which have just such a scope as the one under consideration is evidence that it is easier to write a useful book than one which can claim for itself accuracy, thoroughness and finish. It seems that by this time we must have enough useful books to supply the demand of students and practitioners, and let us hope that from now on the publications of men of large experience and keen insight may cover a less extended field with more completeness and greater authoritativeness. It Is almost necessary, of course, that when one man writes a " surgery " he should take bodily much of the work of other men, and this not always from the original publications, so that by this time the text-books have found, as it were, a dead level, varying little in their treatment and statements, and presenting the hall-marks of much borrowing. Unfortunately in this way 142 [Xo. 157. the individuality of the author tends to be swallowed up in the necessity he is under of accepting so much of other people's work and indorsing it. There can be no doubt that Dr. Da Costa has presented a very useful work, and one that has a definite and indicated mission to the large class to whom he addresses it. Like other books it has an operative department. It is hard to conceive what the value of such a section can be. It is impossible that one could learn to operate or could be guided to any extent by the descriptions given of the operative procedures. They are entirely inadequate to be of aid in the actual technique of surgical work. They may possibly aid to a small extent in elucidating the general principles that should guide the operator. It seems, however, that the day must be almost past when the general practitioner would read the description in his text-book before sallying out to do a laparotomy. One expects the surgery of the present day to be done by trained surgeons. There is always room of course for careful descriptions of operations and improvements in methods. It spealvs well of the author that he and his experience and judgment are not lost sight of through the work. As a matter of fact there are few sections where his surgical personality does not show through and redeem the book from mediocrity. For the most part his descriptions and advice as to treatment are complete, and at the same time succinct. There is an unusual faculty in the book of saying much in a small space. Generally subjects are thoroughly covered for all practical purposes and set forth clearly, tersely and with rare good sense and judgment. The writer's individual suggestions seem to us to be the most valuable part of the work. Where he stops to comment on his own experience and surgical habits or to point out among a number of procedures the ones which, in his opinion, are most fitted for given occasions, one is struck with his broad knowledge, thorough principles and excellent discrimination. There are many places where methods of diagnosis and treatment are impartially set forth with a view more to completeness than to urging any particular one, where we would gladly have the author's personal advice. In other words, more of Da Costa and less of time-honored surgery seems to be indicated, or at least desirable. The book is more up-to-date in its references than most of the other books. There is due appreciation of the work ( the American work especially) done during the last two or three years. The writer seems to have taken time to examine the work of other men, and this alone makes his own observations of more value than those of a more self-centered surgeon. The first section in the book is devoted to bacteriology, and an accurate, practical, concise account is given, with good remarks on antiseptics. The comments on iodoform, its uses and limitations, seem to us to be particularly good. It is recommended for use in abscesses and tuberculous foci, where it is claimed that it stimulates granulation and connective tissue formation, though it is not strictly a germicide. Da Costa says no clinical substitute has yet been found' for it. There is a very clear and satisfactory presentation of the important theories of bacteriology, serum therapy, etc. As to the description of the bacteria themselves, the accounts are rather unsuited to surgical application. Not enough stress is laid on the fact that in addition to the ordinary pyogenic cocci many bacilli and cocci, not ordinarily thought of as pyogenic, invade tissues as pus formers. The chapter on a.sepsis and antisepsis is very good. It is practical and complete enough and up to date. The remarks on the use of gloves, which he commends, are timely and the advice as to the choice of suture materials presents 'the almost united views of the best surgeons. Catgut, silk and silver are recommended as the most useful and reliable. In the description of dressings the mistake is made of cla.ssing silver foil among the non-absorbable dressings, whereas in reality it is a perfectly absorbable dressing allowing blood and serum to go through into the overlying gauze and almost invariably leaving a dry wound. Surgeons have been curiously slow in appreciating this dressing. There can be little doubt that it is an ideal dressing for most new wounds. The description of the phenomenon of inflammation and its treatment and of the process of repair of wounds, etc., is modern and practical. There is a very good account of the pathology of the conditions. Little account, however, is taken of the various organisms that give rise to infections, and the differences in the severity of symptoms and the indications of surgical treatment which depends on the organism concerned. Tuberculosis is discussed quite exhaustively from a surgical standpoint, yet in a concise form. The remarks on the use of tuberculin in diagnosis are rather remarkable in the light of the general modern spirit of most of the book. Speaking of the tuberculin test for purposes of diagnosis purely, he says: "The value of the test is not certain; its results are irregular, a negative result certainly does not rule out positively the existence of tuberculosis; it is not certain that the procedure is absolutely innocuous, and it is certain that the method is entirely useless and possibly dangerous unless employed by a trained and skilful man." This opinion will not hold good, we feel sure, in the face of the rapidly increasing use of tuberculin and the accumulated evidence of its sureness and great value in diagnosis when used judiciously. Its administration is governed by a few simple rules and is practically devoid of bad effects, with a good grade of tuberculin. One of the best accounts is that of sarcoma and carcinoma. The author seems to appreciate, as not all surgeons of large practice do. the necessity of medical treatment in these conditions. In remarking on the operative treatment of cancer of the breast, however, he simply quotes Halsted's description of his operation and makes no comments on it. but leaves the idea that his own advice would be toward a less complete operation. This is also a little surprising, considering the experience of most clinics. A subject that has interested surgeons very recently is that of osteomyelitis. Though Da Costa devotes a good deal of space to this disease and presents many useful facts concerning it, still he fails to give a clear account of the pathological development and sequence of the infection; and the remarks on sequestrum formation will probably have to be revised when compared with the recent careful work of Nichols on the subject. The incidence of septic<emia in acute osteomyelitis and its possible causation of the diagnosis of typhoid fever, so frequently made, is not mentioned. Orthopedic surgery is rather summarily treated with the timehonored remarks and plates that are seen in all text-books. One of the best sections is that on the surgery of the brain. It is full and clear and the descriptions of the operative methods are excellent, as are the figures describing the topography and surgical points on the skull. Much deserved credit is given to Keen. He recommends trepanation for palliative purposes in the treatment of all forms of brain tumor, whether it is thought possible to remove the tumor or not. Headache, vomiting and the advance of optic neuritis are often checked and the patient's last days passed in comparative comfort. He does not speak of the necessity of very careful closure of the scalp and absolute control of hemorrhage in the wound's deeper parts, to avoid the subsequent possibility of brain fungus — a point much emphasized by Gushing. Much space is devoted to abdominal surgery. As usual, bone plates. Murphy buttons, various forms of anastomoses, stitches, etc., are greatly in evidence. The various surgical conditions of the peritoneum and organs are well described and little is lacking to satisfy tlie student or practitioner. On the whole, one April, 1904.] 143 would say that the chapters on abdominal surgery are characterized by a conservatism unusual with American surgeons. In fact, many of the procedures have largely been discarded in the past few years for different and usually more direct methods. It is surprising that the author scarcely mentions excision of the gall-bladder in dealing with cholecystitis, gall-stones, etc. Some surgeons would accuse him of being ten years behind the times in his gall-bladder surgery. He is against immediate operation In acute appendicitis, as the rule. In this he would have the support of many eminent surgeons. Space will not allow a more extended discussion of this most important section. It may be said that its excellencies are many. The student will find it an excellent reference-book of unusual completeness and carefulness. There is one other detail of the work we should like to notice. In dealing with the treatment of hemorrhoids he shows that the Whitehead operation is in great disfavor with him. He says: " Only a surgeon who can master violent hemorrhage should venture to perform it. Primary union is rarely secured. . . . Experience shows that stricture not infrequently arises after its performance, that fecal incontinence occasionally results and that anal anesthesia with inability to restrain the passage of wind is common." It is quite evident that Dr. Da Costa is not familiar with the Whitehead operation. While it is not the simplest of operations, yet for one who aspires to be a surgeon, it offers no terrors from violent hemorrhage or suppuration or following stricture. Like most other operations it can be done in a right and in a wrong way. With moderate care and the application of ordinary surgical knowledge the hemorrhage is never serious, healing per primam is the rule, and stricture the rarest of complications, probably less frequent in this than in the clamp and cautery operation. Fecal incontinence generally lasts two or three days only, and is so rarely a permanent complication that it is hardly considered. An operator so unskilful as to cut the sphincter ani would do poor work in any procedure. The results of the Whitehead operation are most satisfactory when a long series has been studied. The cure is permanent. Dr. Da Costa's book is worthy of a more extended consideration which space forbids, however. On the whole it will be found a very satisfactory work for the readers to whom it is addressed. The evidence of thoroughly good surgical principles is its best recommendation. Clinical Talks on Minor Surgery. By James G. Mumford, M. D. Small 8vo, p. 115. (Boston: The Old Corner Bookstore, 1903.) This small volume the author modestly states in his prefatory note, deals with " homely, commonplace subjects," that " find little place in the text-book and lend themselves but feebly to brilliancy of demonstration." The ten informal clinical lectures, or " talks," that form the basis of the book deal in a general, common-sense way with subjects such as incised wounds, granulating wounds and varicose ulcers, felon, whitlow, paronychia, palmar abscess, boils, ingrowing nails, etc. Though "homely" subjects they are treated in a far from " commonplace " fashion and enlivened, as the chapters are, by frequent historical allusions, by epigrammatic sentences which cling in the memory, all in Dr. Mumford's attractive style, the reader finds that he is able to write " perlegi " at the end of the volume with some disappointment that it is not longer. A third-year student, beginning his acquaintance with minor surgery, will read this little book with the greatest profit; a graduate, with equal interest, and many of them will regret that those simple, everyday subjects were not presented to him in similar graphic fashion in his undergraduate period. In illustration of the crisp style in which the lectures are delivered one may quote the last lines of one of the chapters: " Don't coquet with a carbuncle. Cut it out as you would a cancer, and you will never regret it." At the time of the demonstration the author suited his words with the action. The scene is readily visualized by the reader. H. C. The Treatment of Fractures. By Chas. L. Sciddkh, M. D., Surgeon to the Massachusetts General Hospital. Fourth edition, thoroughly revised, with 688 illustrations. {Philadelphia. Netv York, London: W. B. Saunders cC Co., 1903.) Four editions of this work since it was first published testify to its value. The book is essentially practical, and is intended to serve as a text-book for the student as well as a guide to the practitioner. The various fractures are described in detail and yet concisely, so that the reader gets a good mental picture of the cases. Then, too, each lesion is illustrated not only by photographs of the injured part and of prepared museum specimens, but also by skiagraphs and X-ray tracings. This gives a fourfold aspect of the broken member which greatly assists in the proper treatment. The chapter on gunshot fractures is especially valuable in that it gives the results of observations made during the Boer war upon the modern high velocity projectiles. The Roentgen ray and its relation to surgery, by Dr. Codman, forms another interesting chapter. After discussing its value. Dr. Codman points out the need of skilled interpretation of the negative. The value of the book is greatly enhanced by the number of extremely good illustrations it contains. The skiagraphs and X-ray tracings are particularly interesting, illustrating, as they do, the various fractures. The book is well worth reading. The Worth of Words. By Db. Rai.cy Husted Bell. With an Introduction by Dk. Willlam Colby Cooper. Third edition, revised and enlarged. (New York: Hinds & Noble, Publishers.) This book is mainly interesting to the physician from the fact that It has been written by a physician and the introduction has been supplied by a brother physician. In the introduction we are informed that " Dr. Bell is a poet — not a mute inglorious Milton, but a songful poet." As, however, no samples are given of the work of this " songful poet " we are compelled to receive the statement for what it may be worth. His little book on the worth of words is interesting and often suggestive, although sometimes marred by slang words and sentimental exuberance. The Man who Pleases and the Woman who Charms. By John A. Cone. " Look out lovingly upon the world and the world will look lovingly in upon .you." (New York: Hinds and Noble, Publishers.) This prettily printed little book of more than 100 pages is full of agreeable commonplaces to enforce the precept that courtesy should be studied as an art. The quotations are appropriate and aid to emphasize the doctrine. A good example is the following: " It is not what you wear in this life, gentlemen, it is how you wear it. It is not so much what you do; it is how you do it." Howe's Handbook of Parlimentary Usage, Arranged for the Instant Use of Legislative and Mass Meetings, Clubs and Fraternal Orders, Teachers, Students, Workingmen, etc. By Frank William Howe. (New York: Hinds cG Noble, PubUshers, 1904.) This is a most handy little manual, and one which cannot help being profitable to a timid or inexperienced chairman. Physicians, as a rule, are indifferent presiding officers and prob 144 [No. 157. ably stand in need of a manual of this character more than any other persons. The Complete Medical Pocket Formulary and Physician's Vade Mecum: Containing upwards of 2500 prescriptions, collected from the practice of physicians and surgeons of experience, American and Foreign, arranged for ready reference under an alphabetical List of Diseases. Also a special list of New Drugs, with their Dosage, Solubilities and Therapeutical Applications. Together with formulae, tables, etc., collated for the use of practitioners. By J. C. Wilson, A. M., M. D., Physician to the German Hospital, Philadelphia. Third revised edition. (Philadelphia: J. B. Lippincott Company.) This is a useful and complete book which ought to be consulted by the physician as well as by the medical student. The formulae contained in it should not be blindly followed, but rather should be considered suggestive of lines of therapeutics to be employed in given diseases. The boolv has a recognized place in the library and a definite range of utility. Les Nerfs du Coeur chez les Tabetiques. A clinical and pathological study. By Dr. Jean Heitz, Ancient Interne des Hopitaux de Paris. {Paris: G. Steinheil, Editeur, 1903.) The first part of this work is taken up with a detailed r6sum6 of what is actually known of the cardiac plexus, the anatomy and histology of the pneumogastrics and sympathetics and of the plexus itself. As for the physiology, the author has gone especially into the question of cardiac sensibility and the trophic influence of the plexus on the aorta and the myocardium. The second part gives a complete review of all that has been written on the cardiac symptoms in tabetics. This is followed by the results of a very careful histological examination of the pneumogastrics in four cases, of the sympathetics in six cases, and of the cardiac plexus in twelve cases of tabes. The author shows that in the majority of cases there is a definite lesion in the fibers making up the plexus. Also that there is no causal relationship between these lesions and the aortitis; and that this is not a trophic trouble but should be considered to be of a syphilitic nature. The singular latency of this form of aortitis in so many cases he thinks to be due to the lesions in the sensory fibers of the cardiac plexus. Dispensing Made Easy. With Numerous Formulae and Practical Hints to secure Simplicity, Rapidity and Economy. By Wm. G. SuTHEBLAKD, M. B. (Aberd.), formerly House Surgeon Queen's Jubilee Hospital, London, etc. (Bristol: John Wright & Co.; London: Simpkin, Marshall, Hamilton, Kent d Co., Ltd., 100 Jf.) This is a plain, practical book, written more for English than American conditions. The directions given are clear and concise. The work will be eminently helpful to all physicians who dispense any portion of their own prescriptions. The Physiognomy of Mental Diseases and Degeneracy. By James Shaw, M. D., Member of the Medico-Psychological Association, etc. (Bristol: John Wright <& Co.; London: Simpkin, Marihall, Hamilton, Kent it- Co., Ltd., 1903.) Illustrations of the various forms of mental alienation and degeneracy have a distinct value and a recognized place in medical teaching. The representations of morbid conditions presented in this book are carefully selected and admirably described in the letter-press. The book can be recommended to all students of medicine. Traitfi de Radiologie Mfidicale. Public sous la Direction de Ch. Bouchard, Membre de I'lnstitut, Professeur de Pathologle GSngrale a, la Faculty de Medicine. (Paris: O. Steinheil, PubUsher, 190 J,.) This two-volume edition has been written on the plan so frequently seen of late in our various text-books of medicine, each chapter and division being the product of a different author. Vol. I deals entirely with the technical side of the X-ray and high-frequency currents, each part of an equipment being taken up and discussed at length. In fact, so much detail is given that at times it becomes wearisome. For example, the first 175 pages are devoted entirely to a discussion of electrical currents and their methods of production. In all, about 450 pages are given up to descriptions of the various electrical appliances. Vol. II consists of about 600 pages, and of this nearly 200 more deal with the method of running the apparatus. The remaining 400 pages deal with the value of the X-ray in diagnosis and therapeutics. In this section probably the most interesting chapter is that devoted to the discussion of " The Diseases of the Chest." The methofl of examination is described and one is given graphically and concisely the salient features of the various affections. In the chapter on calculi, the point is well taken that a negative diagnosis does not absolutely exclude the presence of a stone; under certain conditions a soft stone may be present and yet not cast a shadow. In the treatment of carcinomata and various skin lesions the old question is discussed as to whether burns are due to electrical disturbances or the X-ray. This question has been settled so long that one is surprised that the author should think it necessary to give such a detailed explanation defending his belief that the X-ray alone causes burns. In conclusion, we may say that the book as a whole is distinctly disappointing. The subject-matter contains nothing new and is simply a reiteration of existing facts, not even especially well presented. The illustrations are few and for the most part not particularly good. The book belongs more properly to the physical rather than to the medical side of the X-ray. Infectious Diseases: Their Etiology. Diagnosis and Treatment. By G. H. Roger. Translated by M. S. Gabriel. (Philadelphia: Lea Bros, ct Co., 1903.) The author considers first the general character of infectious diseases and of the pathogenic bacteria associated with them, defining an infectious disease as characterized by the phenomena manifested in individuals when undergoing the action of parasitic toxins and reacting against them. Methods of invasion of the organism and the general mechanism of the action of bacteria upon the individual are next discussed, after which the more special subject of the influence of the association of several organisms is taken up. Various special effects of such invasions, suppuration, gangrene, etc., are treated in separate chapters, which are followed by others which describe in more detail the changes produced in the various organs. The mode of onset and development and after-effects of the disease lead to the consideration of the development of immunity and of the efforts which may be made in prevention and cure of such diseases. Such is in general the outline of a book which is original in that it brings together far more closely than usual the recent acquisitions of knowledge made in the laboratory with the observations of the clinic. Evidently M. Roger is an extraordinarily diligent and acute observer in the laboratory as well as in the clinic, for the amount of material is very great — so great, indeed, that in a short review it would be impossible to speak of special points. In general it seems that the author's attitude toward the litera April, 1904.] 145 ture, and especially the French literature, is not a very critical one. Results are frequently accepted and stated as facts when confirmatory evidence would add greatly to one's feeling of security. To quote Ribbert, " Man lasst sich dadurch leicht im eine die weitere Forschung hemmende Sicherheit wiegen." Kspecially irritating are the attempts at the classification of various forms of disease or modes of infection, in which, with the demand for a well-rounded, plausible system so characteristic of the French, elaborate and unnecessary subdivisions and artificial analogies are printed in tables which finally remind one of the lists of phrases in Rabelais. Nevertheless, the book presents a very interesting survey of the work done in connection with infectious diseases up to a recent period. Doubtless in another edition the chapters on immunity and on special infections will be enlarged to represent the still more modern views. It is particularly interesting in that so much of what is written is based on the work of M. Roger himself and of his pupils. Diseases of the Skin: An Outline of the principles and practice of dermatology. By Malcolm Morris. (Chicago: TV. T. Keener & Co., 1903.) This new edition of Morris' excellent outline of dermatology shows a decided improvement over the old edition of Lea Bros.; the binding is flexible, of a pleasing green color, and seems durable; the paper is of a better quality, the printing clearer, and the symptomatology, etiology, etc., of diseases are separated by black type, which is a very helpful change. To keep the scope of the book within the limit of an " outline," and allow for much new material, a careful revision of every article was made necessary. This has been accomplished and the volume of the book increased by only fifty pages. Twelve entirely new articles are added, among which may be mentioned Blastomycetic dermatitis. Von Recklinghausen's disease, Parakeratosis, and Parakeratosis variegata. It is fortunate that the author saw fit to omit the colored plates of the last edition. Very few had any resemblance to the diseases they represented, and all were disfiguring. A much better Idea of the appearance of skin eruptions is conveyed by the numerous photographs and photomicrographs with which it abounds. A Text-book upon the Pathogenic Bacteria, for Students of Medicine and Physicians. By Joseph McFabland, M. D. (Philadelphia, New York and London: W. B. Saunders & Co., 1903.) Recent progress in bacteriology has made new editions of all our standard text-books on this subject necessary, and Dr. McFarland has just presented us with a third edition of his work. In it he has taken account of the new ideas of both German and French scientists as well as of those of American investigators. The book is especially valuable for its very explicit treatment of the subject of toxins from both the theoretical and practical aspects. In the chapters devoted to the consideration of the chemical con•stitution and mode of action of the toxins and the antitoxins, he lias given considerable space to the exposition of Ehrlieh's famous •' side chain " theory, not forgetting at the same time Metchnikoff's no less important theory of " phagocytosis." From the practical standpoint as well, the application of these theories to the preparation of the two most important antitoxins — diphtheria and tetanus — has been especially emphasized. Along with these chapters dealing with toxins and antitoxins, the nature and the action of the whole series of anti-bodies, antirennin, anti-venin, anti-hiemolysin have been carefully considered. Separate chapters are especially devoted to the consideration of each infectious disease, the nature of the etiological factors and the value of remedial agents being carefully discussed. The portions of the text-book dealing with the principles of bacteriology have been considerably enlarged and Improved upon, In comparison with the second edition, especially with regard to the very important subject of species differentiation, and several important and valuable charts have been incorporated in the new material. A new chapter, giving the investigations of Shiga, Flexner and many others, has been devoted to dysentery, and the chapter on yellow fever has been modified so as to accord with the investigations of Reed and Carroll. Despite a few minor errors, and despite the author's failure to exercise a sufljciently rigid critical judgment, the book is full of valuable information, especially for the medical student, and next to Crookshank's Manual is the best book in English on animal diseases — considered from the standpoint of etiology and treatment, with the possible exception of Moore's recent book on a similar subject. A Text-Book of Practical Gynecology, for Practitioners and Students. By D. Ton Gilliam, M. D., Professor of Gynecology in Starling Medical College, Columbus, Ohio. (Philadelphia: F. A. Davis Co., 1903.) Conforming with the prevalent practice of writers of text-books on the diseases of women, the author treats of the bladder, kidneys and rectum in addition to those subjects to which the name gynecology can more accurately be applied. The book is well printed, on good paper, and contains more than 350 illustrations. The arrangement of the matter is systematic. The first chapters are given to a consideration of general etiology, technique at operation, method of examination, etc. The organs are then taken up in anatomical order and considered as to their various pathological conditions. Throughout the treatment is brief, but the frequently associated adjective lucid cannot be here applied. Subjects are served up in a very fragmentary way. The book abounds in detached dogmatism, unsupported by reason or authority. Scant reference is made to the literature. In a word, the book is a poor one, and in the opinion of the reviewer contains little to justify its existence, as so many better ones are already available. Golden Rules for Diseases of Infants and Children. By George Carpenter, M. D. (Lond.), M. R. C. P. Golden Rule Series, No. XI. Second edition, enlarged. (Bristol: John Wright d Co.: London: Simpkin, Marshall, Hamilton, Kent £ Co., Lim.) This admirable little book of 167 pages contains a large amount of useful information respecting the disorders of infants and children. This information, it is gratifying to notice, is modern and helpful. Thus, for example, injections of antitoxin are prescribed for diphtheria, an examination of the blood for malarial disease, and an examination of the blood in typhoid fever for the Widal reaction. We regret to see the word enteric fever used instead of typhoid, as tending to mislead the student. A good index serves to render the contents of the volume more accessible to the reader. A Non-Surgical Treatise on Diseases of the Prostate Gland and Adnexa. By George Whitfield Overall, A. B., M. D. (Chicago: Marsh it- Grant Company, 1903.) This monograph is another example of the alliance, frequently if not always unfortunate, between medicine and applied physics; for when one sees the pages of a book studded with such words as " cataphoresis," " electric osmosis " and " sinusoidal," the mind naturally reverts to Perkinism and the previous as well as the subsequent systems of mechano-therapeutics which have careered, like comets, into medical history and. like comets, have careered out again into the night. Not that the devotion of Professor Overall (A. B., M. D.) to physical therapeutics has biased his mind away from drugs. The pharmacopeia he knows with 146 [No. 157. something of a lover's intimacy. Oil of gurgin, extract of triticum — all the rarer herbs and simples which the ordinary practitioner will do well to have heard of — Dr. Overall knows not only by name but by dosage; and it would seem that the catholicon, for which prostatic surgeons have waited so long, would sooner have been available if the power of drugs when joined, in the mystic bond of " cataphoresis," to the powers of electricity, had not been overlooked. Dr. Overall is an exponent of " no-knife " medicine. He appreciates — possibly it would be well if his colleagues in practice also appreciated it — the very satisfactory results to be accomplished in prostatic cases by massage diligently and intelligently used over long periods of time. Without taking too hostile an attitude to Dr. Overall's generally safe and conservative position, we would, however, say that, if the question became a personal one, the knife would fill us with less horror than the prospect of having a prostate "hammered at" (the expression is his own) " through rectum and urethra until the indurated tissue begins to soften, then atrophy." Ueber die Bedeutung der funktionellen Nervenkrankheiten fiir die Diagnostik und Therapie in der Gynakologie. Von PboFEssoE B. Kkonig {Leipzig: Erlangen. Verlag v. Georg Thieme, 1902.) Kronig has limited himself entirely to functional nervous diseases which he includes under neurasthenia, hysteria and hypochondriasis. He calls attention to the fact that although the ancient view that the pelvic organs were entirely responsible for the development of hysteria and neurasthenia has been abandoned, yet we cannot deny that they bear a very intimate relation to the functional nervous diseases. This view is held by both neurologists and gynecologists. In Part I, under the heading " Diseases of the genital tract secondary to a primary mental disturbance," he includes: 1. Sudden cessation of menstruation due to fright. 2. Sudden starting of the flow due to fright. 3. The so-called nervous or phantom pregnancy occurring after a single cohabitation. The author says: " Die Hysterie nimmt gern die Larve einer Organerkrankung an." As an example of this it is pointed out that hysterical or neurasthenic patients often present symptoms identical with those due to inflammation of the uterus and appendages. In other words, they resemble them identically, although on pelvic examination no abnormality can be detected. He also draws attention to the pain in the left ovarian region so common in hysterical or neurasthenic individuals — " Charcot's ovarian hysteria." These patients have often consulted many physicians previously and come with a diagnosis of inflammation of the ovary. Kronig agrees with Lomer that such cases of ovarian neuralgia are to be classed under hysteria and that this ovarian pain is due to a central disturbance. He speaks especially of hysteralgia of the vaginal portion of the cervix, the pain also involving the vaginal vault, the mere touching of the parts giving rise to violent hysterical attacks. Endometritis dolorosa (hyperesthesia of the endometrium) he considers one of the signs of hysteria. Vaginismus, according to Kronig, is a symptom-complex. It may return after conflnement, after resecting the hymen or splitting the constrictor muscle, may still persist with a relaxed outlet and on the whole yields a very poor prognosis. The author says that great care must be exercised to exclude organic lesions before rendering a diagnosis of hysteria in these cases. He draws attention to the fact that under ordinary circumstances the cervix and a large portion of the vagina can be removed, the patient complaining of very little pain. Kronig describes in detail those nervous cases where there is much tenderness over the lower abdomen and the patient feels that " everything Is dropping out " and yet on examination no lesions exist. He also points out that many patients fall into the hands of the gynecologist instead of the neurologist. Consequently on the former rests the responsibility of deciding whether the backache and pelvic pain are due to disturbances of the sexual organs or whether they be secondary to a general neurosis. A thorough examination of the entire nervous system is necessary. Under vaso-motor trophic disturbances with normal pelvic structures, long cessation of the period and painful profuse menstruation are considered. Kronig says that the nervous character of such menorrhagia and metrorrhagia is shown in the fact that local treatment is often ineffectual while a general building up yields the looked-for improvement. Reports are given where from fright the menses ceased permanently. Kronig thinks that many cases of dysmenorrhea have a purely hysterical basis. The second portion of the book is given up to treatment of these cases. We note with much pleasure that in so-called erosions, lacerations of the cervix, misplacements of the uterus and cases of " small cystic ovaries " he advocates building up the patient first, in the hope that no operation may be necessary. By isolation of the patient in a hospital, suitable diet, massage, exercise of various kinds and particular attention to the patient's mental impressions he has in many cases obtained excellent results without any treatment of the local condition. It is gratifying to note that the treatment outlined is based on that outlined by one of our most distinguished countrymen, Dr. Weir Mitchell, of Philadelphia. Kronig describes it in detail and expresses in the highest terms its value in many cases. In a goodly number of cases it is of course necessary to combine an operative procedure with the rest treatment. Rarely has the reviewer undertaken the perusal of a medical book with greater reluctance. First he feared that the many contradictory symptoms in this class of cases gave little hope of an elucidation of the subject, and second, he knew that the group of patients which try the ingenuity of the physician almost beyond endurance is composed of those who suffer from supposed functional nervous phenomena attributable to the pelvic organs. The work under consideration has been written by a man peculiarly fitted for the task, thoroughly grounded in pathology and bacteriology- and with a large clinical experience. We had reason to expect a well-rounded, clear and unbiased consideration of the subject and have not been disappointed. It is high time that many members of the profession appreciate that the distressing train of nervous symptoms referable to the pelvis are not often due to the so-called cervical erosions or to slight lacerations of the cervix and that the perfunctory local applications to the cervix for supposed " ulceration of the neck of the womb " or the repair of slight lacerations of the cervix be abandoned and the Weir Mitchell treatment or a modification of the same be adopted. The work of Kronig is a most timely one. It embraces not only his own experience, but also gives a complete rcsumi- of the subject. Not only should it be read by the gynecologist, but also by every physician. Thus many women who would otherwise come under the gynecologist's care can be satisfactorily relieved without the necessity of calling in the aid of the specialist, or will come under his care only as a last resort. The Practice of Medicine. A text-boolv for practitioners and students. By James Tyson, M. D.. Professor of Medicine in the University of Pennsylvania, and Physician to the Hospital of the University. Third edition, thoroughly revised. With 134 illustrations, including colored plates. (Philadelphia: P. Blackiston's Son <t Co., 1903.) Appreciative reviews of the two previous editions of this work have appeared in the pages of this journal. The present third edition does not tend to lessen the high regard in which this book has been held by all familiar with it, but rather to increase our April, 1904.] 147 conviction of its excellence. It has become one of the standard text-books in medicine used by English-speaking students, and quite justly so. In the present edition numerous small changes and additions have been made, without, however, increasing the size of the book or modifying to any extent its general plan. As probably our knowledge of the infectious diseases has undergone the most rapid change during the past few years, so the greatest number of changes are to be expected and are to be found in this section. The excellent chapter on typhoid fever was commented on in the review of the first edition. Among the additions to this chapter it is unfortunate that the author has failed to mention the marked effect of the typhoid poison on the blood-vessels, to which a number of observers, especially the French, have lately drawn attention. This Is also omitted in the discussion of arteriosclerosis; in fact, none of the acute infections are mentioned as playing any r61e In the production of this condition. Also, no mention is made of the diagnostic importance of the isolation of the typhoid bacillus from the blood, urine and faaces. These procedures, cultures from the blood at least, in hospitals, or even in private practice, do not offer very great difficulties, and in many cases are of great value in early diagnosis. That the chapter on dysentery has been reviewed by such an authority as Dr. Flexner is In itself proof that the very latest Ideas in regard to this condition are presented. We think that most of those who have had large experience with diphtheria do not quite agree with the author in their treatment of this disease. The present tendency is to give very large doses of anti-toxine, many insisting that from 7000 to 10,000 units should be given at the outset, even to cases of moderate severity. Undoubtedly many practitioners have been employing too small amounts. This, however, is a somewhat debatable point. In the diagnosis of the various forms of meningitis (aside from cerebro-spinal fever) we do not think the author has laid sufficient emphasis on the value of lumbar puncture — under the diagnosis of tuberculous meningitis it is not even mentioned. The statement made in the chapter on cerebro-spinal fever that in tuberculous meningitis the fluid obtained by lumbar puncture is clear, requires some modification. These criticisms, however, most of them directed toward small errors of omission, are simply similar to those which might be presented in regard to any book of so comprehensive a character as this. The remarkable feature of the book is that it contains so much, not that something has been omitted. As in the second edition, the chapter on nervous diseases has been revised by Dr. Spiller, and both in arrangement and matter the standard of the remainder of the book is maintained. It is a great pleasure to review such an excellent text-book, which presents to the students so clearly a summary of our knowledge of disease. > Clinical Treatises on the Pathology and Therapy of Disorders of Metabolism and Nutrition. Part IV. The Acid Antitoxins. By Db. Cabl von Nooeden, Physlcian-in-Chief to the City Hospital, Frankfort-a.-M. CNew York: E. B. Treat d- Co., 1903.) »This little book is disappointing. Instead of a general discussion of the subject the author has limited himself quite strictly to his own ideas of diabetes. A Pocket Book of Clinical Methods. By Chas. H. Meixand, M. D., Lond., M. R C. p., Physician to the Ancoats Hospital, Manchester. (Bristol: John Wright d- Co.; London: Simpkin, Marshall, Hamilton, Kent tc Co., Ltd., 1903.) This little book was certainly intended for the pocket. It is small, the pages number but seventy-five, with a few additional blank pages for memoranda. A few clinical methods are briefly described. The author seems to think that few are valuable. We cannot agree with him concerning his tests for free HCl in gastric contents, because of the slight value he places upon fresh blood examinations, as well as the orthography of eosinophil, neutrophil, etc. The book has little value and is a source of danger to the student who Is Inclined to be lazy. Surgical Anatomy and Operative Surgery. For Students and Practitioners. By John J. McGrath, M. D., Professor of Surgical Anatomy and Operative Surgery at the New York Post-Graduate Medical School, Visiting Surgeon to the Harlem Hospital, etc. 559 pages, with 227 illustrations, including colors and half-tones. (Philadelphia: F. A. Davis Co., 1902.) In the preface the author states that he has endeavored to combine in a practical manner the subjects of surgical anatomy and operative surgery, excluding as far as possible all anatomical considerations not of practical value in the performance of these operations. It is evident at a glance that the author of this volume has undertaken an almost impossible task when he attempts In this limited space to describe the operations of general surgery, even in a very condensed form, especially since more than two hundred of the pages are taken up with surgical anatomy and diagrams. Many of the descriptions are exceedingly concise but in several instances are considerably aided by the diagrammatic plates. The book is divided into ten sections, the first being an unsatisfactory outline of anaasthesia, and a few general considerations. In the sections which follow, the surgical anatomy of each part is given, more or less at length, preceding the description of the operations, which for the most part are much too brief to be of use to one not thoroughly familiar with surgical procedure; for instance, the operations on the liver and gall bladder, including the surgical anatomy and diagrams, are given in eighteen pages. Looking through the book we are struck by the omission of many important operations, among them thyroidectomy, for aneurysm, operations on the heart, for umbilical hernia, the high operation for varicocele, on the ureters, for osteomyelitis and others, both old and new. Plastic operations on the face are considered quite fully, and most of the modern methods of Intestinal anastomoses are taken up. The usual ligatures, amputations and excisions are described briefly, but no mention is made of gynecological operations or those of the special branches. There is as a rule no advice as to the operation of choice when two or more are described, and taking it all in all, the book is too incomplete for either students or practitioners to depend on entirely. The American Year Book of Medicine and Surgery for 1904. Being a Yearly Digest of Scientific Progress and Authoritative Opinion in all branches of Medicine and Surgery, etc. Under the general editorial charge of George M. Gould, M. D. Medicine. (W. B. Saunders n Co., 190 J).) The volume for this year keeps up the usual standard of excellence. A new feature is a short summary for each department of the more noteworthy advances during the year. These are short and well done. There is no possibility of a minute review of a work such as this. We can only express our appreciation of Its value and the excellent way in which it is prepared. 148 [No. 157. THE JOHNS HOPKINS HOSPITAL REPORTS. Volume I. 433 pages, 99 plates. Volume II. 570 pages, with 28 plates and figures. Volume III. 766 pages, with 69 plates and figures. Volume IV. 504 pages, 33 charts and illustrations. Report on Typlioid Pever. By WiLLLUi OsLER, U. D., with additional papers br W. 3. Thatir, M. D., and J. HEWET80N, M. D. 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 Supply of the Cardiac Ventricles in Certain Vertebrates; The Intrinsic Nerves of the Submaxillary Oland of Mu» muscillus ; The Intrinsic Nerves of the Thyroid Gland of the Dog; The Nerve Elements of the Pituitary Gland. Bv Henrt J. Berklst, M. D. Report In Snrsery. The Results of Operations for the Cure of Cancer of the Breast from June, 1889, to January, 1894. By W. S. Balsted. M D. Report In GjrnecolOB7. Hydrosalpinx, with a report of twenty-seven oases; Post-Operative Septic Peritonitis; Tuberculosis of the Endometrium. By T. S. Cullen, M. B. Report In Patbologry. Deciduoma Malignum. By J. Whitbidoe Williaus, M. D. Volume V. 480 pages, with 32 charts and illustrations. CONTENTS: The Malarial Fevers of Baltimore. By W. S. Thater, M. D., and J. Hewetson. M. D. 1 Study of some Fatal Cas^ of Malaria. By Lewsllts F. Babees, M. B. Studies In Typhoid Fever. By William Osler, M. D., with additional papers by G. Blcuer, M. D., Simon Fleiner, 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. Berelet, 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 II.— Serum Poisoning. — Experimental Lesions induced by the Action of the Dog's Scrum 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 Henr» J. Berelet, M. D. Report In Patliolosy. 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 DifTiisnm Rcnipnum. 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 Fleiner, H. D. Volume Vlf. 537 pages with illustrations. I. A Critical Review of Seventeen Hundred Cases of Abdominal Section from the standpoint of Intra-peritoneal Drainage. By J. G. Clare, M. D. n. The Etiology and Structure of true Vaginal Cysts. By James Ernest Stokbs. M. D. III. A Review of the Pathology of Superficial Burns, with a Contribution to oui Knowledge of the Pathological Changes in the Organs in cases of rapidly fatal burns. By Charles Russell Bardeen, M. D. IV. The Origin, Growth and Fate of the Corpus Luteum. By J. G. Clark, U. D. V. The Results of Operations for the Cure of Inguinal Hernia. By Joseph C. Bloodqood, M. D. Volume VIII. 552 pages with illustrations. On the role of Insects, Arachnids, and Myriapods as carriers in the spread of Bacterial and Parasitic Diseases of Man and Animals. By George H. F. Ndttall, M. D., Ph. D. Studies In Typhoid Fever. By William Osler, M. D., with additional papers by J. M. T. Finnet, M. D., S. Fleiner, M. D., I. P. Lyos, M. D., L. P. Hamburger. M. D., H. W. Cushino, M. D.. J. F. Mitchell, M. D., C. N. B. Camac, M. D., N. B. Gwyn, M. D., Charles P. Emerson, M. D., H. H. Yodno, M. D., and W. S. Thayer. M. D. Volume IX. 1060 pages, 66 plates and 210 other illustra tions. Contrlbntlons to the Science of Medicine. Dedicated by his Pupils to William Henry Welch, on the twenty-fifth anniversary of his Doctorate. This volume contains 38 separate papers. Volume X. 61G pages, 12 plates and 25 charts. structure of the Malarial Parasites. Plate I. By Jesse W. Lazear, M. D. The Bacteriology of Cystitis, Pyelitis and Pyelonephritis in Women, with a Con siderat.un W the Accessory Etiological Factors in these Conditions, and of the Various Chemical and Microscopical Questions Involved. By Thomas R. Brown. M. D. Cases of Infection with Strongyloides Intestinalis. (First Reported Occurrence in North America.) Plates II and III. By Richard P. Strono, M. D. On the Pathological Changes in Hodgkin*8 Disease with Especial Reference to its Relation to Tuberculosis. Plates IV-VII. By Dorothy M. Reed, M. D. Diabetes Insipidus with a Report of Five Cases. By Thomas B. Futcher, M. B. (Tor.) Observations on the Origin and Occurrence of Oils with Eosinophile Granulations In Normal and Pathological Tissues. Plate VIII. By W. T. Howard, M. D., and R. G. Perkins, M. D. Placental Transmission with Report of a Case during Typhoid Fever. By Frank W. Lynch, M. D. Metabolism in Albuminuria. By C!has. P. Emerson, A. B., M. D. Regenerative Changes in the Liver after Acute Yellow Atrophy. Plates IX- XII. By W. G. MacCallum, M. D. Surgical Features of T>-phoid Fever. By TH08. McCrae, M. B., M. R. C. P. (Lond.), and James F, Mitchell. M. D. The Symptoms, Diagnosis and Surgical Treatment of Ureteral Calculus. By Benjamin R. Schenck, M. D. Volume XI. 555 pages, with 38 charts and illustrations. Now ready. Pneumothorax: A historical, clinical and experimental study. By Charles P. Emerson, M. D. Clinical Observations on Blood Pressure. By Henry W. Cook, M. D., and John B. Briggs, M. D. The value of Tuberculin in Surgical Diagnosis. By Martin B. Tinker, M. D. The set of eleven volumes -will be sold for sixty dollars, net. Volume.^ 1 nnd II »t111 not be sold separntely. Volumes III, IV, V, VI, Vll, VIII, X, nnd XI will be sold for live dollars, net, each. Volume IX will be sold for ten dollnrs, net. SEPARATE MOXOGR-\PHS REPRIXTED FROM THE JOHNS HOPKINS HOSPITAL REPORTS. Studies In Dernintologry. Bv T. C. Gilchrist, M. D., and Emmet Riiford, M. D. 1 volume of 164 pages and'41 full-page plates. Price, bound in paper, 3.00. The Mivlnrlnl Fevers of Daltlmore. By W. S. Thayer, M. D., and J. Hewetson, M. D. And A Study of some Fatal Cases of Malaria. Bv Lewellys F. Barker, M. B. 1 volume of 2S0 pages. Price, bound in paper.2.75.

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77te Jitima Hopkinn Honpitnl lIuUetiiiH are Uifued moiitlilt/. 'llie.y art printtd by the FUIKDKN WALii Co., lialtimore. Single copies may be procured from the CUSHINU CO. and the liALlIMOHK NEWS CO.. Baltimore. .Subtcripliona, $->.()<) a year, may be addressed to the publiahera, THE JOHNS HOPKINS PRESS, BALTIMOHE single copies xoill be sent by mail for tKentv-ftve cents each. ULLETIN OF HOPKINS HOSPITAL Entered as Second-Class Matter at the Baltimore, Maryland, Postofflce. Vol. XV.-No. 158.] BALTIMORE, MAY, 1 904. [Price, 25 Cents. ## Contents - May Observations on Two Cases of Tuberculous Pericarditis with Effusion. By William Sydney Thayer, M. D., 149 The Relation Between Carciuoma Cervicis Uteri and the Bladder and its Sii;nilicance in the More Radical Operations for that Disease. By John A. Sampson, M. D., 1.56 Caesarean Section and Serious Dystocia Following Ventro-fixation and Suspension. By Frank W. Lynch, M. D., 163 Two Cases of Multiple Saccular Aneurysms of the Aorta, with Rupture into the Pericardium. By P. K. Gilman, 170 Report of Results of Nursing Dispensary Tubercular Patients. By R. Thelin, 171 Proceedings of Societies: The Johns Hopkins Hospital Medical Society, 172 Perineal Zoster [Dr. CasHiNO] ;— Notes on Hydatid Disease in Australia [Dr. Ramsay]; — Intra-pelvic Hematoma following Labor [Dr. Williams]; — Observations on the Coagulation of the Blood [Dr. Boggs] ; — The Limitations of Urinary Diagnosis [Dr. Cabot]; — Observations on Pericarditis with Effusion Dr. [Thayek] ; — Effect of Altitude on Blood Corpuscles and Blood Plates [Dr. Kemp] ; — Vaccine and Vaccination [Dr. Dock]; — Studies in Blood Pressure [Drs. Erlanger and Hooker] ; — Mental Symptoms Connected with Distinct Viceral Changes [Dr. Gamble] ; — The Periureteral Arterial Ple.xus and the Importance of its Preservation in the Operations for Cancer of the Uterus [Dr. Sampson]; — Presentation of a Case of Scleroderma [Dr. Cdllen] ; — A Case of Myelogenous Leukaemia [Drs. Simon and Campbell]; — Remarks on Pneumonia in Diabetes Mellitus [Dr. Futcher] ; — Observations on the Socalled Loco Disease [Dr. Marshall]. Notes on New Books, 183 OBSERVATIONS ON TWO CASES OF TUBERCULOUS PERICARDITIS WITH EFFUSION. By William Sydxey Thayek, M. D. Associate Professor of Medicine in the Johns Hophins University, Baltimore. Case I. — Tuberculous pericarditis. Large effusion. Paracentesis of the pericardium in the 5th space about 4 cm. within the mamillary line. W. E. H., aged 26. Family history, in no way remarliable. Father, living and well. Six brothers and sisters, in good health. One sister died in infancy. The patient is a curtain hanger by occupation, of regular habits and good previous history. He has had none of the serious illnesses of childhood and considered himself perfectly well until the spring of 1S98, when he had a left-sided pleurisy with effusion, which kept him in bed for a month. In the spring of 1901, he had a similar attack again of a month's duration. Three or four weeks ago while dressing, he leaned over to pick up one of his shoes and fell to the ground in a faint. He soon recovered consciousness but felt weak and " giddy " and sent for a doctor who advised him to stay at home. About a week later he began to suffer from shortness of breath, and gradually with increasing dyspncea, there developed a fulness in the praecordial region. The patient was under the charge of Dr. Fenby, who recognized the presence of a pericardial effusion and advised aspiration. On the 31st of October, I saw the patient in consultation with Dr. Fenby. He was in bed lying on the left side. There was marked dyspncea. The expression was anxious, the lips, somewhat cyanotic. The pulse was of small size and low tension, irregular and intermittent, uncountable at the wrist. By stethoscope, about 150 beats could be made out to the minute. The respirations were shallow. 50 to the minute. There was a marked bulging of the whole praecordial region. The movements of the chest were rather more extensive on the 150 [Jy^o. 158. right than on the left. The cardiac impulse was inappreciable on inspection or palpation. On percussion the cardiac dulness was enormously increased, beginning above in the first space, extending outward to the nipple line on the right, and to the left away beyond the nipple into the posterior axilla. The cardiac flatness was also greatly increased, reaching the hepatic flatness at about the mamillary line on the right and on the left far out in the mid-axilla. On the left it began above at the second place. At the left apex the resonance was somewhat dull and tympanitic. On the right there was also a distinct tympanitic quality, though the sound was clearer. In the back there was slight dulness at the left apex, while elsewhere the note was more tympanitic than on the right side. On auscultation, a few fine rales were heard at both bases, while at the left apex the respiration was enfeebled, the breezy quality of the inspiration was lost, and medium and fine, rather sticky rales were heard on inspiration. In the whole prsecordial region the heart sounds were almost absent; entirely so below the fifth rib. Above, they were so extremely feeble and distant that nothing definite could be determined as to their character. It was decided to aspirate immediately. The patient was placed in a chair in a semi-recumbent posture, and a point for aspiration was selected in the fifth space about two fingers' breadth inside the mamillary line. It seemed wise to aspirate at this point in order to establish better drainage than could be obtained by seeking a point nearer the sternum. The danger of striking the heart was deemed to be slight on account of the fact that careful auscultation seemed to definitely indicate that the apex was at a higher point. The history and character of the case were such as to leave little doubt that the effusion was serous, and the danger of infecting the pleura seemed relatively slight. The trocar was introduced at this point and slowly advanced obliquely backwards and toward the median line. Immediately on its introduction, the fluid spurted out with a force indicating that it was contained under considerable pressure. 1250 cc. of almost clear, yellowish, straw-colored fluid were withdrawn. At the end of this time the rate of the pulse had materially diminished although there were frequent intermissions. By moving the trocar upwards the heart could at times be felt and the rubbing of the end of the trocar against the visceral pericardium resulted in the withdrawal of a few drops of blood. During the aspiration the respirations gradually became quieter, the dyspnoea diminished and finally almost disappeared. At the end of aspiration the respirations were 28 to the minute, as compared with a rate of 50 at the beginning. On percussion of the heart after the withdrawal of the trocar, the flatness to the right of the sternum was found to have completely disappeared, the lung having come back into place. The relative dulness, however, still preserved a somewhat triangular shape, the angle between the cardiac dulness and hepatic flatness on the right side remaining obtuse. On the left, the flatness ended at a point inside the nipple line and the cardiac impulse was well felt in the 4th space or about under the fifth rib, just inside the nipple. There was also visible pulsation in the third space. On auscultation, the heart sounds at the apex were loud and accompanied by a very slight to-and-fro pericardial friction which was well heard over the right ventricle, along the sternal border and at the base. The second pulmonic sound was somewhat accentuated. The pulse remained rapid, between 130 and 140, but was regular and of much better size and tension. About a month later, on the 21st of November, the patient who had steadily improved, called at my office with Dr. Fenby. At that time he looked rather pale though the mucous membranes were of fairly good color. The pulse was rapid, about 130 at the beginning of examination, in great part, probably, the result of excitement. On physical examination the left upper chest was found to be distinctly flattened, while the motion on respiration was also slightly deficient. Heart. — There was marked pulsation in the second, third and fourth left interspaces and over the whole prsecordial area. The apex impulse was in the fourth space, 10 cm. from the median line, just inside the nipple. Dulness began at about the second space and extended 5 cm. to the right of the median line. The angle between cardiac dulness on the right and the hepatic flatness was acute, the dulness showing the normal curved outline. There was no flatness to the right of the sternum and no dulness outside of the point of maximum impulse. At the apex the impulse was of moderate intensity, while over the base there was a well marked diastolic shock. The first sound was clear at the apex, the second, reduplicated during inspiration. In the pulmonic area the second sound was reduplicated during the latter part of inspiration. Otherwise the sounds were clear. There was no friction murmur. Lungs. — At the apex of the lung on the left side, the note was duller than on the right; the vocal fremitus was of about equal intensity on the two sides. The respiratory murmur on the left was rather enfeebled; expiration prolonged. Numerous fine and medium moist rales were audible after cough; these were heard throughout the front. The right side was absolutely clear. In the back, the right side was clear throughout on percussion and auscultation. On the left, there was slight dulness with enfeebled respiration in the supra-spinous fossa where fine rales were heard on cough; elsewhere, clear. There was no Broadbent's sign. S-vii-1900. In response to a letter the patient called to-day. He says that he has felt rather weak but has been at work off and on since the fall, working steadily through January, February, May and June. In December his voice became so hoarse, that he could barely talk aloud, and his inability to work steadily has depended entirely upon this trouble, as he has been unable to make himself properly heard. He consulted Dr. Warfield, who discovered that there was paralysis of the left vocal cord. Later, another laryngologist told him that he had an ulcer upon one of his vocal cords. His appetite is good and he weighs as much as usual, 125-128 pounds. The patient looks better than when last seen, though his voice is very hoarse. The color is good; tongue, clean. Pulse, at beginning of examination, 25 to the quarter. Lungs. — Thorax, somewhat flattened in the whole upper left front above the nipple; perhaps a little so in the axilla. Expansion somewhat deficient on that side. Percussion note, somewhat deficient above the fourth rib on the left; clear on the right. Vocal fremitus, more marked on the right. On quiet breathing the respiration is a little puerile in the right front with slightly interrupted inspiration above the clavicle. On the left there is a tubular modification of the respiration; the inspiration is softened and less breezy than usual; expiration, prolonged. Below the fourth rib the respiration is normal. Occasional fine rales above the right clavicle, after cough. Numerous fine and medium moist rales above the fourth rib in the left front, exploding after cou.gh. Vocal resonance, increased. Slight dulness over the upper lobe in the left back with the same rather enfeebled and slightly modified respiration and fine rales. Otherwise the breathing is clear throughout. Heart. — There is well marked visible pulsation in the second, third and fourth left spaces, extending outwards nearly to the mamillary line. There is no retraction at the apex. On palpation the shock of the second sound in the pulmonic area is well felt. The point of outermost impulse is clearly localized, visible and Mat, 1904.] 151 palpable in the fourth space S^o cm. from the median line. The relative dulness begins in the second space and extends obliquely outward to this point. On the right it has a distinctly round outline extending at its farthest point, at about the lower border of the fourth cartilage, 4 cm. from the median line. The cardiac flatness begins at the fourth rib, extending obliquely outward to the point of maximum impulse. On deep inspiration the lung comes down so as to almost cover the cardiac flatness. There is no flatness beyond the left sternal border. The cervical veins are scarcely visible; no diastolic collapse. At the apex the heart sounds are perfectly clear beyond a slight reduplication of the second sound which is heard during inspiration. In the tricuspid area the sounds are clear excepting for this reduplication for several beats with inspiration; the second part of the reduplication is accentuated. In the pulmonic area the sounds are clear. In the second left space the second sound is sharply accentuated. On inspiration this sound is reduplicated during several beats, the second part of the reduplication being accentuated. In the second right interspace the second sound is sharp but not nearly as much so as in the pulmonic area. The same reduplication is heard during inspiration, but the first part of the split sound is accentuated, clearly showing that the reduplication is due to pulmonic delay. There is no indication of Broadbent's sign. When the patient lies on the right side, the apex impulse remains practically in situ; the limits of dulness on the right side do not move. When the patient lies on the left side, the position of the apex impulse changes but little. The actual difference in the position of the point of maximum impulse with change of position, is only about 1 cm., measuring about S cm. when the patient lies on his right and 9 when he lies on his left side. Blood pressure (Riva Rocci) 12S mm.; temperature 98.7°. 9-vii-'03. The patient called to-day on Dr. Warfield who sent me the following note. " Mr. H. called this morning and I find that his larynx has changed since I first saw him. Then the left cord was paralyzed, but now in addition, both cords are thickened and covered with fine superficial ulcers which are clearly tuberculous. The ulcers are very superficial and there is very little infiltration outside of the cord. * * * * " 27-xi-'03. The patient called to-day in answer to a letter. He has been feeling quite well and working steadily since the last note. He has but little cough; does not know his weight. He looks like a different man. The color of the face, lips and mucous membranes is good. Tongue, clean. Pulse, regular, of good quality, 94. The size and pressure are fair; the vessel wall is not palpable. Lungs. — The thorax on inspection shows a well marked flattening of the left front and also a slight retraction of the whole side, with diminished expansion, particularly in the upper part of the front. The vocal fremitus is more marked in the upper left front and there is slight dulness in the first three spaces; little or no dulness below the third rib. On quiet respiration the inspiratory murmur, on the right side, is rather harsh and slightly wavy. On the left side there is a slight tubular modification of the respiration which is enfeebled, occasional medium moist rales being heard during inspiration. Occasional fine and medium rales are also heard throughout the front. On deep respiration and cough there are fine moist rales just above and below the right clavicle and throughout the left upper lobe, more marked at the apex. Throughout the rest of the right front and the lower lobes on both sides, the respiratory murmur is clear. Heart. — There is a wide area of cardiac impulse seen in the second, third, fourth and fifth spaces and over the fifth rib. The whole chest in the praecordial region moves. The point of maximum impulse in the apex region is to be felt. 8.7 cm. from the median line in the fourth space, dulness extending 4.7 cm. to the right. On standing, the impulse becomes dLstinctly more marked and clearly defined. This point is relatively fixed, being 8 cm. from the median line when the patient lies on the right, 10 when he lies on the left side. On inspiration the lung descends a little in the prEecordial region, but scarcely more than a finger's breadth, flatness beginning at the fourth rib on expiration, in the fourth space on inspiration. When the hand is placed over the prfecordium or the apex, two impulses are felt. At the apex the stronger, more deliberate impulse, that resembling the shock associated with the ventricular contraction, is synchronous with the protrusion at the point of outermost impulse. On auscultation, however, it becomes evident that this impulse is diastolic and not systolic; that the whole prwcordium is retracted with systole, rebounding with diastole in such a manner as to simulate an ordinary cardiac impulse. The first sound at the apex is of moderate intensity; the second, associated with the impulse, is slightly reduplicated. This reduplication is heard all over the cardiac area, most markedly in the pulmonic region. The separation between the two parts of the sound is increased on inspiration — clearly a reduplication due to pulmonic delay. In the tricuspid, pulmonic and aortic areas, the first sound is of moderate intensity but clear. The second pulmonic is louder than the second aortic sound. There is no trace of Broadbenfs sign. The more interesting features of the case are: (1) The large amount of fluid obtained on aspiration. (2) The subsequent development of paralysis of the left vocal cord, due undoubtedly to sclerotic changes in the mediastinum following involvement of lymphatic glands or extension of the tuberculous process from the pericardium or lung. (3) The gradual development of the signs of adherent pericardium. (4) The completeness of the recovery after so extensive an effusion. Case II. — Tuberculosis pericarditis. Large effusion. Aspiration in the Gth left space at the sternal border and in the left costo-xyphoid angle, unsuccessful, the needle coming immediately into contact with the dilated heart. Death. On autopsy the enlarged and dilated heart was not adherent to, but contiguous with the anterior wall of the pericardial sac, the fluid, over 1200 cc, lying posteriorly and at the lateral aiigles. R. C. W., aged 59, a German saloon keeper, was admitted to the hospital at half past twelve o'clock on the first of September, 1903. The patient's complaint was of weakness and shortness of breath which had been coming on gradually for several years. The respiratory distress had greatly increased during the preceding few days. No previous history could be obtained. The following note was made by Dr. Cole. " Moderately well nourished, muscles flabby. At the time of examination the patient is lying flat with the head slightly propped up; looks very ill; considerable cyanosis of the lips, ears and finger tips. Respirations, 10 to the quarter. The patient is coughing occasionally; frequent expiratory grunts. The pupils are small; react well to light. Tongue dry, slightly coated. * * * Veins of the neck are very full. No marked pulsation of deeper vessels. No general glandular enlargement. Chest; expansion fairly good, equal. Considerable respiratory distress. Resonance, clear throughout right front and axilla and left upper front, but note is markedly impaired in the lower left axilla and in the lower left back up to the angle of the scapula. On auscultation, on the left, the breath sounds are clear throughout the upper front and upper back except for a few rales in the interscapular space. Below, 152 [No. 158. they are very distant, practically absent at the extreme base excepting just at the angle of the scapula, where they are a little harsher and the suggestion of a pleural friction is occasionally heard. On the right side the breath sounds are quite clear throughout, except in the lower back where there are mucous rales and the breath sounds are distant. Heart. — Point of maximum impulse is neither visible nor palpable. Over the entire prscordium no impulse can be felt. There is a very wide area of absolute dulness. The relative cardiac dulness begins at the middle of the third rib, extending to a point 16.5 cm. to the left in the 5th interspace, when the patient lies on the right side. When on his back, however, the limits of dulness are difficult to make out as they extend well out into the axilla. On the right side the dulness extends apparently 7 cm. outward in the fourth interspace, the angle between the upper limit of liver dulness and the cardiac dulness being very obtuse. There is definite prsecordial bulging, though the intercostal spaces seem no fuller than on the right. At the apex and over the entire priecordiiim no impulse can be felt. At the apex and over the entire prtecordium the heart sounds are barely audible until one reaches almost the costal margin in the fourth and fifth interspaces where the sounds are faintly heard. A toand-fro friction murmur is also audible over the sternum from the third to the fifth rib. The murmur sounds superficial, louder during expiration than inspiration; not apparently increased by pressure of the stethoscope; it sounds suspiciously pericardial in character but not definitely so. The heart's action is of almost foetal rhythm. The sounds are heard more loudly in the second interspace, neither aortic nor pulmonic being especially accentuated. The pulse is very small; it can hardly be counted. The abdomen is full; no movable dulness in the flanks; feet and legs markedly cedematous." At 5.45 P. M. I saw the patient with Dr. Cole. He was at that time prepared for paracentesis of the pericardium. At my suggestion Dr. Cole adopted the method advised by Delorme and Mignon.' The patient was placed in a semi-recumbent position, and an incision about 2 cm. long was made at the left sternal margin at the level of the sixth interspace, ethel chloride having been used previously to deaden sensation. A small trocar was then inserted in the angle between the ribs as close to the sternal margin as possible. This was introduced vertically to about the depth of the sternum, then tilted so as to pass under the sternum and finally inserted carefully into the pericardium, the needle pointing downward, inward and to the right. After withdrawing the rod a small amount of bloody fluid escaped. On inserting the trocar further the rubbing of the heart against the end could be distinctly felt. On withdrawing slightly a few cc. of clear fluid escaped and then the flow stopped. This procedure was repeated several times, each time with a similar result. A Potain aspirator was then attached to the trocar but only a few cc. of fluid were obtained, the tube soon becoming stopped. This was repealed several times, the trocar being moved in different directions but without result. The rubbing of the heart against it was often felt. An aspirating needle was then inserted upward and backward through the left costo-xyphoid angle, but again only a few cc. of fluid were obtained; not more than 40-50 cc. in all were removed. Owing to the patient's moribund condition it was thought best that no further efforts be made. I was unfortunately obliged to leave before the end of this procedure and witnessed only the first attempt at aspiration. At autopsy the pericardium was found to be markedly distended. The distension, however, extended more to the left than to the right; a large sac-like projection almost filling the left axilla. There was also considerable distension to the right. The heart lay almost directly against the anterior wall at the point 'Rev. de chir., 1895, xv, 797; 987; 1896, xvi, 56. where the needles had been inserted. On inserting the needle of a large syringe in various directions above and to the right and left of the heart, about 800 cc. of fluid were removed, and after opening the parietal pericardium about 400 cc. more escaped. From the position of the heart at autopsy it could be seen that the aspiration had been attempted at almost the worst possible place. Dr. Cole observes in a note made after the autopsy: " The fact that the heart sounds were heard loudest over the sternum and along the left sternal margin together with the fact that the friction rub was audible here, should have led me to insert the needle either to the right of the sternum or far to the left outside of the mamillary line." The pericardium contained about 125 cc. of slightly turbid dark, thick, firm, yellow fibrinous exudate. This was rough and shaggy and in many places rounded in the form of ridges. The outer surface of the pericardium on the left, showed many small yellow tubercles, averaging about 2 mm. in diameter. The heart v.-as greatly enlarged and rather soft, the surface, covered with a mass of fibrinous exudate similar to that seen on the parietal surface of the pericardium. The right ventricle was considerably dilated. The aortic valves were thickened and sclerotic. At their base, on the superior and inferior surfaces were numerous small tuberculated calcareous masses. The superior edges of the valve were connected with the aortic ring by many firm fibrous bands. The valve must have offered obstruction to the blood stream. Nothing remarkable in the other valves. The heart muscle was of a dark reddish color and very soft. The papillary muscles showed numerous fibroid patches. The coronary arteries were rather tortuous and showed many small, raised yellow plaques. The left pleura contained about 700 cc. of slightly turbid, straw yellow fluid. Both lungs contained numerous small areas of tuberculous broncho-pneumonia. The bronchial and tracheal glands were enlarged and caseous. These cases have seemed to me worth reporting for various reasous. The former chiefly on acconnt of the amount of fluid obtained by aspiration, the latter because of its bearing upon the question as to the position of the point of greatest advantage for aspiration in pericardial effusions. The Size of Pekicakdial Effusions. The amount of fluid which tlie pericardium may contain is enormous. Verney ' extracted 900 cc. of fluid from the pericardium of a young man of 23, on two occasions separated by an interval of three days. At autopsy, twenty-three days after the first puncture, the pericardial sac contained over 4000 cc. of yellowi.sh fluid. It is not rare to find from 800 to 1000 cc. of fluid in the pericardium. The largest eftusions are, however, usually purulent, and records of the evacuation of from 1- to 2000 cc. of pus are not extremely rare. The largest amounts of which 1 liave found record are in several Eussian cases mentioned in Wesfs interesting article.' In three of these cases four and a half, five and five and a half pounds of blood, respectively, were removed from the pericardium. These were all cases of scorbutus which ended in recovery. In but few instances, however, has the removal intra vitam of a great<T iiuantity of serous fluid been reported than in our first case. = Gaz. hebd. de mfed., Paris, 1856, iii, 793. = Med, Chir. Tr., Lend., 1883, Ixvi, 235. May, U»U4.1 153 Indications fou Paracentesis of the rEiucARDiuM. Altliougli aspiration of the pericardium is a relatively simple procedure, it is not oue which is frequently demanded even in large effusions. Delorme and Jlignon * observe wisely that " The opening of the pericardium should be reserved for those cases only where the limits of the tolerance of the heart are passed or the phenomena of cardiac adynamia begin to appear. . . . Great dyspnoea, irregular and rapid pulse, extensive prsecordial dulness, difficulty in appreciating the heart sounds demand intervention, whatever may be the duration of the STOiptoms and acuteness or chronicity of the affection." Diagnosis of Pericakmal Effusion. There can rarely be serious doubt as to the existence of a pericardial effusion in instances where it is large enough to produce symptoms calling for interference, and yet mistakes have been made even in such cases. Botch ° some years ago, demonstrated clinically and by injections of cocoa butter into the pericardium, that the presence of fluid in the pericardial sac results early in the appearance of flatness in the fifth right intercostal space, contrary to what is usually the case in dilatation or hypertrophy of the heart. But flatness in the fifth right space maii be present under these latter circumstances. The essential point in distinguishing extensive cardiac hypertrophy with or without pericardial adhesions, from fluid in the pericardial sac was pointed out in 1896 by Ewart,° who called attention to the fact that it is not the extent or shape of the area of cardiac flatness (absolute dulness) which is important. This, of course, represents the amount of pericardium uncovered by air-containing lung, and may naturally depend upon a variety of circumstances. The important point is the shape of the area of dulness (relative dulness). The pericardial sac full of fluid alwaj'S has a more or less triangular shape, and the area of pericardial dulness extends obliquely outward on the one hand to the splenic flatness or the lower limit of pulmonary resonance, and on the other to the hepatic flatness. The right side of the heart, Iiowever liypertrophied it may be, always has a curved outline corresponding to the shape of the right auricle, and this curved outline it is possible to make out in most instances by careful percussion. The angle between the relative dulness of the heart and the line of flatness of the liver is thus an acute angle corresponding to the shape of the right side of the heart. If, however, there be fluid in the pericardium the shape of the non-resonant body — the pericardium filled with fluid — which lies in part beneath the lung, is triangular, and the angle between the dulness over the pericardium and the flatness of the liver will be an obtuse angle. Careful attention to this point serves to distinguish good-sized effusions from cardiac hypertrophy where the anterior border of the right lung may be so far removed from the sternum as to cause flatness in the fifth ' Rev. de chir., Par., 1895, xv, 802. ' Boston M. & S. J., 1878, xcix, 389; 421. "Brit. M. J., 1896, i, 717. right space. It is, moreover, especially valuable in the recognition of vci-y early and slight collections of fluid in the pciicardium. A large jjroportion of errors in diagnosis in thoracic affections depends upon the lack of attention to the tedious minutisB of careful percussion of the chest. Those who, in obscure cases of thoracic trouble, take pains to mark out with a pencil the lower limits of the lungs and the outlines of cardiac dulness will often save themselves serious trouble. Accurate diagnosis in thoracic disease demands time, familiarity with theories and methods of physical exploration and some power of reasoning — and I am not sure that time is not the most important of these elements. Method of Procedure in Paracentesis of the Pericardium. Much has been written with regard to the point of election for aspiration of pericardial effusion, and there has been a surprising difference of opinion. On general principles it is best to aspirate at that point at which the most perfect drainage may be obtained. There are, however, several dangers which one commonly seeks to avoid. These are: (1) Infection of the pleura. (2) Injury to the internal mammary vessels. (13) Puncture of the heart. (1) Infection of the Pleura. — Under antiseptic precautions and in ordinary sero-fibrinous pericarditis there is little danger in puncturing at such a spot that the trocar or needle traverses the pleura on its way to the pericardium. This is often true even in purulent pericarditis. There are, however, cases in which puncture of a purulent pericarditis through the pleura has resulted in a serious spread of the infection. Thus in the case of Vaillard,' in an individual with pericardial effusion following typhoid fever, COO cc. of greenish brown pus was withdrawn from a puncture in the fifth space about 6 em. from the left sternal border. Two hours later there was severe pain in the lower left axilla with the rapid onset of a left-sided pleurisy which was followed by death. It may, however, be an extremely difficult matter even inlarge pericardial effusions, to avoid the pleura, as has been demonstrated by the interesting observations of Delorme and JMignon. It is commonly assumed that the border of the left pleura passes the sternal margin at .about the fourth space, and leaves a small area of pericardium uncovered at the sternal end of the fifth left interspace. Delorme and Mignon, however, found the left border of the pleura to be contiguous with, or Ijeneath the sternum — In the 4th space, in 17 out of 32 cases. In the 5th space, in 12 out of 32 cases. In the 6th space, in 6 out of 26 cases, or nearly one-quarter. It is then, by no means always possible to avoid the pleura by puncturing vertically inwards at any point along the border of the sternum. ' Quoted by Delorme and Mignon, op. cit., p. 1013. 154 [No. 158. (2) Injury to the Internal Mammary Vessels. — There is little danger of injuring the mammary vessels if one introduce the needle in any interspace at a point immediately contiguous to the sternal border or four centimetres to the left. In 30 cases Delorme and Mignon found that the distance between the sternal border and these vessels varied, In the 4th space, from 3-20 mm. In the 5t.h space, from 2-30 mm. In the 6th space, from 3-40 mm. (3) Puncture of the Heart. — The possibility of puncturing the heart should always be seriously considered; yet the danger following this accident would appear to be slight. There is record of a considerable number of cases in which the right ventricle has been punctured without serious result. In several instances, however, death has followed, as in the case of Callender ' in which the trocar was introduced in the fourth left space. Two ounces of blood w^ere removed ; five minutes later death occurred from hemorrhage into the pericardium. The right ventricle had been perforated in the middle of its anterior surface. In Baizeau's ° case, which is usually regarded as one of puncture of the heart, the needle was introduced in the 5th space three fingers' breadth from the sternal border. Air entered the pleura, and about iOO cc. of dark blood was obtained. Death occurred two hours afterwards. At autopsy the pleura and pericardium contained blood. Baizeau, however, expressly denies that the heart was wounded. Shajx)jshnikov '" mentions a case reported by Southey where death resulted from a wound of the heart in connection with puncture." Position of the Heart in Pericardial Effusion. — The only method by which we can be sure to avoid puncture of tlie heart is to insert the needle at a point below its lower border or outside of the apex. Despite much discussion, the relations of the heart to the chest wall in cases of large pericardial effusion are not entirely settled. It is probably true as pointed out by Eendu " and Ferrand " that in large pericardial effusions the heart, retained in place by the great vessels, remains practically in its normal position while the diaphragm descends. A much more difficult and still unsettled point, however, is the relation of the heart- to the anterior chest wall. Many, especially German observers who have followed Skoda," have been inclined to believe that the heart tends to fall backwards on account of its greater specific gravity. .The observations of "West: Med. Chir. Tr., Lond.. 1883, Ixvi, 275. "Gaz. hebd. de mfid., Paris, 18G8, 2 s., v., 515, 562. '"Russk. arch. pat. klin. med. i bakt.. St. Petersburg, 1896, ii, 75. " The reference given by S. is " Soci§t6 royale de mi'decine et de chirurgle de Londres, 24 Avril, 1893." Careful search has failed to reveal the original. "M6m. Soc. m6d. des hop., Par., 1882, 86. *Contribution a I'etude de la paracentese du p6ricarde, i", Bordeaux, 18M2, f). s, No. 3. " Abhandlung iiber Perkussion und Auskultation, S\ Wien, 1842, 2. Aufl., 295, Shapojshnikov " suggest that this is not the rule, but that in most cases, even in very largo effusions, the heart remains close to the anterior wall of the pericardial sac. Tliis Shapojshnikov has determined to have been the case in a number of instances under his clinical care, while experimentally, after injection of the largest possible quantities of fluid, he found but a very thin layer between the heart and anterior wall of the pericardium. He especially emphasizes the fact that in very large effusions a friction rub may still be present. Our second case is a striking example in point. With over 1200 cc. of fluid, the visceral and parietal pericardium Avere still adjacent anteriorly. Point of Election for Aspiration. — In view of these facts what then is the best point at which to introduce the needle? According to West," aspiration of the pericardium, while suggested by Riolan in the 17th century, was first practised in 1819 by Eomero of Barcelona, but it was not until about the middle of the last century that the operation was other than of the greatest rarity. Aran," one of the earliest to practice aspiration of the pericardium, sought the spot at which the heart sounds were least audible, in the 5th space, 2-3 cm. from the outer limit of flatness. Baizeau " advised aspiration in the fifth space as close as possible to the sterntun, seeking thus to avoid wounding the mammary vessels and the diaphragm. He advised making a small incision at the end of the fifth space through which he introduced the trocar. While yet in the mediastinum the needle should be removed and the canula pushed inward until it is arrested by the pericardium. By the sensation communicated to the canula one should be able to determine whether it is resting upon the pericardial sac containing fluid or the right ventricle itself. This determined, the trocar is further advanced and a puncture made. At this point, however, there is unquestionably danger of puncturing the heart. Dieulafoy '° advises another method. The patient is raised slightly in bed and the needle is introduced in the fourth or fifth space, best in tlie fifth, 5 or 6 cm. from the left border of the sternum. The needle, connected with a vacuum already produced in the aspirator, is pushed very slowly upwards and inwards. After it has passed for a distance of from 3 to 6 cm., one ought to reach the pericardium or heart. As soon as the fluid begins to come the needle is swung in such a manner that it may lie in a position parallel to the ventricle. The puncture at this point has two objections: (1) danger of puncturing the heart; (2) the certainty of puncturing the pleura. Others have recommended puncturing below the seventh rib in the angle between it and the base of the ensiform cartilage. 1 1', however, the diaphragm be but little depressed "Op, cit. " Med. Chir. Tr., Lond., 1883, Ixvi, 235. "Gaz, d. hop.. Par., 1855, xviii. 517. "Gaz. hebd. de mi'd.. Par., 1868, 2 s., v, 515, 562. '"Traits de I'asp. des liquides morb., S", Paris, Masson, 1873, 279. May, 1904.] 155 wliile the dilated heart lies anteriorly, as is apparently the rule, this is by no means a favorable point for aspiration and the needle may enter the heart before any fluid is obtained. Rendu "" asserts that if one observes a gradual descent of the diaphragm during several successive days, he may safely puncture in the mamillary line about one centimetre above the lower level of flatness which may be in the 5th, 6th or 7th spax;e. It is easy to imagine that a large liver might be a confusing element in such a case. Delorme and Mignon," after a careful consideration of the subject, advise the following procedure: About one finger's breadth above the lower border of the seventh cartilage, at the sternal margin, a cutaneous incision is made of about 4 cm. in length, exposing the fifth and sixth spaces. In the sixth, unless that space be too narrow to allow the introduction of a needle, and if this be the case in the fifth, or very exceptionally in the lower and internal part of the fourth space, a needle, best No. 2 Dieulafoy, is introduced at the sternal border, and passed slowly, vertically inwards. As soon as the needle has entered to the depth of the sternum, that is, about 8 mm., it is turned obliquely inwards so that the point may follow the posterior surface of the bone. After it has entered about 1 or 2 cm. the extremity is lifted slightly and the needle introduced obliquely inwards and downwards by a slow continuous movement until fluid enters. This, the authors believe, avoids as far as possible injuries to the pleura as well as to the heart. But our second case shows how unsatisfactory this method may be, even in the presence of a ver\- large effusion. Shapojshnikov,^ as the result of a careful series of observations and experiments, concludes that it is not always possible to determine the position of the heart before tapping. As a rule it is to be found close to the anterior wall of the pericardium; it does not fall downwards and backwards, as Skoda and others have believed. If, then, one introduce the needle in the fourth or fifth left space close to the sternum, he has chosen a position in which it will be particularly difficult to -avoid the heart. In very large effusions, where the diaphragm is depressed and the semilunar space occupied by flatness, Shapojshnikov advises aspiration in the sixth left space. Where this is not the case he prefers introducing the needle in the third or fourth right space close to the sternum, provided there be flatness at that point. In all cases Shapojshnikov advises an exploratory puncture with the hypodermic needle. This procedure serves two purposes, (a) to determine tJie character of the effusion ; (b) to ascertain the position of the heart. If the fluid be purulent, aspiration should of course be replaced by incision and free drainage. Shapojshnikov observes, with apparent reason, that with proper care there is no danger of injuring the heart by such preliminary exploration. If the physical signs be deceptive and the heart, which was supposed to lie wholly above the point selected for aspiration, be reaily just behind this spot, its movements will be readily felt by the hypodermic needle. Shapojshnikov has never known pleurisy to follow such an exploratory puncture, and in justification of the measure refers to the frequency and impunity with which exploratory punctures of the liver are made in cases of suspected abscess. it! * * * When we consider these various methods it seems to me that the procedure advised by Shapojshnikov is the most rational. It is by no means always possible to escape the pleura by tapping in the fourth or fifth left space close to the sternal border, while from everj' other standpoint this is a most unfavorable point, especially in view of the fact that the heart is usually close to the anterior wall of the pericardial sac. The method advised by Delorme and Mignon may fail, even in very large effusions, as has been demonstrated by our second case. If, then, we abandon the attempt to avoid the pleura, the best place to aspirate should be that in which the drainage would be most perfect. In cases where the apex cannot be localized, where there is no reason to suspect that the heart extends beyond the left mamillary line, the 6th space, at about the mamillary line, would appear to be the point of greatest advantage. It would seem best not to introduce the needle too far out, in order to allow for retraction of the sac. If it be definitely determined that the dilated heart extends beyond the mamillary line, one would then seek a point a little outside of the supposed position of the apex. Aspiration should always be preceded by exploratory puncture. Should the heart be found directly behind the point selected for aspiration, it may well be wise to follow Shapojshnikov's recommendation and introduce the needle in the 4th right space close to the sternum, provided there be flatness on percussion at that point. If the needle be introduced downwards and to the right there ought, owing to the conformation of the right auricle, to be little danger of injuring the heart. "•Op. cit. " Op. cit. == Op. cit. INSTRUCTION IN PSYCHIATRY AND NEUROPATHOLOGY. A limited number pf graduates in medicine can have an opportunity for worlv in the laboratory of the Sheppard and Enoch Pratt Hospital. Instruction in neuro-pathology will be given by the director of the laboratory, and those attending the course will be permitted to attend the clinical and other conferences of the medical staff. Cliijical forms of insanity will be discussed, as well as the hospital and home care of the insane. Physicians taking this course will also have an opportunity to attend the neurological clinics at the Johns Hopkins Hospital. For particulars, apply by letter to Dr. E. N. Brush, Physician-inChief and Superintendent, Sheppard and Enoch Pratt Hospital, Station "A," Baltimore. 156 [No. 158. THE RELATION BETWEEN CARCINOMA CERVICIS UTERI AND THE BLADDER AND ITS SIGNIFICANCE IN THE MORE RADICAL OPERATIONS FOR THAT DISEASE. By John A. Sampson, M. D., Resident Gynecologist, The Johns Hopkins Hospital; Instructor in Gynecology, Johns flopldns University. The relation between carcinoma cervicis uteri and the bladder manifests itself clinically in the anterior extension of the disease, thus involving the bladder, and with the necrosis of the cancerous tissue a vesico-vaginal fistula is formed. Other clinical manifestations of this relation present themselves in the frequency of accidental injuries to the bladder in the operative treatment of this disease, there having been 19 such injuries in 157 hysterectomies for carcinoma cervicis uteri in this hospital; and also in the frequency of cystitis following these operations, suggesting that the operation must be considered an accessory etiological factor in its origin. It is evident that hysterectomy alone cures this disease in but a very small percentage of the cases, because at the time of the operation the growth either by direct invasion or by metastases has involved other parts. From a review of our cases, made in October, 1902, we found that in three-fifths of the patients admitted to this 'hospital the growth had extended beyond operative treatment, and that after a period of three years only 23 per cent, and after a period of five years only 11.+ per cent of the cases were free from recurrence. The extension of the growth into the parametrium with especial reference to its relation to the ureters and the bearing of this relation on the more radical operations have been studied and published,' ' ' as well as the efficiency ' of the periureteral arterial plexus, the effect' of freeing the ureters from their pelvic sheath, and the results of ureteral necrosis, as well as the etiological factors ° in the causation of ascending renal infection. These studies have taught us that it takes but a very slight involvement of the parametrium either by direct extension or metastases, for the growth to reach or extend beyond the ureters and that in these operations the periureteral arterial plexus should be preserved, whether one resects the ureters or dissects them from free, for an injured ureter is a very important etiological factor in the causation of lowered renal resistance and hence renal infection. The more one studies this disease and its invasion of the surrounding tissues the more one is impressed with the importance of a wide excision of the primary growth, especially in the early cases, fur in these there is the greatest chance for a cure and the patients are in good condition to stand the more radical operations. The high percentage of local recurrences also shows the necessity of this procedure. The object of this paper is to see what may be learned from anatomical, experimental and clinical studies as to the indications and feasibility of sacrificing portions of the bladder in these more radical operations. Relation between the Cervix Uteri and the Bladder UNDER Normal Conditions. The following observations were made in order to determine the relation between the cervix and the bladder in different positions of the uterus. Case L— Nullipara. Age 27. Gyn. No. 11,151. Patient complained of pain in the right side and backache ; both kidne}'s were found to be freely movable, the right more so than the left; and the uterus was in retroposition and situated to the right of the median line. In order to determine the source of the pain a cystoscopic examination was made and both ureters were catheterized and fluid injected into them in order to see if the pain caused by the injection of this fluid was the same as that from which the patient suffered, thus indicating whether the pain was renal in origin or not, as has been described by Dr. Kelly.' The patient was first examined in the Sims' posture,' with slight elevation of the table, the bladder dilated well on removal of the obturator from the cystoscope. The urethra was found to be 3.8 cm. long and the distance from the external urethral orifice to a line drawn between the two ureteral orifices was 5.8 cm. and the ureteral orifices were 2.4 cm. apart, and in this position apparently were equally distant from a line bisecting the pelvis. The outside of the cystoscope had been marked in centimeters and half centimeters so that the distance from the external urethral orifice to various parts of the bladder could be read directly on the instrument by pushing the cystoscope into the bladder until the end reached the part to be measured. The distance between the two orifices was measured by swinging the end of the cystoscope from one orifice to the other and determining how many diameters of the cystoscope the orifices wore apart. Other methods of measuring these distances have been described by Dr. Kelly.° The distance from the external urethral orifice to the cervix, which in this position was found to the left of the median line instead of the right, as in the dorsal position, was mea.sured with a uterine sound and found to be 6.2 cm. The patient was then examined in the knee-breast posture and similar measurements taken and both ureters catheterized. In this position the cervix was found to be 7.5 cm. from the external urethral orifice instead of 6.2 cm. as found in tlu^ Sims' posture. On making a bimanual pelvic examination with the ]iatient in the dorsal position the uterus was found in retro]iosition, to the right of the median line and freely movable, and by placing traction forceps on the cervix, it was possible to draw the cervix almost down to the vulvar orifice and push it in various portions of the pelvis, yet these positions, unless extreme, did not appreciably affect the trigonum of fhi' bladder or tlie ureters, as May, 1904.] 157 could be easily detonniiied by the pelvic examination. The trigonum anil ureters were relatively iinniovable as far as the fixed structures of the pelvis were concerned, and the relation of the uterus to tliese structures was dependent on the position of the uterus in the pelvis. See Fig. I, which is a diagrammatic representation O'f the findings in this case. Case II.— Para I. Age 44. Gyn. No. 11,133. Diagnosis. — Very large dermoid cyst of the right ovary, densely adherent to the uterus and dragging the uterus out of the pelvis so that the cervix was pulled to the right of tlie median line and situated 11 cm. from the external urethral orifice. Bladder was examined in the knee-breast posture and found to be only very slightly displaced by the tumor, as indicated in Fig. II, emphasizing that the relation between the uterus and the ureters and trigonum is dependent on the position of tne uterus m the pelns and that displacements of the uterus unless extreme change but very little the relation of the ureters and trigonum of the bladder to the fixed pelvic structures. I have made similar observations and measurements in the Sims' and kuee-breast postures of six other cases and they all showed that the relation of the cervix to the ureters and trigonum of the bladder was altered by the position of the uterus in the pelvis. These relations were studied still more satisfactorily in the pelvis of a multipara a few hours after death. Catheters were inserted in the ureters from above and the bladder was opened so that the trigonum could be observed. A bimanual examination was now made with one hand in the pelvis and the other in the vagina. The uterus was displaced by pulling it up in tlie pelvis, drawing it down, and displacing it to the right and left side. While extreme displacement in any direction would also displace the ureters and trigonum, one could see that the relation between the cervix and these structures was dejjendeut on the position of the cervix in the pelvis. The surface of the cervix rests against the posterior surface of the bladder and the two organs are united to each other with fibrous and adipose tissue, which allows of some play between them and permits of an easy separation of the two organs. The area of tlie bladder attached to the cervix is situated posterior to the trigonum, namely, that portion of the bladder which is relatively mobile as compared with the trigonum. The size of the vesical area varies in different cases, and with the position of the uterus in the pelvis and degree of distension of the bladder. When the uterus is in auteposition the uterus may rest against the bladder for a considerable distance, as shown in Fig. Ill ; on the other hand, when the uterus is in retroposition this area may be much smaller, as shown in Fig. IV. Also in the distended bladder, this area is greater than in the contracted bladder, for as the bladder distends, the uretero-vesical peritoneal fold is pushed up and a greater portion of the bladder lies in contact with the uterus, while the reverse takes place when the bladder contracts. As has been stated, the uterus is attached to the bladder, posterior to the trigonum ami in the different posi tions of the uterus it is the portion of the bladder between the trigonum and the cervix which helps adapt itself to these positions of the uterus. The distance between the cervix and the ui'eteral orifices may be but 3 or 4 mm. in one position and wlien the uterus assumes another position this portion of the bladder and vagina will stretch and the distance may be 1.5 or 3 cm. (see Fig. I), or even as great as 4.5 cm. (Fig. II), and yet the trigonum has been but very slightly altered by these changes. A result of these studies is well shown in Fig. IV, which is a reconstruction made from cross sections of a woman's pelvis where the uterus was in the right side of the pelvis in adherent retroposition, and one can see that both ureters are similarly situated as far as the fixed pelvic structures are concerned and that the relation between the cervix and trigonum and ureters is dependent on the position of the uterus in the pelvis and as the uterus in this case is in the right side of the pelvis, in retroposition, only a small part of the bladder is attached to the cervix and the cervix is much nearer the right than the left ureter and is situated posterior to the right side of the trigonum so that the middle of the cervix is directly back of the right ureteral orifice. Eelation between the Growth and the Bladder. The cervix rests against the posterior bladder wall and as soon as the growth extends thraugh this portion of the cervical wall, it is in contact with the bladder. On the other hand the rectum does not become involved as readily, for the cul de sac is situated between the cervix and the rectum (Fig. III). The rectum can be directly invaded by the growth only when the cervix becomes adherent to the rectum, the two layers of the cul de sac being thus adherent and permitting an extension of the growth from the cervix, or else the vagina may become involved and the growth reach the rectum below the cervix. Whether or not the bladder becomes involved will depend on the origin of the growth, the direction of its invasion, and also its extent. A growth beginning in the cervical canal would have to extend through the entire anterior cervical wall before it would reach the bladder (Figs. VII and VIII). It is difficult to see why in some cases the growth extends in one direction and in another case in an entirely different one. In the case represented in Fig. IX the growth is restricted entirely to the anterior wall of the cervix and, while the posterior cervical wall is compressed and displaced, it has not been involved by the growth. It becomes evident from a study of the anatomical relation between the cervix and the bladder that the bladder is soon involved in these oases, for it rests against the cervix and vagina and the growth does not 'have to extend far either through the cervix or vagina before it reaches the liladder. The portion of the bladder involved is apt to be that part which rests against the lower jwrtion of the cervix, i. e., where the growth is not only so apt to start but also to directly invade surrounding tissue (Figs. VIII, IX and XI). This portion of the cervix is also unfortunately the part nearest the irreters, and here it takes but a very slight extension anteriorlv to involve the bladder and one laterallv to involve 158 [No. 158. the ureters (Fig. XI). On the other hand, the upper portion of the cervix is not as intimately connected with the bladder and here the ureters are further from the cervix, and also the growth may not be as extensive at this level, for it is usually further from the starting place. On this account both the bladder and the ureters may not be involved at this level until late in the extension of the disease (Fig. X; compare with Fig. XI). Effect of the More Eadical Operations ox the Bladder. In hysterectomy for carcinoma cervicis uteri, not only is the entire uterus removed, but also a portion of the vagina. The amount of the lattei* removed varies with the extent of the disease and also with the operator, some operators removing more than others. The posterior surface of the bladder is exposed and injured in freeing it from the cervix and vagina. The greater the difScult\' in freeing the bladder the greater the chance for injur}' to it, and also of leaving cancer tissue attached to the bladder wall. The area of bladder thus exposed and injured varies with the amount of bladder attached to the cervix, which has been discussed, and also with the amount of vagina removed. If one removes a cuff of vagina 2 cm. wide, the iipper portion of the trigonum will usually be exposed, while a cuff 3-4 cm. wide may expose the entire base of the bladder down to the internal urethral orifice besides the portion of the bladder attached to the cervix which extends as far up on the fundus of the bladder as the utero-vesical peritoneal fold. In tlie specimen represented in Figs. V and IX a vaginal cuff only about 2 cm. wide was removed and yet an idea of the amount of bladder exposed may be gained by studjdng Figs. XIII and XIY, where one may see that almost the entire posterior surface of the bladder down to the internal urethral orifice has been exposed and injured. In this case the patient died on the 9th day from ascending renal infection and the bladder was obtained at autopsy and the illustrations made from these specimens. It becomes evident that a large portion of the bladder is exposed and injured in these operations in such a manner that the function of the bladder is interfered with and that the bladder is predisposed to infection, the amount of injury varying with the area of the bladder exposed and the amount of trauma caused in freeing the bladder, which in turn woiild depend on whether the bladder was adherent or not. In freeing the bladder from the cervix, parametrium and vagina, not only are vessels going to this portion of the bladder destroyed, but vessels in the outer vesical wall are also injured, thus interfering with the nutrition of the bladder and impairing its function and predisposing it to infection. The blood supply of the bladder is frequently injured in other ways by the operation, i. e., in the ligation of large vessels, as the internal iliac or its anterior branch from which arise the vesical arteries. I am iinable to see any operative advantage to be gained in the ligation of these vessels over the ligation of the uterine alone, and there is certainly this disadvantage that the blood supply of these parts must be injured, thus making them less resistant to infection. Experimental Work Demonstrating Some of the Etiological Factors in the Causation of Cystitis. During the last year I have made several experiments on dogs in regard to ascending renal infection, using bouillon cultures of Staphylococcus pyogenes aureus as the infective agent. I. In 8 dogs the organism was introduced into the jugular vein and the ureter of one kidney was ligated. In every instance the organism was excreted by the kidneys and obtained from the bladder. Yet in not a single instance did a cystitis develop. On the other hand, the kidney whose ureter was tied became infected, while the other organ did or did not escape, depending on the virulence of the organism, individual susceptibility, etc. II. In 9 dogs the lower end of one ureter was resected and the ureter implanted in the bladder, and 10 cc. of a 24-hour bouillon culture of the organism was injected into the bladder with a hypodermic sjTinge. The dogs were killed in from 4 days to 6 weeks and renal infection occurred in 3 of tlie 9 cases and in these cases there was a marked stricture at the seat of the implantation. On the other hand, except for areas of infection about the silk sutures, used in the uretero-vesical implantation, the bladders were free from any evidence of cystitis except in one case, in which there was a small localized area. These experiments only emphasize that injury in addition to infection does not necessarih' cause cystitis. III. In 4 dogs one ureter was ligated and 2 to 3 cm. of it was excised between the ligature and the bladder, and the vesical end of the cut ureter was also ligated. The bladder was incised and the mucosa injured and in places removed, care being taken not to injure the ureteral orifices. A small rough stone was now placed in the bladder and the incision closed. Ten cc. of a 24-hour bouillon culture of Staphylococcus pyogenes aureus was injected into the bladder. One dog was killed on the 6th day. In this instance the organism was regained from the circulated blood, liver, gall bladder, urinary bladder, and both kidneys, and there was a pyonephrosis of the kidney whose ureter had been ligated. Apparently, a general infection had arisen from the bladder, and the kidney whose ureter had been tied became the seat of a pyonephrosis. The other three dogs were killed at the end of two or five days and all cultures except those from the bladder were sterile. Even in these cases the bladder withstood very well the infection and rough stone. There was some evidence of cj'stitis, but less than I had supposed would occur. These experiments have been previously referred to in an article published on ascending renal infection.' lY. In 3 dogs the blood vessels of the bladder were injured by ligating the main vesical artery, which arises from the uterine arteries, and also by tearing some of the vessels on the surface of the bladder by means of a fine pair of forceps ; 10 cc. of a 24-hour bouillon culture of Staphylococcus pyo HE JOHNS HOPKINS HOSPITAL BULLETIN, MAY, 1904. PLATE XXIV J<— -t« Pcsiticncf It. Ur. Oyificf/ 3.8 CMi IS Piisihoti ofrt-LfrOfi/ict Pcsifiurr 0} l7!f.U.reihro.L Orifice PtSiticnof lt.U1-.0V(/(ce ..J fiositicn cf e.)(tUrefA-ro.l ori^ra 3. y Cni . Fig. I. — Kki-ation between- the Ceuvix and the Tbigonum of the Bladder IN DiFFEEENT POSITIONS OF THE UtERDS. X 7/10. Nullipara, age 'J."!. Utenis in retvoposition, in right side of the pelvis, when the patient was in the dorsal position. Cystoscopic examinations were made in the Sims and knee-breast postures and the length of the urethra and dimensions of the trigonum were determined in these positions The ureters were catheterized with silk Uousies and the position of the cervix was noted in the Sims, knee-hreast and dorsal postures of the patient. The catheterized ureters could easily be palpated and relation of the cervix to them was determined. „ , ^ ,. This illustration is a diagrammatic representation of the hndings in the case as marked out on the anterior vaginal wall i patient in kneebreast posturei. One can see that while the posture of the patient changed the position of the uterus (which was freely movable) in the pelvis, that the position of the uterus did not affect the trigonum of the bladder or ureters and that the relation between the cervix and these structures was dependent on the position of the uterus in the pelvis. -£'fc__)f-.-Pcsi'/"i «/ ft-Ur On^rci Pcsdicn oj i/if Urd/iral Ou-fiCi Pcsifun of exi Ut^-fkral Crt/'d Fig. II. — RELATION between the Cervix and the Trigonum op ti Bladder in Ui'wakd Displacements of the Uterus. X 7/10. Para 1, age 44. Uterus drawn upwards by a very large ovarian cj which was adherent to the uterus ; cervix could Just be palpated and w situated far to the right of the median line when the patient was in t dorsal position. A cvstoscopie examination was made, in knee-brea posture and the length of the urethra and dimensions of the trigonv were determined. This illustration is a diagrammatic representation the findings in the case, as marked out on the anterior vaginal wi (patient in knee-breast posture). One may see that the extreme displai ment of the uterus has only slightly affected the trigonum of the bladd and that the relation between the two is dependent on the position the uterus in the pelvis. Fui. IV.— UKCdNSTiu'CTioN. Showing the Khi.ation between the Utkiiusand tmi. Uladiieii I'lioM Cnoss Sections ok the I'ei.vis of a Mi'i.tii'Aka HUC/l iea»> old. x 1. iKllOM Sl'ECIMF.N IN ANATOMU'AI. l.A BOIIATOH V, .IoIINS Ilol'KINH MEDJC A I, SCHOOL! The uterus was inlhcreMt in rcl nipci.titiou in the right siilc of the |iclvis. , ., ^ .\. II, C. 1) rcprcsontH the ll•lativ(l^ siiiiill area ol the liliKlder at laclimont when I lie uterus 18 in retropositioii. 'I'ho Km- CIl represents the juiu'lioii of the eoi\ i.v uuil vagina. The right ureteral oiitlec is dircetlv ill Iroiil ol the eervi.v. while the left oritice is lateral to the cervix, einiiliiisiziug tliiit the lehition lietwceii the uterus and the ureters and trigonum ot the bladder is dependent on the position ol the uterus in the pelvis. Fig. III. — Sagittal Section Showing the Relation between ti; Uterus and Bladder. Slightly Reduced. From autopsy specimen. Pelvic contents removed in one mass and I hardened in formalin. Tlic uterus is in anteposition and so rests ag; the bladder for a conslderalile distance. The bladder is purposely represented as being pulled away from cervix in order to bring out the relatively loose attachment between two organs, indicating that under normal conditions they may be e; separated. , ^ ,^ j ^ , , One can sec that the gr<iwlh does not have to extend far in orde reach the bladder and also lluit when the entire uterus and a portion of vagina are removed the bladder wall has been exposed over a large ;i THE JOHNS HOPKINS HOSPITAL BULLETIN, MAY, 1904. PLATE XX\ Halt Cancerous lymjyh Wodc, Fig. v.— Represent.* WH.iT May be Gained bv DlSSECTINO THE LYMPHATICS KK(1M THE t^IDES OF THE PeT.VIS AND ALL THE Tissue from Pelvic avai.i, to Pelvic Wall, and then Freeing the Ureters from this Mass. x 1. Gyn. No. 104S3, Gyn. Path. No. biwo. On the other hand, the removal of all this tissue must leave a large area of raw tissue in the pelvis and interfere with the nutrition and functiun of other parts and predispose them to infectiou, which is esjjecially true of the bladder (see Figs. IX. XII, XIII and XIV, which are from the same ease). Fifi. VI.— Kei'RESESTS What May he (Jainkd iiy DrssEOTiNO thk Lymphatics fjiom Z- THE SIDES OF THE I'F,L\1S ANIl ALL THE 'I'ISSIIE FROM I'ELVIC WaLI, TO PEL\'1C W'Ar.L, lNCI,ri>I.N'0 THE LOWEK r* ^ CM. OF THE I'ltETERS. X L GYN. No. lOSO.'i. Gyn. 1'ath. No. iiTl7. The resection of the ureters indicates still another insult to the bladder, for an implanted ureter is never as ellicieut as one with a natural orillce; nevertheless the llrst consideration should be the removal of the growth. THE JOHNS HOPKINS HOSPITAL BULLETIN, MAY, 1904. PLATE XXVI. i Fiu. VII. — Sagittal Section of Canclrous Uteuus, Showing the Relation of the Growth to the Bladder. Slightly Reduced. Gyn. No. lOSOo. Gyn. Path. No. t>707. From the Same Specimen as the One Represented in Fig. VI. The srowtli in this specimen has not extended through the cervical walls and has invaded the anterior and posterior walls about c<iually. Notice the bladder attachment, representing the amount of bladder exposed and injured in these operations. O P -< n P ce \ Fig. VIII. — Saijitt.1l Section of CiXCEHous Uterus, Showing the Rel.ition of the Growth to the Bladder. Slightly Reduced. Gin. No. 9903. Gyn. Path. No. 6103. In this instance tlie growth, while involving both the anterior and posterior walls of the cervix, has extended beyond the anterior wall and is invading the bladder muscle (see Fij;. XI). The cul-de-sac acts as a natural protection against ttie extension o£ the growth posteriorly. Fig. IX. — Sagittal Sectio.v of Cancerous Uterus. Showing the Relation of the Growth to the Bladder. Slightly Reduced. Same Case as One Represented IN Fig. V. The growth is restricted to the anterior cervical wall, and is beginning to invade the bladder anteriorly. The posterior wall of the cervix has been compressed but not invaded by the growth. A small myoma is situated in the fundus. For the injury done to the bladder liv this operation, see Figs. XII, XIII and XIV. ^^(.'^ '^'^er Muscle Car it" <"" 1 •>-.'» I, :'»!. V:^ • - «•» " ' :/' o X p T< >-a/ SieaU Veins ^::-i \ • . / '.. / -UreUr %^ ,' '-.(jrrtcrat Shtufk ^^ .'Lurnen atShettfi -N ^ lOi-atid *~i<iarn fnT Fig. .\. — Snows the Relation between Carcinoma Cervicis Uteri athe lii.ADDER. Upper I'ortion of the Cervix, x 2Vi. Transverse section of llie right par:imetrinm and one half of the cer\i from a specimen where both unMi'ts were resected. Same case represented In Fig. VIII. .Mthough the Madder Is involved at .' level, here it is free. (See Fig. XI. i b> lir, xi^Shows the Relation between Carcinoma Cervicis Uteri and the Bladder. Lower Third of the Cervix, x i'i. From the same specimen from which Fig. X was drawn, only in the lower third of the parametrium. , , . ,, ,, j , » ,, i At this level the growth has invaded the bladder and laterally has extended out to the ureters which unfortunately are nearer tho cer\ i.\ at this h'vel than higher up in the parametrium, as in Fig. X. Notice the protection alTm-ded to the ureters by the ureteral sheath. THE JOHNS HOPKINS HOSPITAL BULLETIN, MAY, 1904. PLATE XXVII. «<?^. \ Fig. Xn. — Lo.vGiTiDi.NAL Section through Right UiiETEiiAi. OniFicE. KEO.M A PATIEXT DyIXG OF U.NILATEIIAI. (ItlGHT) ASCEXDIMi Renal Ixfectiox. x 4. Same Case a.s One Repkesented in Figs. V and IX. Notice how thin the l>la(l<ler wall is posterior to the iuraen of the lU'eter. The infection has apijai-entlv extended throush the biadder wall. A. B. C. 1'. thus involTing the ureter. The vesical portion of the ureter became involved and was converted into a sinus so that pressure over the bladder forced the bladder contents throush the ureter into the pelvis of the kidney. ^ojihonoj I«t.Ur«*hral Ori^KC Fig. XIII. — Postekioi! Surkace of the Bladdek. Showixg the A.mount OF Bi.AiiDEi! Exposed axd Ix.tured is these Opebatioxs. Slightly Reduced. Same case as represented in Figs. V and IX. The entire posterior surface of the bladder has been exposed and injured besinnins above at the utero-vesical peritoneal fold and extendinjr below ahmist to the internal urethral orifice and laterally beyond the entrance of the ureters into the bladder. It is little wonder that the bladder is so injured that it is unable to resist infection, i See Fij;s. XII and XIV. from the same case.) The probable position of the ureteral orifices are represented by x^ x. The vagina is represented cut transversely. * Fig. XIV. — Sagittal Section of Bladdeii fuo.m Patient Dvixg of AscKNinxd Renal Infection Foi.lowino One ok These Operai IONS. Slightly ItEprcEi). Same Case as Represented IN Figs. V, IX. XII. XIII. The bladder area exposed by the removal of the uterus and portion oi" the vai;lrui Is shown. .\ patchy nienibraneous cyst was found at autopsy and the areas corresijonded to (be portions of the bladder which would rest against the retention catheter wlilcb was placed in the bladder in order In keep it empty. I tbink that the inushrooiTi catheler acted as a foreign body, aKsravnIed (he bladder Infection, and niav have been responsible for the renal Infection and death of the patient. Fig. XV. — Sagittal Section of Bladder from Patient Dying Six Days after One of these Operations. Cause of De.vth not Determined at Autopsy. Gyx. No. 10084. Gyn. Path. No. (ii.SJ. The bladder was found to be contracted but free from cystitis. As one can see in the <*ontracted bladder, the walls are thicker and there is less of the raw area exposed than In the distended bladder, as in I-Ms. XIV. Its nutrition should also be lietter. It would seem best to keeji the bladder empty after these operations. .\ retention catlieter is dangerous, acting as ji foreign \mt\y. and it is also liki'Iy to become occluded or jnished too fin* In the bladdi'i-. Krecpient catheterizations are better, and if cystitis develops, niakt* a veslco-vaginal fistula. May, 1904.] 159 genes aureus was injected into the bladder. These dogs were killed in from 2 to 10 days. In even' instance the organism was regained from the bladder but not from the kidneys. In two instances there was some evidence of slough of the bladder and in four of the five cases, marked evidence of cystitis. We have then in the interference of the blood supply of the bladder a means of lowered local resistance, which must be considered an important etiological factor in the causation of experimental cystitis. Another important accessory etiological factor in the causation of experimental cystitis is retention of urine, which may be accomplished by ligatiug the urethra or penis of the animal. This has been shown by many who have experimented along these lines. Clinical Cases Demoxstratixg Injury to the Bladder AS a Eesclt of Hysterectomy for Carcinoma Cek vicis Uteri. The 19 instances of accidental injury to the bladder in 157 hysterectomies for carcinoma cervicis uteri emphasize the close anatomical relation between the two organs and that the extension of the disease soon involves the bladder, so that the separation of the bladder from the growth results in injury to the bladder which may manifest itself as a vesical fistula, recognized either at the time or afterwards. The frequency of cystitis following these more radical operations is another indication of the close relation between carcinoma cervicis uteri and the bladder and indicates that as a result of the operation the bladder is left in a condition of lowered local resistance and that this condition is responsible for the cj'stitis which may later develop, as was maintained by Wertheim " in the report of his second series of 30 cases. Kjronig " has carefully described the technique of closing the raw areas caused by these operations and emphasizes the importance of covering the posterior surface of the bladder by bringing down the utero-vesical peritoneal flap and suturing it to the anterior vaginal wall as a means of protecting the injured bladder and thus lessening the chance for cystitis. Taussig" has reviewed Wertheim's cases and demonstrated the importance of retention of urine as an etiological factor in the causation of cystitis and that in these more radical operations this is especially likely to occur. He calls attention to the fact that ganglia and nerves are found in the parametria of these cases and that their removal may interfere with the function of the bladder and so give rise to the retention of urine. Kolischer," in addition to the other views already mentioned, as, injury to the bladder, blood supply, etc., adds another, i. e., in freeing the ureters certain trophoneurotic disturbances occur which predispose the bladder to cystitis. Biiisch " considers that the main factors in the causation of the cystitis following these operations results from injur}' to the nerves and blood supply of the bladder. He advocates catheterization followed by bladder irrigation as prophylactic measures in the avoidance of this cystitis. In order to make a positive diagnosis of cystitis two things must be done: first, a cystoscopic examination must be made and the inflamed bladder seen; secondly, cultures must be taken and the organism causing the infection obtained. These two steps are essential, for an inflamed-appearing bladder may not be infected, and positive cultures obtained from the urine may come from an infected kidney and the bladder may be normal or the organisms may be excreted by the kidneys and appear in the urine without causing any harm to either kidney or bladder. I have followed the bladder condition in sixteen cases where hysterectomy for carcinoma cervicis uteri has been done. In 14 of these cases both cystoscopic examinations and urine cultures were taken and in the other 3 cases the patients died, one on the ninth day and the other on the seventeenth day, and at autopsy the cause of death was found to be ascending renal infection. The ureters had been sacrificed in one but not in the other of these two cases. In 10 of the 14 cases who lived, cystitis was found to be present, as determined by cystoscopic examination and taking cultures, and in 3 of the 4 cases in which the bladder apparently escaped infection, an accidental vesico-vaginal fistula was present, which apparently prevented a cystitis, for cultures taken in two of these cases showed colon bacillus in large numbers. In 12 of the 16 cases cystitis occurred, resulting in renal infection and death in 2 cases. In all the cases but one the raw areas were covered with peritoneum, and in that one case it was necessary to leave on clamps and pack with gauze in order to control hemorrhage. In these cases the utero-vesical peritoneal fold was sutured to the anterior vaginal wall and the entire denuded vesical wall was protected by peritoneum. In addition, the posterior vaginal wall was sutured to the rectouterine peritoneal fold, thus covering in the raw tissue anterior to the rectum. The pelvis was drained by two small gauze drains extending under the peritoneum on each side and out through the vaginal opening. Yet these cases did not escape cystitis. Eealizing that retention of urine was an important etiological factor in the causation of cystitis I used a retention mushroom catheter in four cases ; in all four cases cystitis developed, resulting in ascending renal infection and death in two, and in one of these there was a patchy, membranous cystitis, the patches corresponding to the parts of the bladder which came in contact with the catheter when the bladder collapsed (see Fig. XIY). Apparently the catheter was responsible for the severity of the cystitis, for it may soon become covered with urinary salts acting as a foreign body (stone) in the bladder. Another criticism against the retention catheter is that it is apt to become occluded or pushed too far in the bladder, and one can never tell whether or not it is doing what it is supposed to do, that is, keeping the bladder empty by draining the urine away as fast as it comes to the bladder. Frequent catheterization was tried, i. e., every three to four hours, in the next nine cases, but cystitis developed in eight of the nine cases. In two of these cases the bladder was irrigated three times a day, and in four cases every three or four hours after catheterization. Why does cystitis occur in these cases? I have been unable to prevent it by covering the injured bladder with peri 160 [No. 158. toneum and also by preventing retention of urine by means of the retention catheter or freqnent catheterization, and in six cases in which bladder irrigations were tried as a prophj'laotic measure the cystitis was not avoided. I cannot see how that dissecting free the ureters, aside from the fact that more of the bladder is exposed and surrounding tissue injured, can be considered an important etiological factor, for I followed the condition of the bladder in three cases in which an abdominal hysterectomy was done for cancer of the body of the uterus, the entire uterus wit.li a vaginal cuff having been removed. Cystitis occurred in two of the three cases and yet the ureters were not seen during the operation. On the other hand, abdominal supravaginal hysterectomies for myomata^ pelvic inflammatory conditions, etc., are very rarely followed by cystitis. The difference between these operations and the more radical operations for carcinoma cervicis uteri must be considered the main accessory etiological factors in the causation of the cystitis, and are as follows: 1. The large area of the bladder exposed and injured in removing the cervix with parametrium and also portion of the vagina. (Figs. XIII and XIV). 2. Interference with the blood supply of the bladder, caused by ligating vessels giving rise to vesical arteries; freeing the bladder, thus cutting off vessels going to it; and the injury of vessels in the bladder wall. 3. Interference with the function of the bladder, it having been injured in freeing it, its blood supply having been interfered with, some of its natural supports removed, and its nerves and ganglia destroyed. This interference with its function may manifest itself in the inability to void urine. On the other hand, in one patient incontinence was present, there being no ureteral or vesical fistula. In other cases the patient may void urine, but there may be a large residual of urine left in the bladder. In one of the above cases this was as great as 300 cc. Organisms may gain access to the bladder in various ways : 1. They may be present in the bladder at the time of the operation. They were present in one of the above cases, although there -was no evidence of cystitis at the time. 2. They may pass through the injured bladder wall through the fundus or trigonum, or along the bared ureters if dissected free or resected and implanted in the bladder. 3. In the process of catheterizing the bladder, organisms may be carried in. 4. Organisms may be carried down from tlie kidneys or conveyed to the bladder by the circulating blood. It becomes evident that the relation between carcinoma cervicis uteri and the bladder is a very important one on account of the early invasion of the bladder and also because of the likelihood of post-operative cystitis with its accompanying danger of ascending infection. The next question which must be considered is the bearing of the above on these more radical operations. The Bearing of the Relation between Carcinoma Cervicis Uteri and the Bladder on the More Radical Operations for that Disease. A study of specimens from these more radical operations emphasizes the importance of a wide excision of the primary growth, and tliat the bladder anteriorly and the ureters laterally may soon be involved in the extension of the disease. A study of the bladders obtained at autopsy from those cases who have died after these more radical operations, as well as the clinical histories of those who survive, shows how frequentlv cystitis follows these operations and that the danger of ascending renal infection is a very important consideration. A very instructive feature associated with these cases is that an accidental vesico-vaginal fistula was present in three of four cases in which C}-stitis apparently did not develop. The presence of a vesico-vaginal fistula meant that intravesical tension was absent and that the injured bladder was put at rest and cystitis did not develop, or was much less severe. We realize that the formation of a vesico-vaginal fistula is the best means we have of treating severe cystitis. The best surgical treatment for infection in any part of the bodv is free incision and drainage, together with rest of the part diseased, and that is what a vesico-vaginal fistula does for an infected bladder. Its significance here is most important. On account of the proximity of the bladder to the uterus the growth does not have to extend far anteriorly to involve the bladder. The avoidance of injury to the bladder means in many instances a return of the growth and cystitis, with the danger of ascending renal infection. The ivide excision of the growth with any portion of the bladder adherent, means a higher percentage of ciir.es and the probable avoidance of cystitis and ascending renal infection. In cases in which the bladder is not involved by the growth it is not necessary to sacrifice a portion of the bladder. In these cases all raw areas should be covered with peritoneum. The utero-vesical peritoneal fold should be sutured to the anterior vaginal wall and the recto-uterine to the posterior vaginal wall. There is no advantage to be gained in the removal of a long portion of the vagina, unless it is involved by the growth, and there is this disadvantage: that the more vagina removed, the greater the injury to the bladder. A wide excision of the tissue surrounding the upper portion of the vagina is more important. Afterwards the patient should be catheterized every three to four hours, and the bladder irrigated after each catheterization, and at the first suggestion of cystitis, as seen by pus in the urine, the bladder should be examined and if there is evidence of a marked cystitis a vesico-vaginal fistula should be formed. A satisfactory cystoscopic examination may be made with the patient in the Sims' posture," and if evidence of cystitis is seen, the opening into the bladder may be made as follows: The handle of the oystoscope is pushed towards the symphysis so that the end of the cystoscope causes the anterior vaginal wall to bulge at a point just posterior to the internal urethral orifice. 1'his bulging point is opened with a knife and the May, 1904.] 161 incision enlarged posteriorly witli scissors. This may be done without even a local anesthetic, for these extensive operations apparently destroy the sense of pain over this portion of the vagina and bladder. I have done this in one instance with apparently most satisfactory results. Under normal conditions the sensibility of the vagina to pain and touch varies in different individuals. In some cases the entire vagina down to the vulvar orifice seems almost insensitive to pain, so much so that such operations as anterior and posterior colporrhaphies may be done without even a local anesthetic and without causing any severe pain to the individual. On the other hand, in other individuals the vagina is quite sensitive to pain. The vulva is always very sensitive and one must be ver\' careful not to pinch or cut it in these operations. I have done several minor vaginal operations without the use even of a local anesthetic, and find that where indicated, and in suitable cases these operations may be done with but very little discomfort to the patient. I refer to such operations as anterior and posterior colporrhaphies and the making and closure of vesico-vaginal fistula. I do not know why there is this great difference in cases. It is not always due to child-birth, for I have found instances among nullipara where the vagina was relatively insensitive. Up to this date I have tested the sensibility of the vagina in over seventy-five cases, by exposing it and pinching it with forceps or pricking it with a right-angle tenaculum. While in many cases the vagina is so insensitive to pain that pieces of vaginal mucosa may be excised and tlie raw areas closed with sutures, as in anterior and posterior colporrhaphies, and the pain and discomfort are so slight that the patient will not cry out and frequently not even wince ; nevertheless, in some cases such operations would give rise to great pain and torture. The interesting feature of this relative insensibility of the vagina is that it is apparently rendered still less sensitive by these more radical operations, so that vesico-vaginal fistulee may be made and closed without the use of an anesthetic and without causing the patient any severe pain. In only one instance have I intentionally made a vesico-vaginal fistula for cystitis following these operations and the parts were so insensitive that the patient did not know when it was done. The restoration of what little sensibility there is in the vagina must be very slow, for I closed a vesico-vaginal fistula following one of these more radical operations six months after the operation, yet the closure of tlie fistula did not cause the patient a particle of pain. Conclusions. I. The cervix rests against the bladder posterior to the trigonum and under normal conditions the two organs are but loosely attached to each other so that their separation is easily accomplished. The size of the vesical area varies in different cases, and also with the position of the uterus in the pelvis and degree of distension of the bladder. II. The growth in its anterior extension soon reaches the bladder, as manifested by the vesico-vaginal fistulre resulting from the necrosis of the growth which has involved the blad der and accidental ojienings made in the bladder in freeing that organ from the cervix during hysterectomy for carcinoma cervicis uteri. III. Freeing the uterus, parametrium, and upper portion of the vagina from the bladder exposes a large area of the bladder wall, extending from above at the utero-vesical peritoneal fold to a point below, which varies with the amount of the vagina removed, but usually exposing a portion of or the entire trigonum. This area laterally extends beyond the entrance of the ureters into the bladder, if the ureters are resected or dissected free. There is no advantage to be gained in the removal of a long portion of the vagina unless it is involved by the growth, and the more vagina removed, the greater the injury to the bladder. On the other Iiand the wide excision of the tissue surrounding the upper portion of the vagina is most important. IV. In freeing the bladder it is injured, the amount of injury varying with the difficulty experienced in freeing it, which in turn is dependent upon whether the bladder is adherent or not. V. The blood supply of the bladder may be impaired by the ligation of large vessels from which vesical arteries may arise, and also in freeing this large bladder area all vessels going to this area are destroyed and in addition vessels in the bladder wall may be injured. VI. Xerves and ganglia are removed or destroyed in these operations, which may be important structures in maintaining the physiological activity of the bladder. VII. The function of the bladder is impaired by these injuries, as shown by the retention of urine or an inability to empty the bladder completely, which is apt to follow these operations. VIII. Injuries resulting from the operation, together with the impairment of function following them, lessens the resistance of the organ, so that it is usually unalile to resist infectious organisms whicli may gain access to the bladder, and cystitis results. In addition to the avenues available for the entrance of organisms into the bladiler a ne^\• one now presents itself, viz.: that is, the injured bladder wall. IX. Cystitis occurred in 12 of IG of these eases where I have followed the bladder conditions after operation, and in two of the twelve cases it resulted in renal infection and death. In three of the four cases in which cystitis apparently did not occur an accidental vesico-vaginal fistula was present, which apparently prevented a cystitis, for cultures taken in two of these cases showed colon bacilli in large numbers. X. The best surgical treatment for infection in any part of the body is incision and free drainage, together with rest of the part diseased; and apparently this is what a vesicovaginal fistula does for these cases. XI. It seems best that following these operations the bladder should be catheterized every three or four hours, followed by a bladder irrigation as a prophylactic means of preventing retention of urine and avoiding or lessening the severity of the cystitis, and should a severe cystitis develop as determined by cystoscopic examinations, a vesico-vaginal fistula should be 162 [No. 158. made, which may be done without even a local anesthetic, and if it does not close spontaneously it may also be closed without an anesthetic, as has been described in this article. XII. The excision of portions of the bladder adherent to the growth improves the chances of a cure and the presence of a vesico-vaginal fistula apparently lessens the chances of a post-operative cystitis and the danger of an ascending renal infection. Eefeeences. 1. Sampson: Ligation and Clamping the Ureter as Complications of Surgical Operations. American Medicine, 1902, IV, 693-700. 3. Sampson : The Importance of a More Eadical Operation in Carcinoma Cervicis Uteri, as Suggested by Pathological Findings in the Parametrium. Johns Hopkins Hospital Bulletin, 1903, XIII, 299-307. 3. Sampson : The Relation between Carcinoma Cervicis Uteri and the Ureters, and Its Significance in the More Eadical Operations for that Disease. Johns Hopkins Hospital Bulletin, 1904, XV, 73-84. 4. Sampson: The Efficiency of the Periureteral Arterial Plexus and the Importance of Its Preservation in the More Eadical Operations for Carcinoma Cervicis Uteri. Johns Hopkins Hospital Bulletin, 1904, XV, 39-46. 5. Sampson : Complications Arising from Freeing the Ureters in the More Eadical Operations for Carcinoma Cervicis Uteri, with Special Eeference to Post-Operative Ureteral Necrosis. Johns Hopkins Hospital Bulletin, 1904, XV, 123-134. 6. Sampson: Ascending Eenal Infection; with Special Reference to the Eeflux of Urine from the Bladder into the Ureters as an Etiological Factor in Its Causation and Maintenance. Johns Hopkins Hospital Bulletin, 1903, XIV, 334-352. 7. Kelly: The Use of the Eenal Catheter in Determining the Seat of Obscure Pain in the Side. Am. Jour. Obs., 1899, XL, 328-334. 8. Sampson: The Advantages of the Sims' Posture in Cystoscopic Examinations. Johns Hopkins Hospital Bulletin, 1903, XIV, 194-196. 9. Kelly : Operative Gynecology. D. Appleton & Co., New York, 1898, Vol. I, 285 and 405. 10. Wertheim: Ein neuer Beitrag zur Frage der Eadikaloperation beim Uteruskrebs. Archiv fur Gyn., 1902, LXV, 37. 11. Kronig: Zur Tecknik der abdominellen Totalexstirpation des Carcinomatosen Uterus. Monat. fiir Geb. und Gyn., 1903, XV, 879-894. 13. Taussig: L'eber die post-operative Harnverhaltung und deren Folgen. Miinch. Med. Wochenschrift, 1902, XLIX, H. II, 1646-1649. 13. Kolischer: Post-Operative Cystitis in Women. Am. Jour. Obs., 1903, XLVIII, 349-354. 14. Biiisch: Erfolge in der prophylaktischen Bekampfung der postoperative Cystitis. Zeit. fiir Gyn., 1904, XXVIII, 380-385. CAESAREAN SECTION AND SERIOUS DYSTOCIA FOLLOWING VENTROFIXATION AND SUSPENSION/ By Feank W. Lynch, M. D. Associate in Obstetrics, Johns Hophins University, and Resident Obstetrician to the Johns Hopkins Hospital. Since the introduction of the various operative procedures by means of which it has been attempted to correct posterior displacements of the uterus by stitching it to, or suspending it from the anterior abdominal wall, reports have from time to time, appeared in the literature of abnormalities during pregnancy and dystocia at the time of labor following such operations. Fortunately, in the vast iiiiijority of cases, the course of pregnancy and labor has been favorable, although in a small, but apparently increasing number of cases, serious disturbances have been noted. As might be expected, the degree of dystocia has varied according to the character of the operation performed. Thus, serious dystocia has so frequently followed vaginal fixation of the uterus that it has become generally ' First published In German in Der Monatsschrlft fiir Geburtshiilfe und Gynapkolojrie, April, 1904, and read by Invltatinn at the Chicago Gynaecological Society, December 19, 190.3. agreed that the operation is not justifiable during the childbearing 2)eriod. On the other hand, there is as yet no unanimity of opinion as to the effect of ventro-fixation upon pregnancy and labor. Most authors believe that it is in general a harmless jjrocedure and attribute the untoward results, which sometimes follow it, to errors in technique : but nevertheless, the impression has gradually gained ground that serious dystocia may occur in a certain proportion of cases, so that many gynecological surgeons have abandoned the operation and recommend that the uterus should be suspended from the anterior abdominal wall by means of newly formed ligaments, which consist merely of a fold of peritoneum. The advocates of ventro-suspension, as it is called, claim that these become stretched as pregnancy advances, and thereby allow the enlarging uterus to ascend freely into the abdominal cavity. Eecent observations, however, tend to show that even this opera Mat, 1904.] 163 tioii is uot devoid of danger from an obstetrical point of view, as in exceptional cases it appears impossible to limit the adhesions to the desired extent, and consequently fixation of the uterus may result, where only suspension was desired. For this reason, many surgeons of experience have recently abandoned it in favor of operations in which the uterus is maintained in the desired position by shortening the round ligaments in one way or the other after opening the abdomen. It is my object in this paper to call attention to some of the serious complications which are sometimes encountered during pregnancy or labor following ventro-fixation, and occasionally even after suspension of the uterus; and particularly, to report in detail two cases of serious dystocia resulting from this cause; and finally, after studying the cases reported in the literature, to inquire whether either of the operations is justifiable from an obstetrical point of view. Case 1. — K. B., a colored woman, 25 years old, was admitted to the Johns Hopkins Hospital on Jan. 21, 1902, with the following history : She was always well and strong as a ' child, but several years ago had an attack of inflammatory rheumatism, which confined her to bed for three weeks, and left her with a shortness of breath after slight exertion. She has had three normal labors and no miscarriages. Menstruation began at the fourteenth year, occurring every four weeks and lasting eight days with considerable pain. Eighteen months after tlie birth of her last child she began to menstruate at intervals of two weeks, and complained of headache, and pain in the back and lower abdomen in the intervals between the menstrual periods. Sixteen months prior to admission to the hospital, her left ovary was removed at another hospital in Baltimore, but as the operation gave no relief, her uterus was stitched to the anterior abdominal wall one month later. At the same time she was told that it would be impossible for her to become pregnant again. She, however, menstruated two or three times afterwards, and believed that her last period occurred eleven months before her admission to the Johns Hopkins Hospital. She had no idea that she was pregnant, though in August she noticed that her abdomen was growing larger. At no time did she experience any of the subjective s^Tnptoms of pregnancy, nor did she perceive foetal movements. Three weeks before her admission to the hospital she was obliged to give up her work on account of cough, pain in the region of the abdominal scar and swelling of the feet and legs. While on her way to the hospital she slipped and fell from a street car, since when she has had sharp, intermittent abdominal pains resembling labor pains. Examinaiion on Admission. — A fairly well-developed negress, with pendulous breasts containing colustrum. Auscultation shows that the lungs are normal, but a rough systolic murnmr, which is transmitted into the axilla, is heard at the apex of the heart. The abdomen is occupied by a soft tumor which extends 25 cm. above the symphysis and approaches to within 12 cm. of the zyphoid cartilage, the umbilicus being K; em. above the symphysis. It contracts at intervals of fifteen iiiimitcs and is identified as an S months pregnant ulerns. with the fcctus lying obliquely with its head in the left upper quadrant. Just above the symphysis pubis there is a somewhat retracted scar 9 cm. long and 2 cm. wide, to which the uterus seems fixed by a firm band of adhesions, which extends upwards and appears to draw the fundus of the uterus downwards and forwards. The round ligaments cannot be palpated definitely. On vaginal examination the cervix isfoimd high up in the pelvis and displaced posteriorly, its canal is intact and the external os sufficiently patulus to admit one finger. The pelvis is generally contracted and presents the following measurements: 23, 27, 28.5, 19.75 and 10.75 cm.; the conjugata vera being estimated at 9 cm. During the greater part of the eleven weeks which the patient spent in the hospital prior to delivery, she was confined to bed by almost constant pain in the ."egion of the abdominal scar. This was so severe that the daily administration of sedatives and hypnotics was necessary. As pregnancy advanced the child came to lie in a transverse position, and the abdominal scar gradually became more and more retracted, its upper extremity apparently marking the lower limit of abdominal respiration. The uterus was so extremely irritable that the patient was several times thought to be in labor, and on one occasion definite painful contractions occurred at intervals of forty-eight hours and then passed away. The patient fell into labor at 4 A. M., April 9, 1902, the pains gradually becoming more frequent and severe during the course of the day. On vaginal examination the child was found to lie in L. 0. 1. T. with the head not engaged, while the cervix had become markedly retracted, as compared with its condition during pregnancy, so that the external os was situated several centimeters above the sacral promontory and almost in contact with the spinal column, forming an acute angle with the anterior portion of the lower uterine segment. The cervix dilated very slowly, and after fifteen hours of hard pains its canal was still 3 cm. in length and the internal os only sufficiently dilated to admit two fingers. As the condition of the patient gradually became serious, operative interference was deemed necessary, and it was a question whether Caesarean section would be necessary for delivery. On accoimt of the softened condition of the cervix. Prof. Williams believed that normal dilatation could be eiTected and the child delivered by the vagina after version. Accordingly, the cervix was dilated by Harris" method with considerable difficulty, on account of the constrained position which the hand was obliged to assume. The membranes were then ruptured, and after version a living child, 48.5 cm. long, and weighing 3070 gms., was extracted with some difficulty. The biparietal diameter measured 9 cm. During tlie third stage the placenta could be distinctly felt lying in the anterior portion of the uterus, and M-as expressed without difficulty by Credes manosavre. Tlio pnorpprium was afebrile, but the patient complained of great pain in the neighborhood of the scar.. This was so severe that she walked in a somewhat doubled-up position, witli hesitating steps. One month after delivery, the uterus 164 [No. 158. was found to be in acute ante-position, firmly attached to tlie abdominal scar by short dense adhesions, and considerably larger than it sliould be. The cervix, however, liad regained its normal position and was somewhat lacerated. As the pain contiuned and was so severe as to prevent the patient from working, she returned to the hospital nine weeks after the operation, seeking relief. Accordingly, the abdomen was opened under ether anssthesia, when a firm mass of adhesions 6 to T cm. long, and as broad as one's thumb, was found uniting the anterior aspect of the fundus w'ith the abdominal scar. Imbedded in the adhesions were three silkkworm gut sutures, which passed through the recti muscles. The uterus appeared to be about twice as large as usual, while the appendages were lacking on one side and normal on the other. The cicatrix was dissected from the abdominal wall and anterior surface of the uterus, the raw surfaces of which were approximated with the catgut sutures, and the organ dropped back into the abdominal cavity. The patient made an uneventful recovery, although she still complained of some abdominal pain, which was sufficiently severe to prevent her from attending to her household duties for several months. On discharge from the hospital, and on later examination, the uterus was found in ante-position, normal in size and freely movable. Case 2. — Mrs. M., white, aged 37. Has always been rather delicate and a mouth-breather since early childhood. She has a tvpical pigeon l)reast, which she claims is hereditary. She has had nine children and two miscarriages, the eldest child being 18 and the youngest 5 years old ; all labors were normal and there was no puerperal trouble. During the past few years she has complained of symptoms referable to the pelvic organs, for which her cervix and perineum were repaired in 1901, without, however, affording much relief. Accordingly, a competent operator suspended the uterus from the anterior abdominal wall by means of two silk .ligatures on April 1, 1903, after which she made an uninterrupted convalescence. Prior to the latter operation the patient bad menstruated almost continuously, but as the subsequent history will show, was pregnant at the time it was performed. Fcetal movements were perceived early in August, 1902, and at the same time she began to complain of sharp pains in the region of the bladder and abdominal scar, which increased so in severity that she took to bed in October and required large doses of morphia in order to procure sleep. I saw the patient in consultation with Dr. W. F. Taylor, of Laurel, Ifaryland, Oct. 31, 1902, when she was suffering from severe abdominal pain, some fever, and excessive vomiting. At the time of the consultation the temperature was 100° and pulse 120. The abdomen was greatly distended, so that twins or hydramnios were suspected, but the uterus was so rigid that a foetus could not be outlined. The cervix could not be detected in making a vaginal examination in the usual manner, and could be felt only after introducing the half hand, when it was found to be short and undilated, with the external 08 at the level of, and pointing somcwliat to, the right of tlie promontory, and closely approximating it. Three days later I saw the patient again, when the temperature was 102°, pulse 120, and respiration 28 to the minute. These symptoms could apparently be accounted for by a severe pharyngitis and laryngitis; but in view of the probability of serious dystocia at the time of labor she was advised to come to Baltimore and enter the Church ffome and Infirmary, which she did on tlie 3d of November, 1902. Examination on admission showed a frail, emaciated woman in dorsal decubitis, who complained of shortness of breath while lying down, and of severe pain in the region of the abdominal sear. The limbs were so emaciated that the upper arm could easily be spanned with the fingers of one hand. The finger tips were clubbed and the nails curved and thickened, and there was some oedema about the feet and ankles. The pharynx and tonsils were red and swollen, while the chest presented the deformity already mentioned. On physical examination, expansion was equal on both sides, vocal fremitus was normal, the lungs were hyperresonant on percussion and a few crackling rales could be heard at the left apex. Forcible pulsation was apparent over the entire precordial area, but there was no thrill, the cardiac dulness extending to the right sternal margin in the fourth interspace, and the heart sounds were clear. The temperature was 100°, pulse 106, respirations 28. The entire abdomen was extremely pendulous, and the uterine tumor extended 45 cm. above the symphysis on a curved line, and to within 8 cm. of the zyphoid cartilage, while the umbilicus was 35 cm. above the former. Immediately above the symphysis was a non-retracted vertical scar, 7 cm. long and 2 em. wide, to which the uterus was firmly adherent. The round ligaments were felt with difficulty, the right extending do-miward and outsvard from the upper angle of the scar, and the left downward and inward into the left flank. A fcetal head was felt In the left upper quadrant, but small parts could not be made out. The foetal heart was heard in the middle line and beat 140 to the minute. The pelvis was normal. On vaginal examination no presenting part could be felt, and the cervix was in the position already described. From the time of admission until labor set in on Xov. 9, the temperature varied between 99° and 101°, and the pulse from 100 to 120, while the patient .complained of sore throat and severe pain in the abdomen and bladder, which could be relieved only by morphia, and even then she could sleep only propped up with pillows. Cover slips from the throat showed large numbers of streptococci, and the urine contained traces of albumin. The uterus remained so tense that satisfactory palpation was impossible, but the presence of a ballottable head in the left flank suggested a transverse presentation. At no time could two fcetal hearts be heard. During the night of Nov. 8th the patient complained of severe abdominal pain, but the uterine contractions did not seem more marked than those occurring previously. The membranes ruptured spontaneously at 4 A. M., Nov. 9, and vaginal examination two hours later showed that the cervix liad risen to tlie level of the fourth lumbar vertebra ; its May, 1904.] 165 caual was intact and the external os closed. In the lower uterine .segment, which bulged into the pelvic cavity, pulsating vessels could be felt, which imparted a thrill suggestive of a placental bruit. Half way between the symphysis and sacrum a definite transverse ridge could be distinguished in front of which the tissues appeared more si^ongy, so that it was thought that the placenta was implanted low down upon the anterior uterine wall. At this time the temperature was normal and the pulse ViS. As it appeared impossible to deliver the patient per vagina, except by means of Diihrssen's vaginal Caesarean section, it was thought that delivery could be effected most conservatively by means of a classical Caesarean section. The operation, however, was not begun until 9 A. M. on account of some delay in obtaining a priest, by which time the maternal pulse had arisen to 144. Upon opening the abdomen it was found that the entire portion of the uterus visible above the upper angle of the scar was derived from the posterior wall, the fundus being firmly fixed to tlie scar by a short band of adhesions 4 or 5 cm. thick, while the anterior bridged over the superior strait. At the same time the entire organ was displaced to the left, and so twisted upon its axis that the median end of the right round ligament was adherent to the scar in the midline. After cutting through the adhesions, the enormous uterus was delivered through the abdominal wound, when it was found to be so pendulous that its long axis formed nearly a right angle with the spinal column. The incision was through the anterior uterine wall, which was unusually thin, and two children were delivered, one having presented in the L. Ac. I. D. A., and the other in the E. 0. I. P. position. Hemorrhage was readily controlled by compression of the cervix, but at the same time the uterus contracted so poorly that it was necessary to massage it constantly while the sutures were being placed. After closing the uterine incision, the raw surfaces left after severing the adhesions were covered over with peritoneum, after which the abdominal woiind was closed in layers of catgut. The patient left the operating table with a pulse of 130, which shortly afterwards fell to 130 and maintained approxijnately the same rate until death occurred on the sixth day. After a preliminary rise to 102.6° the temperature varied between 99.4° and 101.8°, and the respirations between 38 and 38. The bowels were readily moved on the third day. At no time was there any abdominal distension, nor any signs of intestinal obstruction or peritonitis. The patient, however, slept poorly and took but little nourishment, and failed gradually, dying five and a half days after the operation. Autopsy was refused, but on inspecting the wound it was found that it had healed per pi-imam, and presented no signs of infection. One of the twins was a boy and the other a girl, and weighed 4% and 3y2 lbs., and measured 45 and 43 cm. respectively. The former developed in a satisfactory manner, but the latter died suddenly two and a half days after birth. Both of the cases reported in this paper present several features which appear worthy of mention. In each instance the operation resulted in fixation of the uterus, being intentional in the first and unintentional in the second. In the second case it would seem tliat the patient had been operated upon during the first montli of pregnancy, and it is probable that the increased vascularity of the uterus incident to the condition played a prominent part in the production of the abnormal adhesions. In each of my own cases the fixation was in the neighborhood of the fundus, but in neither of them was the pelvic inlet obstructed by a mass of uterine muscle, as is frequently observed, since in both the anterior wall of the uterus was normal in thickness. Both patients complained of almost constant pain, and were bedridden for several months before labor ; and at the same time their uteri were so irritable that it was impossible to say at any given time whether labor was imminent or not. In each case the almormal position of the cervix was noted during pregnancy and liecame accentuated diiring labor. Complications of Pregnancy from Ventro-fixation. The complications of jjregnancy which may be ascribed to ventro-fixation vary greatly in degree, and doubtless depend upon the extent and length of the adhesions which fasten the uterus to the abdominal wall. Fortunately, in many cases, even though the adhesions be firm and dense, little or no difficulty is experienced, while in others, adhesions of the same character may give rise to serious complications, which have been taliulated by Kelly as follows : 1. ifarked retraction of the scar due to the tugging of the adherent uterus. 3. Constant hypogastric pain. 3. Ketraction and displacement of the cervix, even up into the abdominal cavity. 4. Formation of a tumor obstructing the pelvic inlet, resulting from hypertrophy and deficient expansion of the anterior uterine wall. 0. Excessive thinning of the posterior wall of the uterus. 6. Abortion or premature labor. 7. Persistent and excessive nausea. During labor the following complications may be noted : 1. Prolongation of pregnancy. 2. Inertia of the uterus due to excessive thinning of its walls. 3. Dystocia due to the tumor formed by tlie contracted anterior wall of the uterus. 4. Inability of the cervix to dilate, owing to its abnormal position. 5. Increased frequency of abnormal jn-esentations. 6. Rupture of the scar of fixation. 7. Rupture of the uterus. Noble, in 1896, collected from the .Vmerican literature .56 cases of pregnancy following 808 operations for ventro-fixation or suspension of the uterus, in which at least one ovary remained. At the time of his report 6 patients had aborted and 43 had gone on to term, with 3 deaths ; one patient having died from heart disease before labor, the second from infection occurring before delivery, and the third from infection following a Porro-Caesarean section. As the first two deaths 166 [No. 158. could hardly be attributed to the operation, he figured out a mortality of a little over 2 per cent, although it would appear that one of the other patients, who was undelivered at the time of the report, died subsequently. Later, in the same year, Borland tabulated 179 cases of pregnancy following these operations, and adduced a number of interesting observations; thus, in only 38 per cent of the cases did both pregnancy and labor pursue an uncomplicated course, although pregnancy was normal in 67 per cent and labor in 62 per cent of the cases, with 9I/2 per cent remaining undelivered. After deducting the latter, and the li per cent of cases which ended in abortion or premature labor, thei-e remained for consideration 137 cases wliich presented the following abnormalities : Eetraction of the cervix to the level of the promontory or higher 10 cases (7 per cent) Threatened rupture of the uterus 9 " (6.5 per cent) Abnormal presentations (6 transverse) 9 " (6.5 per cent) Serious dystocia 23 " (17 per cent) Post-partum hemorrhage 3 " (2.2 per cent) Retained placenta 3 " (2.2 per cent) The cases presenting serious dystocia were delivered by forceps in 11 instances and bj" version in 9 ; while Caesarean section became necessary in one case — 8 per cent, 6.5 per cent and 2 per cent respectively; while the foetal mortality was IS per cent and the maternal 1.5 per cent, leaving out of consideration the deaths which were not directly due to the operation. In addition to the case reported in this paper, I have collected 20 others from the literature, in which Caesarean section was necessary, and in all but one of them the data were more or less complete. Thus, in the 20 cases of which the number of antecedent labors was mentioned, we find that 4 patients had 1, four 2, three 3, two 4, and the others 5, 7 and 9 children, respectively, while four were pregnant for the first time. In 12 cases the time was given at which the membranes ruptured. This occurred at or before the onset of labor in 9 cases, after four and a half and fourteen hours respectively in two other cases, while one patient was delivered by Caesarean section before the membranes ruptured. In 17 cases the time was given which elapsed between the onset of labor and the Caesarean section, 2 cases going four hours, 4 eight to twelve hours,- 4 twenty to twenty-four hours, 2 two days, 2 four days, and 1 five days, while another case was operated upon two weeks after rupture of the membranes, twenty-four hours after the onset of hard labor; while in the seventeenth case the operation was performed before the onset of labor, and after futile attempts to induce it by manual dilatation of the cervix and the use of the rubber bag. Moreover, it is interesting to note that in 7 cases some manipulation other than external version was attempted before resorting to Caesarean section. In each of the 19 cases in which the position of the cervix was mentioned, it was situated above the promontory of the sacrum, and in 2 cases at so high a level that it could not be reached by the fingers. Among the other data the following facts may be mentioned: The pelvis was normal or only slightly contracted in every case but one, twins were noted twice, transverse presentations in 15, vertex in 3, and breech in 2 cases ; while in 3 otliers the position was not given. Eight mothers died (38-(- per cent), while in the 18 cases in which the result to the foetus was noted, there were 8 deaths, a mortality of 44I/2 per cent. The conservative Caesarean section was performed in 14, and the Porro operation in 6 cases, with four deaths following the former and three the latter operation ; while no particulars were given concerning the remaining fatal case. While searching the literature for reports of cases of Caesarean section following ventro-fixation and suspension, I have met with the records of many other cases, in which the dystocia was attributable to abnormal fixation of the uterus, and which required delivery by forceps or version; but I have made no attempt to collect them, or the cases of death from rupture of the uterus, in which delivery was not effected ; and would refer the reader, who may be interested in this accident, to the reports of Dickinson, Mackenrodt, von Guerard, Noble, Broadhead and Morrill. I might also mention that instead of attempting Caesarean section, laparotomy was performed ia at least two other cases and the adliesions freed, after which delivery was effected in one case through the natural passages. Admitting that the cases of Caesarean section referred to constitute b\it a small proportion of the total number of pregnancies occurring after ventro-fixation, the results following the operation are, nevertheless, so serious as to warrant careful consideration, and to lead one to inquire how they may be improved or prevented. In the majority of cases the fixation was intentional, as the uterus had been sutured directly to the abdominal wall; though it is probable that in certain of them other operative procedures, carried out at the same time, contributed to the formation of denser and firmer scars than was originally intended. On the other hand the advocates of ventro-suspension have claimed that the adhesions created by that operation are never firm or resistant enough to complicate pregnancy or labor, and it must be admitted that in the hands of competent operators this is almost universally the case. Yet, at the same time, it occasionally happens that from onecause or another, the area of adhesions may be increased, and the intended suspension may be converted into a fixation. Such a result may be attributed to lack of operative skill and faulty technique, suppuration of the abdominal wound, intensification of the adhesions from other operative procedures,, or the increased vascularity of a pregnant or puerperal uterus. That the latter condition may occasionally be the cause of fixation is apparent from the consideration of my second case, and one other which I recently observed in the lying-in ward of the Johns Hopkins Hospital. In both instances ventro-suspension had been performed when the operator was unaware of the existence of pregnancy, the operation being complicated by the removal of a dermoid cyst and the stitching in place of a floating right Iddney in the latter case. Fortunately, dystocia did not occur, although definite fixation resulted. May, 1904.] 167 = i; = £s %> % V !s ^ ►J C) >J ^ ^ ll >5 : e « a ti a ?v §2 > o tog's •'^ Z.C > > j^ Q^ C54J 5.2 §« " kJ U a . A a £.2 o u o CO O !^ O < « Q « « h^'-oS S a Q ^ *- o q f5 =i M « t^ o O Om O a o o Oi o o a .: c u g 12^-2 la B o.-. 53 ^-w El. ^ 2 "c S3 rt _ ?3 .a x: >.S • CD 3 S 2'S <» h iu i;.2i > 1.2 p.© W4-3 a: 2 5 S3 o a " s a 03 S « g a S C-3 , 5+^ 03 CD t" ? © S  sSoSo as a; i S'oj ?.; ^SoEaS < ja — -H -.0= ° 2J .3 iJ fc," O ^' +j. K g 00 a S 3 S SSo ai •U0IJ09S s.iojnq .loqB'i JO noijijJnd 3 3;^ O o J3 .a 1^ CD £^ «3.Sco o 2'0 s notjBjnosoij X > > > H H H H H e H 2i 1C > M tf a u a. 2 <L) R ^ ^ « t^.; a o £3 8oais pesdBia atatx B9T0GTiaS9J(I uiJoViinj snoiAOJj •oay .S O;: > > > « £ o oca OS i ^^1 Sp.Ol'HoS SES-f: Cl s :i a « /J.a 3 2-3fS -2 >.^ s'Sb'S .S n c= o"3~B = **^^'^> '-' '-' _. K. aj en C 'J .^ ^. .X M ::; X r. = .i •:£ . 03-r rt':z::i-r^i' "::..:: " I * I " I w,, © o *^ o i' o — fl t4 C t- C !-( " _.J^ +J .p- +J .-. +J -J^ ) 5 q; 1 §1 §^= 02 =5 eg o-^ go 4- 3t^ ^0 "iS ?.9 5 cc = ca ©a "rS, "^s 5 r- . a my. ntroplioi ntro S.2>.si ^sa^i (B a D^ r^is^ m-t^j;^ O;^ ^M^^^ft - -w rv r- — 2a.S © rt o w O 2 S a CO 10 -^ .3-" ^ a © i gS3 .. ot-go s s o ^ id S a g 03 U 5 5 JZ © 168 [Xo. 158. The vascularity of the puerperal uterus may act in a similar manner, as was illustrated by another case coming under my observation, in which it was attempted to suspend the uterus seven weeeks after labor. At the operation the sutures repeatedly cut through the friable uterine tissue, so that considerable manipulation was necessary. As a consequence, when the patient recovered, the uterus was found to be firmly adherent to the anterior abdominal wall, instead of merely suspended from it. That neither of these favoring circumstances are absolutely necessary to the formation of dense adhesions, was shown by another case in which the uterus, although suspended by a competent operator, in the absence of any abnormality save displacement, became firmly fixed to the abdominal wall. This patient entered the lying-in ward when eight months pregnant, and presented dense adhesions between the uterus and abdominal wall, which were readily jialpated. They stretched but little during pregnancy, and jirevented the uterus from rising in the normal manner. Fortunately, the roomy jjelvis compensated for this, and dystocia did not occur; though at the time of labor the cervix appeared at the vulva, where its dilatation could be followed with the eye. The cause of dystocia in all these cases can be readily understood upon considering the anatomical conditions resulting from the operation. Thus, if the fundus be firmly attached just above the symphysis by dense adhesions, the anterior uterine wall will be iinable to expand, and consequently the increase in size of the organ miist be effected altogether at the expense of its posterior wall. As the ascent of the fundus is thus impeded, the foetus tends to accommodate itself in an oblique or a transverse position, and by its further growth causes the posterior wall to become so thin as to approach the verge of rupture. At the same time the tension exerted by it tends to draw the cervix upward from its normal position, until it comes to lie in the neighborhood of the sacral promontory. Moreover, in a certain number of cases the thickened anterior uterine wall may form a tumor which obstructs the superior strait, and it would appear probable that such a condition is more apt to occur when the fixation is by means of the posterior wall of the uterus, since it was absent in the two cases here reported, in which fixation was by the anterior wall. In such cases, in the latter months of pregnancy, dense adhesions can be palpated extending from the abdominal cicatrix to the body of the uterus, and as pregnancy advances the scar may become retracted. At the same time, when the round ligaments are palpable, their upper extremities will be found in the neighborhood of the upper end of tlic scar, thus showing that the fundus is in the neighborhood of the symphysis, instead of at the vertex of the uterine tumor. At the time of labor, dilatation of the cervix is effected very imperfectly, if at all; since the bag of waters and the presenting part, in.stead of imjiinging directly upon the internal OS, exert their force upon the portion of the uterus anterior to it, and consequently, no matter how strong the contractions may be, labor comes to a standstill, and unless suitable operative interference is undertaken, rupture of the uterus must become imminent. TEEATMENT. Considerable discussion has arisen as to the most suitable means of treating this class of complications when observed in pregnancy, and the following methods have been advocated : (a) Induction of premature labor; (b) Freeing the adhesions after laparotomy; (c) Allowing the patient to go to term, and should dystocia occur, to attempt delivery by forceps or version, after manual or instrumental dilatation of the cervix, or if necessary, to perform the classical Caesarean section or Diihrssen's vaginal operation. It seems to me that the field for the induction of premature labor is extremely limited for three reasons : In the first place, it does away with the possibility of spontaneous labor at term; and secondly, it is associated with a tremendous foetal mortality. Moreover, the operation may prove extremely difficult in the cases in which it may be indicated, and in some instances prove impossible of accomplishment. The performance of laparotomy followed by the freeing of adhesions is indicated only in the exceptional cases in which the patient is seen early in pregnancy, and complains of intense abdominal pain. On the other hand, when the patient is only seen before labor, the procedure is contraindicated for several reasons: In the first place, a large wounded area will be left on the uterus, which must be covered over by peritoneum, and thereby greatly increase the chance of premature termination of pregnancy. Moreover, in the second place there is considerable doubt as to the advisability of allowing a iiterus, which has recently been subjected to so severe a procedure, to stand the strain of labor; not to speak of the fact that the freshly formed abdominal cicatrix may be severely damaged. As far as I can ascertain, Goubaroft' and Bidone attempted such a procedure after the onset of labor, in the hope that spontaneous delivery would follow; but their results were not sufficiently encouraging to tempt one to imitate them, for, in the former's case, the hemorrhage was so severe that Caesarean section became necessary to prevent the woman from bleeding to death ; while in the latter 's the procedure was not followed by the desired result, and it later became necessary to dilate the cervix manually, after which version was performed and extraction attempted. As this could not be accomplished, craniotomy was resorted to, and even then the child was delivered only after the greatest difficulty, and the mother developed a peritonitis which nearly cost her life. Diihrsseu's vaginal Caesarean section, or the modification proposed by Hiibl, has been practiced in a number of eases of dystocia following vagino-fixation of the uterus, in which manual dilatation of the cervix was out of the question. It would appear, however, that in the class of cases under con May, 1904.] 169 sideration, the clanger of hemorrhage is considerable after this operation, and may be so profuse as to make it necessary lo sacrifice the nteriis in order to prevent death. And, moreover, the adhesions which gave rise to tlie condition cannot always be readily separated through the vagina, and therefore should the woman recover, .she may be exposed to a similar danger in a subsequent pregnancy. In view of the various considerations Just advanced, it would seem to me a better practice to allow the patient to go on to term, unless the pain in the region of the abdominal cicatrix be so severe as to demand relief during pregnancy. If, at the time of labor, the fixation is dense and the cervix displaced above the level of the sacral promontory, I believe that the best results will be obtained by resorting to Caesarean section at the onset of labor, and without any attempt at delivery through the natural passages. In such cases, after releasing the adhesions the operation is readily performed, and should give satisfactory results, provided it is done by a competent operator under suitable surroundings. Up to the present time, however, the mortality following .such operations has been extremely high, and would seem to be due to infection contracted during intra-uterine manipulations which had previously been undertaken; though, in the few cases in which the operation has thus far been performed primarily, the condition of the patient was so serious as to make its outcome very doubtful. Whether the results of Caesarean section, for this variety of dystocia, will ever be as favorable as those performed for pelvic contractions, remains to be seen; but there is no reason why they should be anything like so serious in the future as they have been in the past. In conclusion, I think it should be inquired whether operations likely to result in fixation of the uterus to the anterior abdominal wall are ever justifiable during the childbearing period. The untoward results following ventro-fixation clearly indicate that the operation should be abandoned; while the few cases in which unintentional fixation has followed supposed suspension of the uterus, render it questionable whether even this more conservative operation should be employed. For my part, I am inclined to take the ground that neither procedure is justifiable until after the menopause, as it does not seem proper to undertake an operation for the cure of a condition wliich does not threaten the life of the patient and merely exposes her to a certain amount of discomfort, when we know that it may give rise to most serious dystocia should she become pregnant. Which will prove the most suitable operation for the cure of displacements of the uterus during the childbearing period cannot as yet be definitely predicted, though it seems to me that some of the procedures which aim to maintain the organ in position l)y shortening the round and the utero-sacral ligaments, will eventually prove to be the operation of clioice. It is possible that Alexander's operation may prove the ideal procedure when the uterus is movable; but when it is adherent the abdomen must be opened, in order to free it, and under such circumstances some intra-abdominal method of shortening the ligaments would appear most rational. LiTERATDRE. Abel : Eine neue indication zur Sectio Caesarea nach Porro. Berliner Kliuisch. Wocheusc. 189G, No. 13, S. 280. Batcuelok: Caesarean Section for Dystocia Following Hysteropexy. Australasian "Medical Gazette. 1899, 18, Octo. 28th. Bidone: Distocie gravi da isteropessi. Atti della Societa Italiana di ostetrieia e ginecologia. 189G, 3, p. 258. Blooaiiiardt: ' Dystocia following ventro-fixation. American Medicine, January 11, 1902, p. 73. Brodhead: Eemarks in Discussion of Paper by Dickinson, q. V. American Journal of Obstetrics, 1901, Vol. H, p. 253. Brown : Caesarean Section Necessitated by Ventro-suspension. American Journal of Obstetrics, 1902, August, p. 197. Cragin : Caesarean Sections. Medical Record, 1901, Vol. 59, p. 695. Dickinson : Pregnancy Following Ventral-fixations, One Ending in Rupture of the Uterus, and One in Caesarean Section. American Journal of Obstetrics, 1901, July, p. 34. Dorland: Gestational Complications and Dystocia Subsequent to Anterior Fixation of the Uterus. University Medical Magazine, 1896, December, p. 163. Edebohls : Shortening the Round Ligaments : Indications, Technics, and Results. American Gyaecological and Obstetrical Journal, December, 1896, p. 725. Goubakoff: Dystocie due a une Hysteropexie necessite I'operation Cesarienne. La Semaine Medicate, 1895, p. 245. Also Medical Week, Paris, 1895, Vol. Ill, p. 305. Von Guerard : Koliotomie bei Geburtsstoriing nach ventrifixur. Centralb. fiir Gynaek., 1896, 20, p. 531 III : Ten cases of Caesarean Sections. American Journal of Obstetrics, 1901, November, p. 648. Kelly : Operative Gynecology, 1902, Vol. ii, p. 157. Milander: Ventrifixation des Uterus; Schwanger-schaft und Querlage des Kindes. Zeitschrift fiir Geburtsh. u. Gynaek., 1895, XXXIII, S. 464. Mijller: Beitrag zur Operationen Behandlung der Retroversio-flexio uteri. Inagg. Dissertation, Wiirzburg, 1896. Negri : L'isteropessi studiata dal punto di vista ostetrico. Annali di Ostetr. e ginec., 1896, 18, p. 460. Noble: Suspensio Uteri with Reference to its Influence upon Pregnancy and Labor. American Journal of Obstetrics, 1896, Vol. 34, p. 160. PiNZANi : Quattro casi importani di laparatomia a scope ostetrico. Atti della Societa Italiana di ostetr. e ginec., 1894, Vol. I, p. 37. ' The same case apparently has also been reported by Findley. Journal Amer. Med. Ass'u, Aus- 33, 190'3, 170 [No. 158. PoLTOvicz: Remarques sur quelques cas d'hysteropexie d'apres les observatioBS recueillies a la clinique chirurgicale de Lausanne. Eevue Medicale de la Suisse Eomandc, 1895, p. 21. Pozzi: Contributo alia casistica delle distocie da ventrofissazione dell' utero. Giornale della R. Accademia di Medicina di Torino, 1900, Vol. G, p. 603. Eapin: Multipare. Bassin rachitique. Operation Cesarienne. Revue Medicale de la Suisse Romande, 1895, p. 213. ScHUTTE : Ueber Geburts-complicationen nach ventro-fixatio uteri. Moiuitsschr. fiir Geburtsh. u. Clyn., 1899, No. 10, S. 489. Strassmax : Zur Kenntniss des Sehwangerschaf t unci Geburts-verlaufes bei antefixirtem uterus. Archiv. f . Gynaek., 189G, No. 50, p. 473. Werder: Two Cases of Dystocia Following Ventrafixation, One Requiring Caesarean Section. American Journal Obstetrics, November, 1899, p. 615. TWO CASES OF MULTIPLE SACCULAR ANEURYSMS OF THE AORTA WITH RUPTURE INTO THE PERICARDIUM. By p. K. Gilmax. {yotes from the Pathologiciil Lnhoratory of the Johns Hopkins Hospital.) The following cases of multiple saccidar aneurysm formation in the arch of the aorta with rupture into the pericardium have some anatomical interest, and are reported through the courtesy of Dr. W. G. MacCallum. Case I. — C. S., a colored coachman aged 39, was admitted to the hospital several times during the years 1901-1903 witli signs of aneurysm formation in the region of the arch of the aorta. There was great variation from time to time in the physical signs, the prominence caused by the aneurysm and the area of maximum pulsation being somewhat movable. During the last admission and up to the time of the patient's death there was present a well-developed tracheal tug and a leathery friction rub was heard in the left upper chest. At autopsy a large irregular sac was found in the pericardial region densely adherent to the left hmg, which in turn was compressed and bound firmly to the thoracic wall. The pericardium was distended with blood which, in addition to being firmly clotted, was sho-rni to be partly organized, the organization being more advanced at the apex than elsewhere. The clot was thickest over the base of the lieart posteriorly and thinnest about the apex. The heart itself was generally hypertrophied, though its valves were delicate. From the arch of the aorta there arose three aneurysmal sacs, the largest, 1? cm. in diameter, involving the anterior face of the vessel from 4 cm. above the valves to the origin of the innominate artery, the second, 6 cm. in diameter, involving the convex portion of the arch and giving off the innominate, left carotid, and subclavian arteries, the third, 2.5 cm. in diameter, springing up from the descending aorta about 2 cm. below the second. The largest of these sacs extended downward and to the left, compressing the right auricle downward and backward. It was lined in its lower portion by a firm laminated clot 2 cm. thick. In its lower right portion was an irregular ragged slit which communicated with the pericardium, and through which the hojmorrhage had occurred. The second aneurysm had compressed the left bronchus and had given rise to a generalized bronchiectasis in that lung. which, in addition, had undergone a very extensive tuberculous consolidation. The right bronchus had suffered no compression, and the lung was voluminous with widely dilated air cells. This case, aside from the anatomical peculiarities, is chiefly interesting from the fact that the extensive haemorrhage into the pericardium had been survived long enough to permit partial organization of the clot. Case II. — E. L. W., a negro aged 43, who died with signs of aortic aneurysm and pulmonary tuberculosis. At autopsy there was found disseminated tuberculosis of both lungs with extensive caseation of the bronchial and peritracheal lymph glands. The pericardium was much thickened and hsemorrhagic, and was covered with ragged fibrous adhesions. Its cavity was distended with a laminated clot, showing some organization where it adhered to the pericardial surfaces. But for a general hypertrophy the heart was not greatly altered, though the aorta was enormously dilated from a point 3 cm. from its origin, the dilatation measuring 9 cm. in diameter. This was rather an aneurysmal dilatation than a saccular aneurysm. The walls of the dilatation were roughened by irregiilar patches of sclerotic thickening of an extreme grade, thougli there was no calcification. There were several irregular saccular bulgings of the walls, reaching sometimes 2 cm. in diameter, and filled with thrombus masses. At the upper part of the ascending portion of the aorta one of these sacs had ruptured, and the opening, about 2 cm. in diameter, bore a lobulated corrugated thrombus mass. A probe passed through this opening entered a cavity hollowed out in one of the large caseous bronchial glands and thence passed into the pericardium, showing the path of the hemorrhage into tlie pericardium. Sections of tlie pericardium showed a well-developed tuberculous pericarditis, and it seems probable that the path ultimately followed by the stream of blood may liave been the original path followed by the tubercle bacilli in their spread from the lymph glands to the pericardium. May, 1904.] 171 REPORT OF RESULTS OF NURSING DISPENSARY TUBERCULAR PATIENTS. By E. Thelin, Visiting Nurse for Tuberculosis. The results of three months' visiting of tuberculous patients from the Johns Hopkins Hospital Dispensary are, on the •whole, encouraging. The work is as yet retarded by the need of a room where a separate clinic can be held, but this want is soon to be filled, we hope, through the generous donation of Mr. Henry Phipps. • Under the present arrangement, the nurse is not able to be present at the clinic, but is given the names of the patients by the doctors in the dispensary. She also accepts names from the Federated Charities, and, if possible, brings those patients to the dispensary for a definite diagnosis. The majority of the dispensary cases are from the laboring classes, many of them intelligent working men, who have spent their all on doctors or on quack medicines. They say that when they had money to pay a doctor, they did not think it right to go to a free dispensary. Now, their money gone, they come to the dispensary, too late, in many cases, to be saved ! In many instances they receive the new ideas with favor and after trying the experiment of sleeping with an open window, generally feel so much better tliat they are more than willing to continue it. Out of sixty-five cases seen, thirty-eight have been willing to sleep with their windows open, and are continuing it more or less faithfully. In the winter months it has been more difficult to get tubercular patients out in the day-time, either from weakness and lack of energy on their part, or from lack of proper clothing when they had the energy. Nor has the plan of sitting with open windows, well wrapped up, been very successful as yet. The doctors urge the patients to go to the country, if possible, and in nine instances they obeyed so promptly that they were gone before the nurse could get to see them. As the Hospital for Consumptives at Towson can accommodate only twenty-five patients we usually find out whether the patients can make arrangements to go to friends in the country before considering Towson as a possibility. We have sent four white patients there, and three colored patients to the Hospital for Tuberculosis at Bay View. As regards diet, the help afforded by the Federated Charities is immeasurable. Thirteen patients only are able at present to supply themselves with the necessary quart or more of milk daily, but twenty-eight are daily supplied with one quart of good milk and two fresh eggs by the Federated Charities. They have also supplied a cot for a colored boy who was sleeping with his mother and sister. In another case of this sort, the boy was sent to Bay View. The precautions to prevent the spread of infection are generally taken up by the family with great care. Sometimes a feeling of disgust and fear of the poor patient lias developed on the part of friends and neighbors which has added to his already too heavy burden. Strange as it may seem, there is also a certain class of tubercular patients who, becoming embittered by their hard fate, refuse to be considered as sources of infection to others and strenuously oppose the efforts of their families to protect others from the disease. The existence of this cla-ss points to the necessity of such stringent laws as are now being enforced in New York. Our health authorities have not done much in the matter of legislation against tuberculosis as yet. Even fumigation is not compulsory; the request to have a tuberculous house fumigated must be accompanied by a signed order from the owner or tenant. Notwithstanding our discouragements there is ground for hope in the fact that the work of visitation has been begim, and that four patients are undoubtedly gaining in weight and strength as a result of it. Two of these, who were too weak to walk one block, are now able to attend to their ordinary housework. One recently walked two miles, and hopes soon to be strong enough to go to work. Report of Work roR Three Months. Total number of visits for December 72 " " " " " January 86 " " " " " February 87 Total for three months 245 Dispensary Patients 42 Patients from Federated Charities or Interested persons .... 25 Not seen because of wrong address 11 " " " gone to the country 9 " " " sent to hospital 3 THE JOHNS HOPKINS HOSPITAL BULLETIN. The Hospital Bulletin contains 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 XIV is now completed. The subscription price is$2.00 per year. The set of fourteen volumes will be sold for $50.00 172 [No. 158. PRCXEEDINGS OF SOCIETIES. THE JOHNS HOPKINS HOSPITAL MEDICAL SOCIETY. December 7, 1903. The meeting was called to order by the President, Dr. Futeher. Perineal Zoster. Dk. Gushing. An herpetic eruption rarely occurs over the sacral areas. According to Head's tabulation of .3T8 cases, in seven instances only did the eruption have a sacral distribution, the lowest segment of which mention is made in his paper being the third sacral. Fig. 1. Fig. Fig. ].— Outline sketch of area of vesiculation over perineum in Case I. Fig. 2. — Diaj^ram showing postoperative area of anaesthesia in Case I, with an outcrop of herpes facialis on the opposite side. Fig. 3. Case II.— Distribution ot facial and bilateral cervical herpes. Note that the postoperative aniesthetic area remains free, indicating' that the eruptions presumably originated from lesions in the posterior root ganglia (cervical and tri);eminal|. Twice, in the writer's series of cases of trigeminal neurectoraj^ has the operation been followed by an outcrop of herpes. In the first case the distribution of the vesicles on the perineum was taken to represent a lesion of the fourth sacral posterior root ganglion (cf. Fig. 1). There was an accompanying vesiculation of the herpes febrilis type on the nonansesthetic side of the face (Fig. 2). In the second case sensory symptoms, such as are the frequent precursors of herpes zoster, appeared after the operation, having a bilateral perineal distribution similar to that in the first case. The symptoms were interpreted as indicating a lesion of the posterior root ganglia (S. iv.), which did not suffice to cause vesiculation; "herpes zoster" without eruption, as described by James Mackenzie. This perineal disturbance was accompanied, as in the first case, by a quite extensive facial herpes which again failed to encroach upon the skin-field rendered anssthetic by the ganglion extirpation (Fig. 3). The pathology of herpes facialis seu febrilis has been the occasion of dispute. Many have thought the lesion to be quite distinct from that which produces true herpes zoster. Howard, however, has fotnd lesions in the Gasserian ganglion in a case of common facial herpes accompanying pneumonia. This observation together with those above cited, that after Ga.sserian ganglion extirpation an herpetic eruption does not occur over the resultant aufesthetic field, suffices to render it most probable that posterior-root ganglion lesions are responsible for the common forms of herpes about tlie lips and nose as well as for zoster. The perineal eruption in the first ca.<e and the hyperassthetic area in case two with a similar distribution, allow of certain generalizations as to the cutaneous skin-fields of the lower sacral segments. In the ordinary diagrams with the subject in the erect posture the lower (fourth and fifth) sacral fields are completely hidden. It is necessary to put the body and lower extremities in the embryonal position in order to understand clearly the configuration of the skin-fields below the second sacral, this being the lowest to enter completely into a leg distribution. The coccygeal, fifth, fourth and third sacral areas surround the caudal end of the body in concentric fashion, the strips running from mid-dorsum to midventer just as do the thoracic and abdominal skin-fields, and like these retain in large measure their simple, primative and undistorted arrangement. Notes on Hydatid Disease in Australia. Dr. J. Ramsav, of Laiinceston, Tasmania. Dr. Ramsay gave an account of hydatid disease in Australia, where it occurs more commonly than in any other country in the world except Iceland. Dogs, rabbits, kangaroos and oxen are affected. The chief source of infection in man is from the feces of dogs. The successful treatment is surgical and consists in a removal of the hydatid cysts. Discussiox. Dr. C'u.sui.vg. — I was very much interested in what Dr. Eamsay said about the rarity of hydatid in the spine. One of the very few cases of hydatid I have seen operated upon was one in which multiple cysts in the spinal canal had been the cause of a pressure palsy. The case was operated upon by Sir Victor Horsley a few years ago in London. Dr. McCrae. — We are indebted to Dr. Eamsay for this excellent paper. Hydatids are of course rare in this locality, but it is well to bo on the lookout for them. It is interesting to see how exploratory puncture has fallen into disfavor for the diagnosis of hydatids. Twenty-five years ago puncture was done in ap])eni]ix conditions, ten years ago for distended gall May, 1904. J 173 bladder, and I suppose ten years hence many of tlie punctures done now will have been abandoned. Dr. Fctciier.— Hydatid disease is undoubtedly rare in this country. Dr. Lyons' statistics were referred to by Dr. Ramsay. lie found that up to 1902 there had been 241 cases reported in this country, only one of which was known to be a native-born American. In 136 the patients were foreigners. In 92 the nativity of the patients was not known. Ten were negroes and two were Canadians. It is interesting to note that there were 56 cases in the Province of Manitoba, Canada. The explanation for this is that there is a large settlement of Icelanders in that province, and hydatid disease is very common in this race. Only one instance is known in a Canadian-born offspring of an Icelandic emigrant. Dr. Eajisay. — Our statistics of hydatid of the kidney are a little different from those usually compiled. Neisser found 8 per cent, I believe, but with this exception it is said to have been rare. You are to be congratulated upon knowing nothing about hydatid in this country. I advise you to keep the disease out of the country. Intra-pelvic Hematoma following Labor. Dr. Williams. I wish to report a case which I saw in consultation about a month ago with Dr. H. L. Smith, which was of great interest to me, both on account of its rarity and the favorable result following operation. I saw the patient on the evening of November 2, 1903, and obtained the following history: Thirty-three years old, married three years, and had been delivered a few hours previously of her first child, which weighed a little less than six pounds. The labor was quite slow and was terminated by an easy low forceps operation without ansesthesia. The statements concerning the delivery were made by the nurse, as Dr. Smith did not deliver the patient himself, being called in some hours later in the absence of the regular medical attendant. The placenta was expelled shortly after the birth of the child and everything seemed to be most satisfactory. There was no hemorrhage. Almost immediately after delivery the patient began to complain of intense pain of a tearing character about the rectum, which was so severe as to require the administration of a hypodermic of morphia. The patient stated that this pain was more intense than any she had felt during labor. Her general condition was good, as was evidenced by the fact that her physician, who lived in the country, left her at the end of an hour, saying he would see her the next day. After his departure, the pain became much more severe and the patient gradually passed into a condition of collapse. Three hours after delivery she was seen by a neighboring physician, and later by Dr. Smith. At that time she was greatly shocked, pulse 160-70, and complained of intense pain. After the subcutaneous injection of normal saline solution and the administration of strychnia and whiskey, her condition improved somewhat, but soon changed for the worse, when a diagnosis of internal hemorrhage was made, and I was asked to see her. The patient was a large, well-nourished woman, with a very pallid face and a rapid thready pulse of f-O. On palpation, the lower abdomen was filled by a rounded fluctuant tumor, the size of a man's head, reaching up to the umbilicus. At first glance it seemed to be the enormously distended bladder, but only a few drops of bloody urine could be obtained on catheterization, while the tumor maintained its original size. Careful examination then showed that it was surmounted by a hard, rounded body about the size of two closed fists, which was clearly the contracted body of the uterus. On vaginal examination, the posterior and left vaginal fornices bulged markedly, and through them a wave of fluctuation could be transmitted to the abdominal tumor. The cervix showed no signs of a tear, and was displaced upward and backward, so that the external os lay to the right of and just in front of the sacral promontory. In the absence of external bleeding in a patient presenting the symptoms of acute anfemia, the only possible diagnosis was internal hemorrhage, which was supposed to be due to an incomplete rupture of the uterus, with escape of blood between the folds of the broad ligament. As the patient's condition had become worse in the interval between my arrival and the completion of the examination, I recommended immediate operation, laying clearly before the family the dangers of such a procedure, but pointing out at the same time that it offered a much greater chance of success than expectant treatment. Accordingly, preparations were made for a laparotomy, the necessary appliances being transported from the hospital. This necessitated considerable delay, so that the operation could not be begun until 1 A. il. At that time the patient w^as practically pulseless at the wrist, though the heart could be distinctly heard on auscultation. Only a minimum amount of ether was necessary to anesthetize her. After the usual preparations, an incision was made in the middle line of the abdomen extending 15 cm. upward from the symphysis. On cutting through the fascia, the ordinary components of the abdominal wall could not be distinguished, and a loose, blood-stained tissue came into view, which was readily broken down by the fingers. Then, instead of reaching the peritoneiim, the fingers passed directly into a large cavity, filled with partially clotted blood, situated between the symphysis pubis and the anterior and inferior wall of the bladder, and extending between the folds of the broad ligament to the left wall of the pelvis. It was bounded below by the pelvic floor, so that the fingers emerged beneath the ascending ramus of the ischium anteriorly, while laterally they came in contact with the tuber ischii. Being still under the impression that I had to deal with a ruptured uterus, I extended the abdominal incision upward and exposed the body of the uterus, which was perfectly normal, except for its unusual position. To make the matter absolutely sure, however, I requested an assistant to pass his finger up through the cervix, when it was found that there was absolutelv no communica 174 [No. 158. tion between the uterine canal and the cavity just described. The peritoneum above the hematoma was then closed, so as to prevent any contamination of the abdominal cavity, and the hematoma rapidly cleared of the clots contained within it. An attempt was then made to locate the source of the hemorrhage, which was found to be from an oozing surface upon the anterior and inferior surface of the bladder, there being no large vessels involved. As it was impossible to apply ligatures, the only means of checking the hemorrhage seemed to lie in packing the cavity with iodoform gauze. This was accordingly done, the vagina being tightly packed at the same time, so as to afford counter pressure. The abdominal wound was then closed to within 5 cm. of the S3'mphysis, a tight abdominal bandage applied and the patient put to bed in slightly better condition than at the beginning of the operation. During the night she rallied considerably, and by the following morning was practically out of danger. At that time the dressings were so soaked with a bloody discharge that it was necessary to renew them, though the packing was allowed to remain in situ for three days before it was replaced. At that time, a sound introduced into the wound extended downward and backward on the left side of the pelvis for a distance of 10 inches. The wound rapidly closed, so that a smaller pack was used at each dressing, and at the present time all that remains of it is a small sinus three inches long and only large enough to admit a lead pencil. Intra-pelvic hematoma following labor is extremely rare, hardly more than twenty cases being reported in the literature. The first clear description of such a condition is to be found in Deneux' monograph upon puerperal hematoma (18.30), in which it was pointed out that such structures could be divided into two great groups, according as they were situated below or above the pelvic floor, the former being comparatively frequent and the latter extremely rare. Hugenberger in 1865 published a communication upon the subject, in which he reported five cases of his own and collected ten others from the literature. Since that time only isolated cases have been recorded, the great majority of which died, though a few recovered spontaneously. As far as I have been able to learn, this is the first case of the kind upon which an operation has been done, and I feel that the result justified its performance. It would appear probable that the cause of the hemorrhage was due to tearing througli the ante-vesical plexus of veins during the forceps operation, although it was not necessarily responsible for it, as several cases have followed normal and spontaneous delivery. As far as diagnosis is concerned, it would appear impossible for one to differentiate between the condition in question and an incomplete rupture of the uterus, though this is practically a matter of comparative indifference, as in either event, operative interference is demanded if the hematoma increases in size and the patient's condition is at all serious. Meeting of December 21, 1903. The meeting was called to order by Dr. Hurd, the President arriving later. Observations on the Coagulation of tlie Blood. Dit. T. R. Bogob. Dr. Boggs showed an instrument for timing the coagulation of the blood which was a modification of the apparatus first devised by Brcdie and Russell, and gave relatively good results. Dr. McCrae. — We are all very much indebted to Dr. Boggs for telling us about this method and I am sure we will welcome any simpler method than that now in use. I would like to ask him whether the length of coagulation time as taken by this method is approximately the same as that taken with Wright's tubes. The observations upon gelatin as described are interesting. Clinically we have practically discarded the use of gelatin to increase the coagulability of the blood, certainly in aneurism cases. We believe in the local application of gelatin to bleeding surfaces. The Limitations of Urinary Diagnosis. Db. R. C. Cabot, of Boston. One of the ideals dearest to the student of medicine is the ideal of accuracy. I suppose there is no ideal to which any of us pay homage more regularly. In the attempt to stir ourselves out of the slough of vague guesses in which the practice of medicine has wandered so long, we catch at anything that seems to make for greater exactness in every department of our work, but although we know very well that we want exactness, I do not think we all know by any means what we mean by accuracy in clinical work and I want to say a few words about what I think that word means. It is a truism to say that exactness is relative and never absolute, and yet if we recognize that as a truism we would recognize a corollary of that, that accuracy is always relative to our purpose and what may be accurate enough for one purpose is not enough for another and perhaps too accurate for a third. Perhaps I had better say that misdirected exactness is a danger into which the better trained of the students of medicine in the present are prone to fall. The art of medicine is long and our life is short. We cannot too soon realize that we have got to be inexact somewhere and that the wise man is he who knows where to be accurate and where to get along without exactness. A well-known practitioner of Boston, whose name would be recognized by many of you, was visited by a patient who complained of gastric trouble. The doctor made an exhaustive examination of the abdomen, extracted the contents of the stomach, and analyzed them, measured the size of and marked out the position of the stomach, analyzed the urine, quantitatively, examined the blood, made an estimate of the hfemoglobin, and prescribed for the patient. The patient got no better. The doctor had been very accurate in certain directions, but he had been very inaccurate in taking the patient's history. It turned out that the patient was pregnant. Now the pregnancy could not linvc boon determined by any method May, 1904.] 175 of physical examination, so far as I know, at the time he made his examination, but it might possibly have been determined by taking a careful history. The point that I want to make is that he chose the wrong place for his accuracy. Had he been more careful about the history and less so about the percentage of hfemoglobin, he would perhaps have done better. Misdirected accuracy, then, is possible, as you see from the illustration. I should like to spend more time on this part of my subject, but must pass to the consideration of a subject upon which I believe that a large amount of misdirected activity is spent — the subject of urinary analysis. My main thesis, in brief form, is that a large part of the time now spent on urinary analysis is entirely wasted. I am speaking especially now of the urinary analyses in renal disease. I shall not speak of those used in diabetes and other diseases in which the kidney is not directly concerned. Dr. Councilman, in a report on acute and subacute nephritis in 1897, said of urinary analysis that it does not give any sure information as to the type of renal lesion present. At that time I looked upon that statement as a surprising one, but it seems less and less surprising as my own experiences have accumulated. I will begin by giving the accounts of two cases that serve to illustrate my thesis: Case I. — An Italian, 27 years old, was brought to the Massachusetts Hospital entirely unconscious having been taken from a vessel which had touched at several South American ports. No history obtainable. Temperature 102.8 with moderate leucocytosis and a slight amount of evidence of consolidation at the apex of the left lung. He had nothing wrong with the abdominal viscera so far as we could demonstrate. There was some retraction of the head and stiffness of the neck. Fourteen ounces of urine drawn by catheter showed a little over i/^ per cent of albumen. The color was high but not distinctly blood)', and the specific gravity 1.017. The sediment showed the largest number of casts I have ever seen in any urine — from 10 to 20 in every field of a No. 5 Leitz. The character of the casts were mainly granular with a few epithelial. Prolonged examination of the blood excluded malaria. Yellow fever, cerebro-spinal meningitis and uraemia were considered. Lumbar punctures gave no growth. He died next day. Autopsy showed cerebro-spinal meningitis, and the diplococcus intracellularis of Weichselbaum was isolated. The kidneys showed absolutely nothing so far as Dr. Wright could determine ; they were normal macroscopically and microscopically. Case II. — More recently a patient entered the surgical wards of the Massachusetts Hospital for abdominal aneurism, as it turned out. It was an abdominal tumor without a clear diagnosis and an exploratory laparotomy was done. Prior to that operation the urine was normal, but immediately afterwards the urine fell to 15 ounces in the 24 hours and never rose above that amount. He died a week later. The urine after the operation was pale, turbid, with a specific gravity of 1.014, and contained .7 per cent albumin. Among the casts, which were very numerous, were many waxy or highly refractile. The diagnosis at the time of death was urajmia. At autopsy absolutely nothing was found in the kidneys, microscopically or macroscopically. Now, although I had begun the study of this matter long before those cases came to my attention, they served to strengthen my interest. I have been all over the autopsy records of the Massachusetts Hospital since 1893 and I picked out all those in which any definite lesions in the kidneys were found post mortem. Then I went to the histories of those cases and tried to determine how often the lesion discovered could have been determined in life. Then I took the number in which the kidneys were found post mortem to be normal and tried to see whether their histories tallied with the findings. The total result of that study would be too long to go into here and I will only mention its application to three types of nephritis. I have taken account of no cases in which there was not careful examination of the kidneys by microscope and no cases in which the urinary analyses were in any way faulty. Perhaps I should say that I believed those urinary examinations were made with special care, for every man that goes out of Harvard knows a good deal about urinary analysis, even though he may know nothing else. The post-mortem examinations were all made by Dr. Wright. Out of the 19 cases in which acute glomerular nephritis was found post mortem only five were recognized during life and those were the cases in which oedema existed. Chronic glomerular nephritis gives what at first appears to be a different story; of 17 cases post mortem, 15 were correctly diagnosed during life. But we must remember that the picture of this disease is unusually distinctive without any consideration of the urine. In many of these cases, although the diagnosis was made, I doubt if it could have been made from the urine. The urine showed no more in these cases than in the two cases I have described in which nothing was found post mortem. Of 37 cases of chronic interstitial nephritis, 14 were properly diagnosed as some type of nephritis; four were diagnosed as chronic interstitial nephritis, and the remainder were not diagnosed as any kind of nephritis at all. Now I have given you these facts in the barest way, but I do not see any way of getting around them. The only other thing I want to do is to consider in more detail some of the points in which we have usually placed reliance in urinary diagnosis. In the first place, as to the presence of albumin. I have quoted you two cases in which a large amount of albumin was present without anything in the way of blood or pus in the urine to account for it and no nephritis found. That is a familiar enough fact, but not sufficiently insisted upon in teaching. I shall speak of another point that I trust I need not speak of here, but which needs to be spoken of in our part of the country, that is as to the amount of urine taken for a specimen without regard to the total amount of the 24 hours' secretion. Time and again I have seen teachers point with pride to the narrow zone of the nitric acid test and compare it with the thick zone period as seen earlier in the course of the same case. Now in many of those cases the difference was only due to the greater quantity of water. In regard to the 176 [No. 158. presence of casts, I will only allude to the fact that in using the centrifuge machine you often get casts in what you had every reason to believe was normal urine. Again I will allude to the statistics published seven or eight years ago by F. C. Shattuck, who analyzed 1000 cases of persons apparently healthy and more than 40 years of age. He showed that more than 70 per cent of those persons had casts, and that without the aid of a centrifuge machine. You all remember Dr. Osier's article on the advantage of casts to persons more than 40 years of age. The two cases I referred to first go to show that the presence or number of casts does not go to prove the degree of kidney lesion. Finally, I think the misdirected attempts to be accurate is shown in our part of the country most strikingly in the effort to estimate the iirea and other solids, without any effort to ascertain the patient's general metabolism. I think 90 per cent of the examinations made for urea in the Massachusetts General Hospital are worthless because no study is made of the metabolism. Perhaps the cause for this is that we still cling to the idea that there is some relationsliip between urea and uraemia. We still treat the amount of urea as a measure of the activity of the kidney instead of considering it in connection with what the patient takes to eat. On the whole the methods that seem to me to give the best information are the simplest and easiest methods, the timehonored ones of studying the color of the urine, the 24-hour quantity, and the specific gravity. Discussion. Dk. Welch. — Dr. Cabot, as usual, has presented to us an interesting and suggestive communication. He says that he was surprised by Dr. Councilman's inference from a comparison of anatomical and clinical observations that there was often a striking lack of concordance between symptoms and diagnosis during life and the condition of the kidney found after death. It is perhaps worth noting that the converse is equally true. The pathologist cannot tell accurately from an examination of the kidneys what the function of these organs has been during life ; he cannot construct clinical histories from post-mortem appearances. The explanation of these discrepancies is not far to seek. We do not know upon what precise anatomical lesions urinary changes, especially albuminuria and the presence of casts, depend, notwithstanding much experimental work on the subject. There are, to be sure, many theories. Consider for a moment albuminuria. The primary difficulty is to explain the absence of albumin in the normal urine, for the urine is in part a transudate from the blood, and such transudates are usually albuminous. If we accept the common idea that albuminuria results from some disturbance in the conditions of the walls of the glomerular capillaries and in that of the glomerular epithelium, and consider that such disturbance may be of a subtle nature and that the investigation of these structures is difficult, we can understand that on the one hand there may be marked lesions of the kidney without albuminuria, and on the other hand albuminuria without easily domon strable structural alterations of the kidney. Similar statements can be made regarding the occurrence of casts in the urine. All of this is well known, and has been discussed by Cohnheim and many others. We are grateful to Dr. Cabot for presenting this subject. His views have evidently struck a welcoming note in the hearts of our students, to judge from their applause, and I trust that we may hear from their instructors in the subjects touched upon by Dr. Cabot. Dr. Emerson. — I am now going over our hospital records concerning nephritis, and while I have not yet finished I am quite sure the results will be almost the same as those Dr. Cabot has reported this evening. We agree with him heartily concerning the value of considerable of the quantitative work on the urme unless the food consumed is known. On one point, however, we beg to differ; the relative value of total albumin and the percentage of albumin. If careful albumin charts be kept it will be seen that the line of the total albumin means little, while the line of albumin per cent depends directly on the diet, the position of the patient, his temperature, etc., and we believe that a urine with a low per cent of albumin means a much better condition of the kidney than one with a high per cent, even though the former, due to the greater total amount of urine, contains a much greater total albumin than the latter, in which case but little urine was passed. As regards the point which the speaker has emphasized so strongly, the uselessness of accurate work and the sufficiency of simple, quick, approximate methods, our position is the following: We teach accurate methods that the student may be able to use approximate ones. There are three ways of working : inaccurate, which are worse than none, since the results merely mislead; accurate, which w"e would all do if we had the time (I use the term accurate in the ordinary sense of the term, meaning thereby the best method we know, although we admit that even it leaves much to be desired) ; and approximate, which we believe can only be safely done by one well trained in the more accurate methods of which the approximate are usually abridgements. To illustrate, the third year class is now in the throes of blood work and the amount of practice involved to gain the standards of accuracy we require is very considerable. We believe that for the practitioner of medicine there is no better method of haemoglobin estimation than the quick Tallquist scale, but only those can use that safely whose eye has been trained by more careful methods with controls. It is said of a certain famous clinician of Vienna that from the drop of blood on a handkerchief he can guess the haemoglobin within one-half of one per cent. But how could he gain any such accuracy (undoubtedly exaggerated) ? Only by long, patient experience with the Gowers, v. Fleishl, and especially the Miescher instruments. I believe that a trained worker can make a satisfactory blood count by counting one unit square (that is, onesixteenth of the ruled millimeter surface), but were a student to try to do that the first time his result would be approximate indeed. We therefore insist on a great amount of prac May, 1904.] 177 ticc with control counts until we are sure liis technic is such as would justify a diminution in the number of units counted. Although I sympathize with the class just now I see no reason for lightening their burden and shall insist that the prescribed work be done. Dr. Cabot. — The attitude that it seems obvious I ought to take in regard to what Dr. Emerson says about the table of percentage albumin contained recalls to my mind a remark of Dr. Fitz, whom you all know. He had stated to the students one afternoon at his three o'clock lecture that in typhoid fever there was a constant leucocytosis. The matter was called to my attention and the next morning when I met him on his way to the wards I taxed him with it. He said, " I back down." That is my answer to Dr. Emerson. Observations on Pericarditis with Effusion. Dk. Thaveb. (See Bulletin for ilay, 190-1, page 149). Discussion. Dr. Cabot. — My experience has been very much like that of Dr. Thayer. Most of the taps of the pericardium I have seen have been dry taps. Most of the fruitful ones have been taps well outside the nipple line. Dr. Cole. — The second case reported was of very great interest to me, and the study of it during the short time we had the patient under observation and a study of the condition found at autopsy convinced me that we should be more radical in the treatment of such cases. Unfortunately, the l^atient was in a desperate condition on admission, and after inserting the needle twice, as Dr. Thayer has stated, I thought best to discontinue the attempt to obtain fluid for a short time at least. A couple of hours later I was making preparations to insert the needle in the axilla when the patient died. At autopsy the heart was found lying closely against the anterior chest-wall, so that in this case the usual situation advised for inserting the needle proved to be the worst possible one. In fact, at autopsy, on inserting a needle through the pericardiiim at this point practically no fluid could be obtained. However, we could have drawn off a considerable amount of the fluid either in the axilla or by inserting the needle in the back, as the pericardium was distended into a large pouch pushing up the lung and lying against the posterior chest-wall. Considering the impunity with which the pericardium is freely opened by surgeons in pyo-pericardium or in injuries to the heart muscle, it is a question whether in such cases as this, instead of inserting a small needle, it would not be advisable to either insert a large trocar and through this insert a small soft rubber tube, as a small rubber catheter, or even to make a small incision through the pericardium and through tins opening insert such a tube or catheter. This could be inserted as far as desired so as to pass around and below and behind the heart, and by means of an aspirator attached to the external end all the fluid could be withdrawn, even though it lay behind or outside the heart, as in tliis case. There would thus be no danger of injury to the lieart, and with careful technique there would be no danger of infection. After removal of the tube or trocar a stitch could be taken in the pericardium. T simply offer this as a suggestion, but I can see no objection to a trial being made in a suitable case. Jammry 4j 190 Jf. The meeting was called to order by the President, Dr. Futeher. Effect of Altitude on Blood Corpuscles and Blood Plates. Dr. G. T. Kemi>. The work of which I will give you an account this evening is that of an expedition organized from the graduate students of the University of Illinois, with which I am connected, and I want to say at once that this work was not done by a set of students just entering the University, but by experienced men. Each of the party had had at least one year's experience in special work with the instruments they used on the expedition. I took the party from Champaign, Illinois, to Cripple Creek, Colorado, for two weeks and went from there to Pike's Peak for a stay of eight days, and then back home. We took the record of blood plates and corpuscles, first at Champaign, then at Cripple Creek and Pike's Peak and at home. Each one of the six of the party was in a thoroughly healthy condition. Our daily routine work involved the following observations : Count of the red corpuscles, ratio of blood-plates to red corpuscles, determination of haemoglobin, determination of specific gravity, count of the white corpuscles, examination of the blood under various conditions, with a -^ oil immersion objective. The blood was drawn from the finger by an ordinary spring lance and each one, standing by to take his observations, was supplied with the same drop of blood so that all the comparisons were accurate. The first thing to which I will draw your attention is this composite curve made up from observations on all six of the party. All followed very closely the same lines : we were thus dealing with a law and not an accident. The red curve represents the number of red corpuscles, while the ratio of blood-plates to red corpuscles is shown by the blue line. Now as to the red corpuscles, it is an old story that they increase as we ascend to higher altitudes. That was discovered first by Paul Bert in animals kept under diminished atmospheric pressure, and has been corroborated over and over again. On the 11th of July we reached Cripple Creek and on that day our blood count was the same as for the two days prior. Two days later the numlscr of red corpuscles had risen from 5,200,000 to .5,900,000. On the 2d of August it dropped unaccountably in five of us and I could find no cause for it except the possibility of some climatic change. The drop was only temporary. It is a short journey from Cripple Cj'eek to Pike's Peak, but we found in that change from an altitude of 9400 feet to one of 14,200 feet that the corpuscles increased to about G.OOO.OOO. On Pike's Peak we 178 [No. 158. took records both morning and evening and we were astonished to find that the morning count ran from 600,000 to 900,000 higher than the afternoon count; that is the average of the six ; in individual cases is was over 1,000,000. Now let us consider the haemoglobin curve. The first thing we found was that it rises and falls in a general way witli the curve of the red corpuscles, but that it does not follow this absolutely. As we went to a higher altitude the hsemoglobin percentage increased on the first day before the red corpuscles had increased in number. With this point in mind we could actually predict, several times, an increase in the number of corpuscles from a rise in hsemoglobin percentage, and, in general, if you figure it out you will find that the hsemoglobin varies less than the corpuscles, and that when few red corpuscles are circulating they carry a larger percentage of hfemoglobin. While the number of corpuscles changed markedly between morning and afternoon counts the haemoglobin vai'ied much less. It is unreasonable to suppose that these red cells die between morning and afternoon, and I am quite prepared to believe that they are simply witlidrawn from the circulation for a time; I am even prepared to believe that they are taken into the spleen for some purpose and that possibly they go there to shift their hicmoglobin. It is certainly a fact that when the smaller number of corpuscles are circulating the percentage of haemoglobin is higher than when the reverse condition obtains. Now as to the blood-plate ratio. At Champaign the figure was abnormally high. In the winter it ought to be low, from 1 : 7 to 1 : 15, but during the summer, the only time our party investigated it, we found it 1 : 24. Within 24 hours after arrival at Cripple Creek the curve fell enormously and then gradually from the 12th to the 27th of the month. Please note that the curve represents the values of x in the equation. Plates : Eeds : : i : x, therefore a fall in the curve represents a corresponding increase in the number of bloodplates. The numerical changes in the blood-plates are far greater than in the red corpuscles, and the change in the ratio between the plates and corpuscles is of longer duration and far more regular. As we returned to Champaign the ratio fell again. So regular is this ratio that if you suppose you are treating a patient at a low altitude, and he is sent higher and falls in the hands of a man who does not possess a bloodcounting apparatus, but is able to make a good observation with the microscope, he could count the corpuscles and platelets and obtain a fair index to the changes going on in the blood, from the ratio between the two. It seems that we have here a new index to the development of corpuscles at high altitudes. It might be said here that the Icucocjrtes were not changed by the changes in altitude, either in number or kind. Now I would like to say a few words about some observations we have made upon the plates in regard to their chemical nature wliich may throw some light upon the question as to what they are. I am not prepared to say what they are or what they do, but we have strong evidence in favor of the discarded view of Hajrem, who claimed that the blood-plates were haematoblasts ; that is, they made red corpuscles. He is the man who re-discovered the blood-plates and he has done a great deal of work upon the subject, but his claim that they contained hasmoglobin and were really young corpuscles has not been generally accepted. Three years ago I was in Switzerland and started to make some observations on my own blood on the Corner Grat. I had counted my red corpuscles and plates for several days in Paris, and went as directly as possible to the top of the mountain. I was surprised to find that my count in Paris, which was 4,800,000, had risen to over G,000,000, but the rise in the blood-plates was twice as great ; and yet not a sign of haemoglobin could I find in any one of them. I looked for that very carefully too in this work at Cripple Creek, and we found that along about the 21st, ten days after our arrival, haemoglobin was seen in the blood-plates. Prior to that the number had increased enormously but no trace of color had been foimd in them. Just before their number reached its highest point we found the hemoglobin, and at the same time we found microcytes, but no hemoglobin could be seen in them either. After the haemoglobin was found in the platelets we repeatedly found connecting links between the platelets and the red cells. These were, as far as we could judge, identical with Hayem's " globules nains." From other observations we had made, it appears that the red cells contain comparatively little nuclear matter, whereas the blood-plates are exceedingly rich in nucleo-proteids. This can easily be shown by fixing them on the slide, hardening in alcohol and digesting with artificial gastric juice. We also tried other tests, that of MacCallum and that of Fisher with the nuclear stains. The stains proved that in the specimens of blood-plates the nuclear matter was spread about in them as granular matter while the red cells did not so stain. It thus looks as if the blood-plates were related to the nuclear substances and that they are not derived from the stromata of the red corpuscles. An account of our methods for numeration of the bloodplates may be found in American Journal of Physiology, Vol. V, 1901, p. iv. Dry preparations will not give accurate or even approximately accurate results. Discussion. Dr. Osler. — As one of the oldest students of the bloodplates it gratified me extremely to hear that one of them had ever been seen by so good an observer as Dr. Kemp in a state of hajnioglobinic redness. I have spent many weary hours over them, but I never caught one " blushing." It really is a ])oint of a very great deal of interest, and that one so familiar with blood-plates as Dr. Kemp, one who has studied them so long, shouhl have made this observation is of extreme value and I am only sorry that the distinguished French observer, llayem, who wrote so learnedly about them as progenitors of the red cells, is not here to-night to hear the good word. It does not seem possible with our present knowledge to say what the blood-plates arc or what they do. May, 1904.] 179 Di!. Kemp. — Gentlemen, I have searched with the same assiduity as Dr. Osier, for years, for some trace of haemoglobin in the platelets and I have not only failed before to find it but I have written against and spoken against the theory ; 1 believe, however, that when a man finds he has been wrong it is well for him to acknowledge it. We did not observe haemoglobin in the plates until we had remained on the mountain ten days and probably if I had stayed that long in the Alps I should have succeeded there. Dr. Welch made a point I should like to mention, namely, that no one should ever suppose that a consumptive was improving simply because the plates had increased in their ratio to the corpuscles. We had studied our conditions very carefully before starting on the trip, and the same would have to be the case with a patient under treatment. I believe the ratio will prove to be quite as good an inde.x of improvement as a count of the red corpuscles. Vaccine and Vaccination (Illustrated). Arbor, Mich. Db. George Dock, Ann (See Bulletin for April, 1904, page 109.) Discussion. Dk. Osler. — We have listened with a great deal of pleasure to Dr. Dock's remarks, no portion of which comes home to us more here and in all American schools than that regarding the systematic neglect of vaccination. I do not know that any of our schools demand a certificate of instruction in vaccination before graduation. Such certificates are universally demanded in English and German schools. The question he has raised of government supervision is most important. It would probably be difficult to get national control, as it is rather a State matter, but the government at Washington might take hold of it through the Bureau of Animal Industry or the Marine Hospital Service and provide free a good vaccine, and thus swamp the private producers. The machinery is there and might well be used. January IS, 1904 The meeting was called to order by the President, Dr. Futcher. Studies in Blood Pressure, Dr. Eklaxgeb and Mr. Hooker. After describing the method and apparatus, Dr. Erlanger gave the details of a case of cyclic albuminuria, with reference to arterial pressure. It was found that when the patient was lying down, the pressure was lowest; that it raised if he stood up, and fell again if he sat down. His albuminuria disappeared when the patient was sitting or lying down, but reappeared when he stood up. An increased pulse-rate pressure gave a diminution in the urine output, with an increase in the solids and the nitrogen. This article will api)ear in full in Volume XII of the Johns Ilojih-ins llosjiilal llcports. Discussion. De. Hurd. — I know nothing about these functional albuminurias, but I am impressed with one point in connection with Dr. Erlanger's remarks. It has been noticed that in melancholia there is often great mental distress in the morning. Very often after an extremely comfortable night, and when the patient may have slept better than usual, the mental distress in the morning is more severe than in the latter part of the day. After the patient has arisen and gone about and has had muscular exercise he begins to brighten up and feels better, and usually in the evening is fairly comfortable. In looking at the figures presented as to the differences between standing and lying down you get an explanation of the distress of these patients in the morning. The output of solid substances has evidently been much greater during the night on account of their recumbent position, and the blood has thereby become more poisoned. Of course there may be some derangement of metabolism back of that in melancholia, but the contrast presented in the figures in the recumbent and sitting postures here given is very striking. Dk. Gushing. — The society is to be congratulated on the privilege of listening to the report given us of this beautiful piece of work. I feel as if I had taken a mental gallop, and I do not feel as capable of discussing the subject as I should like to do or as I might if we had been given more of the work and seen a demonstration of the apparatus which has been instrumental in bringing about the results. The result that has been obtained in the study of this case of albuminuria is not, of course, the least interesting part of the demonstration, and it is important from our side of the fence because it shows how useful the study of blood pressure may be made in the interpretation of certain obscure clinical phenomena. If we had an Erlanger to attach to each of our .eases in the hospital to study the blood pressure we might progress much more rapidly than we have done. Dr. Erlanger. — It is now generally believed that the maximum pressure is lower in the standing posture than in the recumbent. This results from the fact that most blood-pressure determinations have been made with instruments that give the maximum pressure only. Quite recently Potain, using such an instrument, has foiind that the maximum pressure may either rise or fall, the effect depending largely upou the previous condition of the subject. On the other hand Colombo, using the Mosso apparatus, found, as others have since his time, that the change from the recumbent to the standing posture is associated with a rise of pressure. Both of these observations are correct. For, as has been shown, the averages of the pressures indicate that the maximum pressure remains more or less constant but that the minimum pressure rises. This is, however, true of the general averages only. In an individual determination both pressures may either rise or fall, but they invariably approach one another. Therefore, the onlv constant feature is a diminution of the pulse pressure. Dr. Futcher. — I have had an opportunity during the last 180 [No. 158. week to make a few observations on tlie urine and blood pressure in a case of albuminiiria for Dr. Osier, and tbere are some iDoiuts I would like to get information upon, and I hope Dr. Erlanger will be able to give it to me. The case brings out one feature of importance and that is the apparent necessity of taking minimum blood pressures in cases of this kind. The determinations I made were with the Kiva-Eocci instrument, which takes the maximum pressures only. The patient was a young girl about 14 with the history of transient attacks of albuminuria. A specimen of urine taken on Wednesday morning showed a specific gravity of 1.014, a trace of albumin and no casts. The urine was free from casts throughout the period of observation. Wednesday afternoon the patient came in for a blood-pressure determination, and after she had been on her feet all day the urine that evening showed about 1-20 per cent of albumin. On Thursday the patient was on her feet most of the day and had some of the nitrogenous foods cut off. That morning the urine contained no albumin whatever, Dut in the evening there was again approximately the same percentage as before noted. On Friday the patient remained in bed, and morning and evening specimens of urine were examined; the first contained absolutely no albumin and the evening specimen the merest trace. The blood pressure at 5.30 P. M. on Friday was 112, while on Wednesday afternoon it was 150. I had e.xpected that there would be no albumin in the Friday evening specimen, but I found the patient sitting up in bed. I woiild like to ask whether, in these cases of orthostatic albuminui-ia, the assiimption of the sitting posture in bed will cause the albumin to persist in the urine or whether it is necessary for the patient to be on his feet. Mental Symptoms Connected with Distinct Visceral Changes. Dk. Caky Gamble. (To appear in a future number of the Bulletin.) The Periureteral Arterial Plexus and the Importance of its Preservation in the Operations for Cancer of the Uterus. Db. Sampson. (See Bulletin for March, 1904, page 72.) Discussion. Dk. Hukd. — I desire to call attention to the great value of the studies which Dr. Sampson is making in this branch of surgery. We have had very few papers presented here which have shown more originality of thought and more care in working out details than the several papers presented by Dr. Sampson this winter. I wish to congratulate him on his successful work. Feh-uary 1, 1904. The meeting was called to order by the President, Dr. Futcher. Presentation of a Case of Scleroderma. Dr. E. K. Culi-e.v. The patient, a young girl 14 years of age, has a sclerodermatous patch over the posterior aspect of the left shoulder. The lesion dates from an injury inflicted twent3'-five months before, the patient having struck the affected area against a dresser. The general health has been excellent and the family and personal liistory are negative. The area of scleroderma extends from the tip of the acromion process to witliin a few millimeters of the base of the scapular spine, upwards to the anterior border of the trapezius and downwards to one finger's breadth below the spine of the scapula. The patch is slightly irregular in outline. The center presents an atrophic and ivory white appearance. At points, particularly about the outer edge, are fine, glistening scales, while scattered throughout are little irregular areas showing a light brownish pigmentation. The skin, which over the entire area feels hard and thickened, is pinched up with difficulty, but at only one point near the base of the scapular spine is there any pain experienced during this procedure. The border is thin, undulating, slightly elevated, and appears to be formed by a minute plexus of vessels. In its outer and upper parts the border is more prominently defined than in its lower and inner parts where it shades off gradually into the normal skin. Treatment. — On August 8, the date of admission to the dispensary, treatment by thyroid extract was commenced. The compressed thyroid tablets were used in the following dosage : Grs. iiss once a day for two days. Grs. iiss twice a day for two days. Grs. iiss three times a day for two days. The thyroid treatment has been continued for the past five and a half months, with only a small intermission of a week, on two occasions. Xo ill effects have been observed and the patient has continued to increase in weight. The skin has become much softer and is gradually assuming the normal consistence and color. Discussion. Dk. Osler. — The case is an ixnusually interesting one, particularly from the standpoint of the patient's condition at present. It is very unusual to see so rapid improvement. Of course the local scleroderma is a more hopeful condition than the generalized form. A great many cases recover completely and onl}' a few instances progress to the diffuse form. There is no essential difference between the conditions, although most text-books consider them separately. I have had under observation 18 cases of scleroderma (8 of which I have reported), only two of which were of the local type. Of these, one has been very much helped by the thj'roid extract; she has been under my observation three or four years, and while not cured, the skin has become soft, all the induration is gone and there only remains the extensive pigmentation. Of course in the general features the diffuse and the localized scleroderma are quite distinct. I do not know that there is any disease that brings to the patient so much distress and suffering as does the diffuse type. One of our recent cases was literallv encased in a shirt of Nessus. Ho was unable to May, 1904.] 181 move liis arms or legs, his entire body was as stiff as a frozen pigThere is a groiijD of cases intermediate between tlie localized and diffuse form. A young man in a neighboring town has a condition of the left arm like Growers described as local panatrophy, in which the process has involved skin, muscles and bones. In two of our cases of the diffuse type it may be said that the disease has been arrested. One of them has been under observation for ten years, and while his hands are distorted he is able to go about in fairly good health. In another of the cases which I reported, the patient had a most extensive scleroderma of the hands and legs. I hear through Dr. Thayer that the patient is wonderfully better in spite of an ardent devotion to Bacchus. He says he could not live without thyroid extract. A Case of Myelogenous Leukaemia. (With exhibition of the patient.) Dns. C. E. Simon and D. G. J. Campbell. The patient is a woman, ast. 35, with nothing of moment in her family or personal history until about two years ago (1901). She then noticed a bulging from below the ribs on the left side, which gradually increased ana extended to the left groin. On first examination, at the City Hospital (March, 1903), the growth was recognized as the enormously enlarged spleen. Blood examination at that time showed a typical picture of a myelogenous leukaemia. Within a month the leucocytes fell from 350,000 to 4000 and have since not risen beyond normal values. The relative percentages, barring a persistent increase of the mast cells, became practically normal, and ever since May, 1903, the spleen has been barely palpable on deep inspiration. Fowler's solution was used in large doses. (At the time of writing, April, 1904, the patient's condition remains unchanged. The case is thus the only one on record in which both the splenomegaly and myelsemia have disappeared and improvement has persisted uninterruptedly for a year.) The full report of the case with a review of the literature will appear in the Medical News. Discussion. De. Oslei!. — We have had three cases here in which the letieocytes have disappeared entirely in leukaemia. In the case Dr. Campbell referred to, reported by Dr. McCrae, the leucocytes disappeared entirely and he left the hospital apparently well, though, if I remember rightly, he had some blood changes left that were suspicious. As Dr. Campbell remarked, his subsequent history was not clear. He died in California. In the other two cases the spleen did not disappear, but remained large while the leucocytes fell to normal. One of those cases is reported in the American Text-book of Medicine, in the article on Icuktemia, and the other case some of you have seen during the year in the hospital wards. Those are the only three instances in my recollection in which I have seen the leucocytes fall to normal and remain so. The second point of interest in this case is the length of time during which he has taken arsenic and in sucli large doses. I would be inclined to attribute the good effects secured in this ease to the arsenic and think there is no question but that in the full and complete treatment with it we do see stich marked improvements. It is just these cases that stand the long-continued treatment with arsenic and have a cliance to improve. Remarks on Pneumonia in Diabetes Mellitus. Dr. Futcher. DiSCDSSION. Dr. Osler. — I think one of the interesting points about this case is the acuteness of its course, by far the most acute case we have had in the hospital in an adult. It does occasionally happen in the adult that the disease runs a very acute course, and I saw one case in which from start to finish it was only three weeks. It is often a matter of surprise in making a routine examination in diabetes to find extensive pulmonary lesions, and it is often noticed that without cough or fever a patient may have progressive wasting, and that may alone be the feature indicative of progressive disease in the lung. Dr. Fkaxk K. Smith. — About three years ago I was called to see a man in a comatose condition and his doctor told me that for two years there had been a large amount of sugar in his urine. He said the case was undoubtedly one of diabetic coma, and opinion with which I at first fully agreed. We examined him carefully, however, and fotind he was suffering from pneumonia. He got over the pneumonia, the sugar disappeared from the urine, and nine months later it was still absent. I do not know his ultimate condition. We sometimes accidentally discover diabetes that has been going on for a long time. About a month ago a man came into my office complaining only of a slight sore throat, but while there asked if he might pass his urine. He passed about a pint and a half of clear urine with a specific gravity of 1.035 containing a large amottnt of sugar. I had inquired about thirst and hunger before making the examination, and he said he was never thirsty, although he might have had a habit of drinking a good deal of water. A case of ihis kind might have been going on for many months, and I mention it to show how difficult it often is to establish the exact date of the onset of the disease. Loco weed Disease of SIneep. Dr. Marshall. Dr. Marshall took part in an expedition sent out by tne United States Department of Agriculture during the autumn of 1903 to investigate the loco weed disease in Montana. Loco disease is a disease affecting horses and sheep and occasionally cattle and goats. Tlie victims are supposed to be poisoned by the loco weed, for which they form a preference, eating the weed to tlie exclusion of other diet. Astragalus mollissimus and Aragallus spicatus are the two commonest loco weeds. Accessory factors are considered of great importance by tlie ranchers. (1) Age. Almost without ex 182 [No. 158. ception the disease appears before the end of the second year. (2) Insufficient food is frequently the important predisposing factor. (3) Insufficient supply of water is equally important. Lack of salt is considered by many ranchers to be the most important of all predisposing factors. Ifany think that if animals are well supplied with salt they will escape loco disease altogether. (5) All ranchers agree that heaUhy animals never acquire loco weed disease. A lowered state of vitality is always a precursor of loco weed disease. This malady has been known for 50 years or more. It was first recognized in Mexico or Texas. It gradually spread north and reached Montana about ten or twelve years ago. It is found from western Kansas to California on the prairies and foot-hills at an elevation of about 4000 to GOOO or 7000 feet. The incidence varies from year to year. In affected regions from 10 to 25 per cent of the annual increase die from this cause. The disease spreads in epidemic manner, appearing first as a rule not sooner than 10 or 15 years after a region has been settled. The disease appears in early spring and late autumn. The sj-mptoms come on insidiously. Tame, well-broken animals become unmanageable. Defective vision, mental and nervous symptoms develop. Ultimately the victim emaciates, eats nothing except loco weed, in the search for which he spends his time, and after a long period, usually months or years, dies from weakness or intercurrent disease. The only " locoed " animals that could be found on the recent expedition were sheep. x\bout 1000 " locoed " sheep w-ere seen on different ranches, from which number reliable and experienced rangers selected a few of the sickest and most typical " locoed " animals for study. Experiments indicated that these " locoed " sheep did not prefer a diet of loco weed to one of grass or alfalfa. Feeding experiments caused no new symptoms. The symptoms were not alike in all cases. All of the cases were in lambs or yearlings; all were undersized, emaciated and weak, with stilted gait, drooping head and dull eyes. Sensation, sight, hearing, etc., appeared normal. Many of the " locoes " showed defects in the incisor teeth. In one or two flocks large numbers of animals were afflicted with bronchitis, conjunctivitis, etc. Usually the fleece was rough. One animal had a muscular tremor. Autopsies were held upon the freshly killed animals. Tissues were fixed in Zenker's fluid and examined microscopically. No anatomical evidence was found of injury produced by the loco weed. In every case the sheep were infected with from one to five parasites. The parasites found were: (1) Thysanosoma actinioides or " fringed tapeworm," obstructing the bile ducts in 9 cases; (2) JJaemonch'us sp. in the 4th stomach in four cases. This worm which appears to be a new species similar to the Strongylus contoriv.'s, is being worked up by the United States Bureau of Animal Industry; (3) Metastrongylus filaria in the bronchioles in 5 cases; (4) Sarcoajstis tenella in the muscles in 7 cases; (5) Cysticerciis temdcoUis adherent in peritoneal cavity in 5 cases; in one of these cases a cyst was also found free in the pericardium. Dr. I'has. W. Stiles kindly identified the worms for Dr. Marshall. In addition, an extradural basilar abscess was found in the animal which exhibited muscle tremor. These results were obtained from 11 complete autopsies. Many other partial autopsies gave the same results. The " fringed tapeworm " produced a dilatation of the bile ducts and often of the pancreatic ducts and there was strong evidence that it also produced occasionally an obstructive biliary hepatitis. From its resemblance to iS. contortus it seems probable that the Haemonchus is a dangerous enemy to the sheep. Its exact action could not be determined, but it evidently is less virulent than the iS. contortus. The Metastrongylus filaria was found in all of the cases with bronchitis, conjunctivitis, etc. The Sarcocystis tenella was found in every case in which the tissues were studied microscopically. Apparently it is harmless, as is the Cystic cercus tenuicollis. After a discussion of his findings and of the data obtained from the literature and from the ranchmen. Dr. Marshall concluded that the evidence indicates that there is no true loco disease of sheep produced from eating the weed, but that so-called " locoed " animals suffer from bad feeding, insufficient care, and a variety of other diseases, the most important of which are the parasitic diseases. NOTES ON NEW BOOKS. The Lymphatics. General Anatomy of the Lymphatics. By G. Delamere. Special Study of the Lymphatics in Different Parts of the Body. By P. Poibier and B. CuNfio. Authorized English translation. Translated and edited hy CechH. Le.\f, M. a., M. B., F. R. S. (Eng.), Assistant Surgeon to the Cancer Hospital, etc. With 117 illustrations and diagrams. (Chicago: W. T. Keener <i Co., 90 Wabash Ave., I'JOJ,.) The book represents the results of the labors of Prof. Poirier and his pupils brought up evidently to 1902. The first part deals with the general conceptions of the anatomy of the lymphatic system and with the physical and chemical nature of the lymph. Following this is a rather minute consideration of the morphological elements of the blood and lymph in which Ehrlich's views receive due discussion and the classification of cells adopted is essentially his. Morphology, physical and chemical properties, biological characters and modes of development and reproduction of these cells are entered into in detail. All of this is characterized by great breadth of view and fairness of judgment. We may, however, criticize certain statements as premature, for example on p. 35, it is said that, " It is proved that a leucocyte can become a connective tissue cell and it is at least very probable that a connective tissue cell can become a white coll." Again the objections to the use of the term myelocyte on pp. 36-37 seem insufficiently supported. The descriptions of the various types of cells are excellent. Then follows a historical sketch of the development of our knowledge of the anatomy of the lymphatic vessels up to the work of V. Recklinghausen and Ranvier. Throughout this chapter the view is held that there are completely closed vessels lined with endothelium and that there is as good evidence for the view of V. Recklinghausen as to their free communication with the tissue. Ranvier's conception of the lymphatic system as a gland emptying into the veins is given, but at the time the book appeared May, 1904.] JOHNS HOPKINS HOSPITA.L BULLETIN. 183 the authors had evidently not seen Dr. Sabin's classical description of the development of. this system. Some interest attaches to the discussion of the distribution of lymphatics especially in the statement that it is still very uncertain whether or not any lymphatics exist in the brain and meninges. A minute account of the anatomy, development and physiolo,!;y of the lymph glands follows, characterized by the same breadth of view and abundance of detail. The second part of the book, and by far the larger part, is devoted to the study of the regional anatomy of the lymphatic system. The literature references which are arranged in chronological order are very complete and since the translation is very good the book forms an excellent book for reference, even if one can refrain from reading it through. A Text-book of Legal Medicine and Toxicology. Edited by Frederick Peterson, M. D., President of the New York State Commission in Lunacy; Clinical Professor of Psychiatry, Columbia University. New York; General Consultant to the Craig Colony for Epileptics, Sonyea, New York, and Walter S. Haine.s, M. D., Professor of Chemistry, Pharmacy and Toxicology in the Rush Medical College, Chicago; Professorial Lecturer on Toxicology in the University of Chicago. Volume II. (Philadelphia. Neic York and London: W. B.Saunders & Co., 190 J,. 825 pp.) The completion of this excellent work will be welcomed uy teachers of this subject as well as by physicians and lawyers who find it necessary to consult a fairly comprehensive work on forensic medicine. Part 1 of volume II is devoted to the subjects relating to sex, insanity and malpractice and contains a brief but well written chapter on the medico legal relations of the Rontgen rays including the interpretation of skiagraphs and a discussion of the X-ray burns. Part 2 is devoted to toxicology and this portion is exceptionally good. Many references to the original sources of the material are given. The various subjects are written by eminent specialists. Thus it might be mentioned that the chapter on the alkaloid poisons is written by Prescott. Vaughn contributes a chapter on the ptomains and other bacterial products in their relation to toxicology. Taken altogether the work is a most satisfactory one and deserves to be largely used. A. S. L. Blood Immunity and Blood Relationship. A demonstration of certain blood relationships amongst animals by means of the precipitin test for blood. By George H. P. Nuttali,, M. A., M. D., Ph. D., University Lecturer in Bacteriology and Preventive Medicine, Cambridge; including Original Researches by G. S. Graham-Smith, M. A., M. B., D. P. H., Cambridge; T. S. P. Strangeways, M. A., M. R. C. S. (Cambridge: At the University Press, I904.) This volume of 400 pages summarizes the results of the original researches of Dr. Nuttall upon the subject of the precipitin reaction, portions of which have already been published either alone or in connection with his two co-workers, Graham-Smith and Strangeways, in various numbers of the Journal of Hygiene, British Medical Journal and other periodicals. It aims to put in concise form, ready for accurate reference, not only the observations made in Cambridge, but also those of other workers who have busied themselves along similar lines. This publication is particularly interesting, because primarily Nuttall was, early in the days of the Pathological Laboratory of the Johns Hopkins University, a most valued assistant in bacteriology and hygiene and while here established a reputation for enthusiastic painstaking and accurate investigations, his work being noted both for the originality of his ideas and for the original methods by which they were put in execution. Secondarily it may be mentioned that Dr. Nuttall's early studies of the bactericidal properties of normal blood serum, conducted while working for his doctor's degree in Fliigge's laboratory in Breslau, were th^ starting point for that enormous development of the study of the blood sera of normal and immunized animals, and in a certain sense, of the development of the humeral theory of immunity, even though Nuttall's work was antedated by some isolated observations of others, and in spite of the fact that Nuttall has not received merited recognition for this work in Germany itself. The main thesis of Nuttall's present publication is the claim that by means of the precipitin reaction seen on mixing the blood serum of an animal treated with the blood serum of an alien species, with portions of the original serum employed, the j)hylogenetic relationship of various members of the animal kingdom may be determined with almost absolute accuracy, with far greater accuracy indeed than the study of morphological or functional characters has thus far. been able to carry us. For the proper understanding of the main portion of the book, including extensive tables giving records of over 16,000 different tests, the first third of the book at least Is given up to an accurate analysis of the literature of the subject of precipitins and of those closely allied subjects of agglutination and haemolysis, including here a brief consideration of Ehrlich's theories. Quite aside from the main purpose of the book the preliminary portion is invaluable, not only because it is the first extensive literarj' study of precipitins, but because it is invested with the accuracy and completeness of Nuttall's usual methods. The experiments of nearly every observer in this field are cited, their methods criticised, their results analyzed, and a careful opinion passed upon the value of their work. Extensive consideration is given to the various factors v/hich may influence the precipitin reaction, while the effects of chemicals, heat, cold, and putrefaction are all made the subject of personal investigation by the author and his associates. The methods of obtaining blood sera, the manner of immunization of animals, and the technique of the reaction itself are all described with painstaking exactness. The principal part of the book of course is taken up with the consideration of Nuttall's own experiments. During the progress of his investigations he has prepared anti-sera for a very large number of animal species, including man, chimpanzee, ourang, monkey, hedgehog, cat, hyena, dog, seal, pig. llama, hog-deer, Mexican deer, antelope, sheep, ox, horse, wallaby, among the mammalia; fowl and ostrich, among the aves; turtle and alligator, among reptilia; frog among the amphibia, and lobster among the Crustacea. With the sera thus obtained Nuttall has tested the blood of nearly every known species of domesticated or wild animals, specimens being sent him from nearly every quarter of the globe. These specimens were obtained in the field by collectors, dried on strips of filter paper, sealed up in cases, and sent to Cambridge, where they were carefully catalogued and preserved. Each anti-serum was now tested with the serum employed in Immunizing the animals, an homologous serum, and with sera from various other species, heterologous sera. The sti'ength of the reaction obtained with the homologous serum, as measured by the amount of the precipitum was now carefully compared with that seen with the heterologus sera. Thus anti-human serum was tested with human serum, with various fluids from the human body, ascitic and pleuritic effusions and urine, with serum from other primates Including chimpanzee, gorilla, mandrill, guinea baboon, monkey, lemur, and from a number of less closely related species. In the same way anti-monkey serum was tested with a similar series of bloods, while the sera obtained from the employment of other orders, were tested against the blood of members of that order. Thus anti-horse serum was tested with 184 [No. 158. blood from the equidas especially, and from as many other closely related families as possible. It is apparent at once what an enormous number of observations would result from faithful adherence to this system, over a relatively long period of time. As a result of several thousand reactions Nuttall concludes that the blood serum of an immunized animal alivays gives an abundant precipitum with that from the species employed for immunization, but gives as well a similar but quite positive reaction with the blood sera of species closely related zoologically. The latter reaction Nuttall would term the mammalian reaction. The conclusions derived from these reactions and the relationships suggested by their application to such a large number of species afford the morphologist a most interesting theme for speculation. A few examples of the relationships indicated must suffice. Anti-human serum reacts most markedly with the serum of man. but gives definite reactions with the blood serum of the simiidae and the cercopithecidae, although little or no reactions develop with the serum of the lemurida?. Anti-chimpanzee serum reacts markedly with the blood of the bomidje and the simiidie not at all with that of the lemuridse, partially with that of the cercopithecidae. Anti-ourang serum reacts most markedly with the blood of the simiidae and the cercopithecidfe, partially with that of the homidae. Anti-monkey serum reacts best with the serum from the cercopithecidae, less with that of the homidffi, not at all with that of the lemuridae. Prom these and other observations Nuttall concludes that " if we accept the degree of blood reaction as an index of blood relationship within the anthropoidea then we find that the Old World apes are more closely allied to man than are the New World apes, and this is exactly in accordance with the opinion expressed by Darwin." Again the anti-sera for hyenidte give positive reactions for the homologous blood of hyenas and for the closely allied blood of cats, while the anti-sera for cats gives positive reactions not only for cat's serum but for that of the hyenidae. Other sera were negative and one is thus led by the precipitin test alone to conclude that hyenas and cats are closely related genetically. Similarly anti-reindeer serum reacts with reindeer serum, with serum from other cervidae and with the closely related bovidae, not with the serum from other mammals. Anti-sheep serum reacts most markedly with sheep's blood and the blood of the cervidfe, partially with the blood of the suidae, not at all with other mammalian bloods. Anti-pig serum, however, while giving most marked reactions with the blood of the suidfe also reacts abundantly with the blood of the cetacea, an unexpected result confirming the hitherto expressed opinion of Flower and Lydekker that the cetacea are more closely related to the ungulata than to the carnivora, and that " the old popular idea which affixed the name of sea hog to the porpoise contains a larger element of truth than the speculations of many accomplished zoologists of modern times." It may be noted in passing that Nuttall's results with antihuman serum and with anti-monkey serum absolutely confirm the experiments of Wassermann and Uhlenhuth, whose observations, however, were conducted upon a considerably smaller number of species. Finally not only are the reactions carefully estimated qualitatively but by means of a specially designed apparatus for measuring the quantity of the precipita obtained from the mixtures of various sera, Nuttall and Strangeways have made a large number of quantitative determinations of the reactions studied previously qualitatively, the former series of observations confirming in every particular the latter. The last section of the book is in many respects the most interesting. Here Nuttall considers the precipitin test in its application to legal medicine in the identification of blood stains, especially in the identification of human blood by means of antihuman serum. He first considers in detail Wassermann's and Uhlenhuth's experiments bearing upon this point as well as his own previous communications upon the subject, and analyzes the many factors which may have any bearing upon the carrying out of the blood reaction in its application to forensic medicine, such as the action of chemical substances, rust, dyestufts and other materials upon blood tending to vitiate Its properties to such an extent that it may fail to react with its peculiar serum, as well as the presence in suspected material of substances which may give reactions simulating the precipitin reaction. In this connection he quotes a number of experiments of Graham-Smith and Senger, upon blood stained weapons and fabrics obtained from Scotland Yard, in all of which, despite the great age of some of them, as much as 25-30 years, a positive reaction was obtained with anti-human serum, and no reaction with anti-ox serum. Special observations were made to determine the effect of drying blood upon metal, organic materials, leather, of mixing it with lime, mortar and earth, only one of the latter substances, lime, being shown to actually destroy the blood when brought in contact with it. With no other material was human blood so affected that it did not give a positive reaction with anti-human serum. The general conclusions of the book are summarized into two final pages. The entire volume is filled with most interesting information not only in regard to the work and ideas of others, but in regard to the results actually obtained in Cambridge. Many of the tables presented seem at first sight difficult to understand, but after a certain amount of study and close observation of the various symbols utilized in preparing the tables, they become quite explicable. When one considers moreover the vast number of reactions given one realizes that some definite system of recording the strength of the reactions had to be employed. There is but one adverse criticism which can be made and that is applicable to all who work upon the complex problem of immunity. There is too great a tendency to explain the occasional occurrence of anomalous reactions, especially if somewhat unexpected, by errors in the collection of the samples of sera. While it is perfectly possible that errors may have arisen, such as the occasional interchange of samples ana labels, or the rubbing of one blood against another in the process of drying, in view of such an enormous number of positive results testifying to the care with which the specimens were collected, it is hardly fair to claim that when a few sera fail to give the desired reaction, some mistake must have been made in collecting them. While unexplainable and unforseen reactions do mitigate to a certain extent the absolute or relative specificity of the precipitin reaction, no one who has done any piece of investigation with immune sera will fail to admit that occasionally reactions develop which are absolutely out of keeping with any knowledge we now possess in regard to these very complex and intricate phenomena. In spite of this tendency, this book of Dr. Nuttall's upon " Blood Immunity and Blood Relationship " is not only the best publication upon the entire subject of precipitins, now extant, but contains such a mass of new material, new facts, and new conclusions, that it substantiates the author's own claim that " in presenting the results given in this book he is safe in saying that they constitute the first scientific demonstration on general lines of the specificity or relative specificity of precipitins." The book is dedicated to Ehrlich and Metschnikow. vr. w. Foru. The John» Hopkinu Hospital Bulletins are issued monthly. Thef) are printed by the VlilEDENWALD CO., Baltimore. Single copies may be procured from the CVUHINO CO. and the BALTIMORE NEWS CO., Baltimore. Subscriptions,$'3.00 a year, may be addressed to the publishers, THE JOHNS HOl'KINS PltESS, BALTIMORE ; siiiyh copies will be sent by mail for twenty -five cents each.

BULLETIN

OF

'^^' n)\\o^'^%<

THE JOHNS HOPKINS HOSPITAL

Entered as Second-Class Matter at the Baltimore, Maryland, Poatofflce.

Vol. XV.-No. 15 9.]

BALTIMORE, JUNE, 1904.

[Price, 25 Cents.

CONTENTS.

The Biography of Stephen Hales, D. D., F. R. S. By Perct M.

Dawsok, M. D., 185

A Case of Cancer of the Mamma Cured by Means of Roentgen Rays.

By Professor E. Schiff (Vienna), 192

Thrombosis of the Internal Iliac Vein during Pregnancy. By F. C.

GOLDSBOROUGH, M. D., 193

Changes in the Nervous System after Parathyroidectomy. By Colin

K. Russell, M. D. (.McGill) 196

The Relation between Carcinoma Cervicis Uteri and the Rectum and

its Significance in the More Radical Operations for that Disease.

By John A. Sampson, M. D., 198

Observations on a Study of the Subclavian Artery iu Man. By

Robert Bennett Bean, M. D. , 303

The Blood in Pregnancy. By William Lawton Thompson, M. D., 205 A Case of Generalized Lead Paralysis, with a Review of the Cases of

Lead Palsy Seen in the Hospital. By Henry M. Thomas, M. D., 209 Notes on New Books 212

THE BIOGRAPHY OF STEPHEN HALES, D. D., F. R. S.'

By Perot M. Dawson, M. D., Associate Professor of Physiology, Johns Hopkins University.

Just as the name of William Harvey stands foremost in that chapter of physiology which deals with the circulation, so does the name of Stephen Hales begin the sub-chapter on haemodynamics.

In this sub-chapter the first important conception to be grasped by the student is that of the blood pressure, and the first experiment is designed to demonstrate its existence and to estimate its amount. This experiment is familiar to us all. It consists in connecting the femoral artery of a dog to a long glass tube. Into this> tube the blood mounts up and up to a height of five or six feet and then oscillates up or down with each contraction or relaxation of the heart. Such a tube, as the student already knows, is called a manometer, and he is then told that this particular form of manometer, so simple in principle and construction, is called the " Hales manometer " after its inventor, a certain Dr. Hales. Thus every student of physiology becomes acquainted with the name of Hales, but to most of us it is a name and nothing more.

'Read before the Johns Hopkins Hospital Historical Club, April 20, 1903.

Stephen Hales was born in 16?7. His grandfather. Sir Eobert Hales, of Beckesbourn in Kent, was made baronet by Charles II. Sir Robert's eldest son, Thomas, married Mary, the daughter and heiress of Richard Wood. They had many children, and Stephen was their sixth son.

Of Stephen's boyhood there is nothing known. In his nineteenth year he was sent to Cambridge and was entered a pensioner of Corpus Christi College under the tuition of Mr. Moss, the future dean of Ely. Having taken the degree of Bachelor of Arts, he was pre-elected into a fellowship into which he was admitted in the following year. In the samd year (1703) he obtained his degree of Master of Arts. Some time afterwards he entered into orders and became a Bachelor of Divinity in 1711. During his residence in the college, a period of about twelve years (1696-1708 or 1709), he applied himself with great zeal to the study of natural and experimental philosophy.

In William Stukeley,' afterwards M. D., F. R. S., who came

^William Stukeley, 1687-1765. In his undergraduate days he ' went," he says, " frequently asimpling, and began to steal dogs

186

[No. 159.

in 1704 to live in Corpus Christi College, Hales seems to have found a very congenial companion, though Stukeley was the younger by ten years. Together the two used to ramble over Gogmagog Hills and the bogs of Cherry-Hunt-Moor to gather simples. One carried in his pocket Kay's Catalogue of Plants, to which Stukeley, who was a ready draughtsman, added a map of the country to guide them in their walks. Sometimes they collected fossils from the gravel and chalk pits and sometimes hunted butterflies, having contrived an instrument for taking them. The two friends also studied anatomy together, dissecting frogs, dogs and other animals; while Hales devised an ingenious method of obtaining a preparation of the lungs in lead. They moreover studied chemistry and " repeated many of Mr. Boyle's experiments " and prepared various substances, " some of use, some of curiosity."

At this time Vigani,' of Verona, the first professor of chemistry at Cambridge, was lecturing at Queen's College Cloysters, and thither Hales and Stukeley used to repair, and were also witnesses of the chemical operations which Vigani was accustomed to perform in a room in Trinity College which had formerly been the laboratory of Sir Isaac Newton. Hales was also a student of astronomy and constructed a brass machine for demonstrating the movements of the planets, and of this Stukeley made a sketch.

About 1710 Hales was made perpetual curate of Teddington. He afterwards accepted the living of Porlock, in Somerset, vacating his fellowship in so doing, but this living he soon exchanged for that of Farringdon, in Hants. Teddington he made his home, though he appears to have occasionally resided in Farrington.*

The date of his marriage seems to be uncertain. His wife was Mary, daughter and heiress of Dr. Newce, rector of Halisham. In 1721 Mary died,° leaving no children. Hales never married again.

In 1718 Hales waj elected Fellow of the Royal Society and became a member of the council of that body in 1727. In 1732 he was appointed one of the trustees of the newlyfounded colony of Georgia." In 1733 the University of Oxford conferred upon liim the honorary degree of D. D., which was the more significant in that Hales had pursued all his studies at Cambridge In 1739 he received the Copley medal.

and dissect them " and once when at home, he " made a handsome sceleton " of an aged cat. Hales and Dr. ,1. Gray of Canterbury, were his botanical associates and he made large additions to Ray's Catalngus Plantarum circa Cantabrigiam.—T). N. B.

'John Francis Vigani, 16507-1712, born in Verona; probably came to England about 1C82, to Cambridge about 1683, where he gave private lessons in chemistry and pharmacy. In 1703 a grace was passed by the senate for " investing with the title of professor of chemistry John Francis Vigani, a native of Verona, who has taught chemistry with reputation for twenty years previously." — D. N. B.

• Letter preserved in the Library of the Royal Society, F. D.

See L. L., Ill, 507.

"In 1734, Hales published a sermon which ho had delivered at St. Brides, before the rest of the trustees of the colony, his text being Gal. VI, 2.

In 1750, on the death of Frederick, Prince of Wales, he was appointed, without his solicitation or even knowledge, clerk of the closet and almoner of Her Royal Highness the Princess Dowager. In 1753 he became one of the eight foreign members of the French Academy in the place left vacant by the death of Sir Hans Sloane, president of the Royal Society.'

The work and writings of Hales embrace a very broad field, which includes chemistry, botany, physiology, medicine and public hygiene, not to mention sermons and temperance tracts. In 1719 he reported before the Royal Society some experiments which he had lately made on the effect of the sun's warmth in raising the sap in trees. This procured him the thanks of the Society, which also requested him to continue his research. " With this request," writes the biographer,' " which was like the charge given by Pharaoh's daughter to the mother of Moses, to take care of her son. Hales complied with great pleasure, and on the 14th of June, 1725, he exhibited a treatise in which he gave an account of his progress." At the request of the Society this treatise was published an appeared in 1727 under the following title: "Vegetable Staticks; or, an account of some statical Experiments on the Sap in Vegetables: being an Essay towards a Natural History of Vegetation; also a Specimen of an Attempt to analyse the Air by a great Variety of chemio-statical Experiments, which were read at several Meetings of the Royal Society." The " Vegetable Staticks " was so well received that a second edition was published in 1731. In the preface of this edition the author promised to add a second volume, and in 1733 he published his second famous work, entitled " Statical Essays : containing Hjemostaticks, or an Account of some Hydraulick and Hydrostatical Experiments made on the Blood and Blood- Vessels of Animals ; also an Account of some Experiments on Stones in the Kidney and Bladder; with an Enquiry into the Nature of these anomalous concretions. To which is added an Appendix containing Observations & Experiments relating to several Subjects in the first Volume." These two books were again edited under the title, " Statical Essays, Vols. I & II."

Through the " Statical Essays " Hales came to have an international reputation, for not only was the first volume translated into French by BufEon, and the second into the same language by Boissier de Sauvages (1744), but before long there appeared German and Italian translations.'

If one were required to state the essential and distinguish

' " Stephen Hales, D. D., is elected member of the Royal Academy of Sciences at Paris, in the room of Sir Hans Sloane, Bart. Deceased." G. M., Feb., 1757, XXIII, 103.

'Peter Collinson, 1694-1768, F. R. S., 1728; naturalist, antiquary, and merchant; Quaker.

' These works contained copious notes by the translators and to the volume on Hiemostatics two memoirs by de Sauvage had been added one on inflammation and one on fevers. The two volumes were re-edited in 1779 as one book. In 1748 the two French works were translated bodily (memoirs, notes and all) into German. In 1750, M. A. Ardinghelli published her translation, Emastatica, in Naples; the text was translated from the English; the notes from the French of de Sauvage.

June, 1904.]

187

ing characteristics of these essays, the unhesitating reply would bo that the work which they describe is quantitative. In everything that Hales did, one sees this constant effort to be exact. Qualitative results were never sufficient; Hales must needs weigh and measure everything, and every phenomenon must be expressed numerically so as to serve as the basis of calculations and tlius lead to new discoveries.

It will be remembered that Hales studied chemistry under Vigani and that Vigani was the first professor of chemistry at Cambridge. In fact. Hales' life fell very early in the history of scientific chemistry, in that period when experimentation, though often suggestive, is usually indefinite and always incomplete.'" Hales made a careful study of gases, or, as he called them, " air." To him air was an element which entered into the composition of a surprising number of substances, and so he studied the generation and absorption of " air " during distillation, fermentation and many other chemical processes. In his experiments he must have prepared hydrogen, oxygen, hydrochloric acid, carbon dioxide and ammonia, and though they were all " air " to him, he introduced some important improvements in the way of chemical apparatus and manipulations, and was perhaps the first chemist to employ quantitative methods."

With respect to the purely botanical part of the " Statical Essays," suffice it to refer to a statement of Sachs. This wellknown botanist writes that in the revival of plant physiology which took place in the eighteenth century, the work of Hales was the most original and most important contribution." It was in honor of Hales that John Ellis, the " bright star in Natural History," as Linnaeus has called him, named a newly discovered genus of plants Halesia.'*

The contributions of Hales to animal physiology are many and important. His experiments in this field are described partly in the first volume of the Essays, but chiefly in that section in the second volume which is devoted to hemodynamics A discussion of this part of Hales' work will, however, be reserved for another communication.'"

In 1739 he published an octavo volume entitled: "Philosophical experiments : containing useful and necessary instruc

""He (Hales) had learned to interrogate but not to cross examine nature." F. H. Butler: History of Chemistry, Encyclo. Brit.

"See Herman Kopp: Geschichte der Chemie. Braunschweig, 1845.

•=P. D.

•^D. N. B.

"Title: "Of the Plants Halesia and Gardenia." "In a letter from John Ellis, Esq., F. R. S., to Philip Careret Webb, Esq., F. R. S. The intent of the letter is to exhibit the characters of two new genera of plants growing in Mr. Webb's garden, which Mr. Ellis calls after Dr. Hales of Teddington and Dr. Garden of South Carolina." P. T., XI, 508.

Francis Darwin appears to be in error in the statement that .lohn Ellis was governor of Georgia. The governor was Henry Ellis, F. R. S., arctic explorer and hydrographer, also governor of Nova Scotia.

" See Bulletin of the Johns Hopkins Hospital for July, 1904.

tions for such as undertake long Voyages at Sea; showing how Salt-water may be made fresh, wholesome, and how Fresh Water nuiy be preserved sweet; how Biscuits, corn, &c., may be secured from the Weave], Maggots, and other Insects; and Fle.sh preserved in Hot Climates by salting Animals whole; to which is added an account of ExperiiTienls and Observations on Chalybeate or Steel -w-aters, with some Attempts to convey them to distant places, pr&serving their virtues to a greater degree than has hitherto been done; likewise a proposal for cleansing away Mud, &c., out of Rivers, Harbours, and Reservoirs." This work, which contained so many useful instructions for voyagers, was dedicated to the Lords of the Admiralty.

In the same year he reported to the Royal Society an account of some " further experiments towards the discovery of a medicine for dissolving the stone in the kidneys and bladder, and preserving meat in long voyages," and it was for this that he received the gold medal of " Sir Godfrey Copley's donation." In the following year he published an account of some experiments and observations on Miss Stephens' medicines for dissolving stone, in which their dissolving power was inquired into and demonstrated. This work on stone was subsequently translated into French."

The contributions of Hales to the " Philosophical Transactions " were numerous and dealt with a great variety of topics. Besides those which are mentioned elsewhere in this article the following may be enumerated :

A Method of conveying Liquors into the Abdomen during the operation of Tapping. IX, p. 8.

A Proposal to bring Small Passable Stones Soon and with ease out of the Bladder. IX, p. 159.

Remarks on Dr. Cromwell Mortimer's paper on a new metallic thermometer. IX, p. 407.

A Proposal for Checking in some Degree the Progress of Fire. IX, p. 498.

Remarks concerning some Electrical Experiments. IX, p. 534.

Of the strength of several of the principal Purging Waters, especially that of Jessop's Well. X, p. 48.

Of some Trials to keep Water & Fish sweet, with Limewater. X, p. 551.

Of the great Benefit of Blowing Showers of Fresh Air up through Distilling Liquors. X, p. 635.

Of Some Trials to cure the 111 Taste of Milk wdiicli is occasioned by the Food of Cows, either from Turnip.s, Cabbages, or Autumnal Leaves, &c. Also to Sweeten Stinking Water. X, p. 642.

Whenever these papers seemed to him to be of value to the public or to deal with topics of general interest, he would

'""Etat de la Medicine, etc., par M. Clifton," translated by M. I'Abbfi des Fontaines, " avec les Espi'riences sur le Remede de Mile. Stephens, fait par M. Hales," etc., translated by M. Cantwell of the Royal Society, doctor of the Faculty of Montpellier. Paris,

1742.

188

[No. 159.

publish a popularized version in the Gentleman's Magazine^ But besides these abstracts this magazine contains numerous articles from his pen, of which the following are the more important :

A description of a Back-IIeaver, which will winnow and clean corn, both much sooner and better, than by the common methods of doing it. July, 1745, XV, 353.

A Description of a very great Improvement which is made to the Back-Heaver; which tvill not only winnow corn nnirh sooner and better than any other methods hitherto used; but will also clean and clea/r it of very small Corn, Seeds, Blacls, Smut Balls, cCc, to such perfection as to make it fit for Seed Corn. July, 1747, XVII, 310.

A Description of a Sea Gage, to measure unfathomable Depths. May, 1754, XXIV, 315.

A Proposal for the more speedily and effect^ially cunng Men, Ships, and Goods, of Pestilential Infection. Dec, 1754, XXIV, 543."

Rational and easy method to purify the Air, and regulate its heat in Melon-Frames and hot Green-houses. April, 1757, XXVII, 165.

The year 1741 is ever memorable in the history of Hygiene, for it was in this year that three persons of very different stations in life conceived the idea of constructing ventilators. These persons were Sutton, a coffee-house keeper in Aldersgate Street; Martin Triewald, captain of mechanics to the King of Sweden, and the Eev. Dr. Hales.

The methods devised by Hales and Triewald seem to have been identical, and the history of their invention is told by Hales in his book on Ventilators published in 1743. Prom the introduction of this work, it appears that in the beginning of September, 1740, Hales wrote to Dr. Martin, the physician to Lord Cathcart, the general of the forces which lay embarked at Spithead, for an expedition in America, to propose (besides the usual sprinkling between decks with vinegar) the hanging up very many cloths dipped in vinegar in the pi-nper places between decks, in order to make the air more wliolcsome: and in case an infectious distemper should be in any ship, to cure the infection with fumes of burning brimstone. " It was from these considerations, which often recurred to my Thoughts, that it occurred to me in the March following that large Ventilators would be very serviceable, in making the Air in Ships more wholesome ; this I was finally so fully satisfied of, that I immediately drew up an account of it; several coppies of which were communicated, both by myself and others, to many Persons of Distinction and Members of the Royal Society: before whom I laid a large Account of it ... .

"See G. M., .Tuly, 1755, XXV, 310. April, 1747, XVII, 200. March, 1756, XXVI, 130. December, 1749. XIX, 554. February, 175(i, XXVI, 78. September, 1757, XXVII, 410. November, 1757, XXVII, 503.

"The method consisted essentially in fumlRalion by means of burning a mixture of brimstone and charcoal. Persons subjected to the fumes were to have their faces properly covered to prevent suffocation.

" November the Gth following .... Martin Triewald, Captain of Mechanics and Military Architect to the King of Sweden, and Fellow of Ihe Royal Society al London, in a Letter to Cromwell Mortimer, M. D., and secretary of the Royal Society, says that this Spring he had invented a Machine, for the use of his Majesty's Men-of-War, which went to block up Petersburg, in order to draw out the bad .\;r from under their Decks, the least of which does e,\haust 36173 cubick Feet of Air in an Hour . . . . "

" It was a very extraordinary Circumstance that two Persons at so great a distance from each other, without getting a Hint of it, one from the other, should happen to hit on inventing a like useful Engine."

For this invention Triewald was granted a privilege for life by the King and Senate of Sweden. He then wrote a " deduction " on the usefulness of ventilators which the King caused to be distributed among his naval officers. This " deduction " was read before the Royal Society in 1743. In it Triewald recommends the use of ventilators " in Hospitals and Barracks for the sick, Men-of-War and Hospital Ships."

The book, of which the introduction above quoted forms a part, was dedicated by Hales to " the Commission for executing the office of Lord High Admiral," and in the list of its members is found the name of the Right Honourable Lord Baltimore. An idea of its contents may readily be obtained from its very lengthy title, which is as follows: "A Description of Ventilators: whereby Great Quantities of Fresh Air May with Ease be conveyed into Mines, Goals, Hospitals, Work-Houses and Ships in Exchange for their Noxious Air. An Account of their great usefulness in many other Respects: As in Preserving all Sorts of Grain Dry, Sweet, and free from being Destroyed by weavels, both in grain.\RiES and ships: And in Preserving many other Sorts of Goods. As also in drying, corn, malt, hops, gun powder, &c., and for many other useful purposes."

The Hales ventilators were nothing more than ingeniously contrived bellows which sucked the foul air from the rooms or spaces to be ventilated and blew it out of doors. When large, these bellows were worked by means of a wind-mill; when small, by hand. The ventilator fixed in Newgate by order of the Lord Mayor and Aldermen of London was a large one and was connected by a system of tubes with twentyfour wards. It is figured and described in detail in the Gentleman's Magazine."

Not content with playing the part of a mere inventor. Hales added to that role that of the philanthropist, for seeing that it would be of great benefit to humanity, he wrote constantly on the subject and used what influence he had to obtain the introduction of his ventilators. Success crowned his efforts. In a few years his ventilators had been put not only into Newgate and the Savoy prison," but also into the Winchester

""A description of Dr. Hales on Ventilators fixed in Newgate; where being ivorked by a Windmill they draw foul Air out of the several Wards; which were made by Mr. Stibbs, Carpenter in Fore Street, London Wall." G. M., April, 1752, XXII, 179.

Jdne, 1904.]

189

Ciaol," the Diirliam Coimty Gaol,^ then the Gaols of Slirowsbury," N()rlliaiii[itciii " and Maiilstonc."' The results were remarkable. During the first four inoiitlis after their introduction into Newgate, the death rate was reduced by nioi-e than fifty per cent, while in the Savoy prison the rate fell from fifty or a hundred per annum to one or two per annum. Equally gratifying were the results at the smallpox hospitals. This institution contained thirty-two rooms, each accommodating two patients, and here the mortality was soon reduced to two-thirds of what it had formerly been.

Meanwhile at the recommendation of the French Academy the whole French fleet had been equipped with Triewald ventilators and many English vessels had adopted those devised by Hales. Excellent results followed, as can be seen from such letters as the following, which was published in the Gentleman's Magazine i"^

A letter from Captain Ellis, on his late Arrival from a Guinea Voyage, to the Rev. Dr. Hales. Sir,

Could anything increase the pleasure I have in a literary intercourse with you, it would be to find that it answered your end in promoting the publick good Those [ventilators] of your invention which I had were of singular service to us; they kept the inside of the ship cool, sweet, dry, & healthy: The number of slaves which I buried was very inconsiderable, and not one white man of our crew (which was 34) during a voyage of 15 months; an instance very uncommon. The 340 negroes were very sensible of the benefits of a constant ventilation, and were always displeased when it was omitted. Even the exercise had an advantage not to be despised among people so much confined."

Ellis adds, however, that we must not forget that there are other causes of siclcness at sea, infections brought on board, bad food and insobriety. On the last factor he dwells at some length, and to the unusual sobriety of the crew he ascribes some of their good health. His conclusion is as follows : " Could I but see the immoderate use of spirituous liquors less general, and the benefit of ventilators more known and experifenced, I might then hope to see mankind better and happier."

It was without doubt the receipt of such letters as these that prompted Hales to report before the Royal Society " On the Great Benefits of Ventilators in many Instances in Preserving the Health and Lives of People, in Slave and Transport Ships." '^

The Gentleman s Magazine also contains the following articles : On keeping corn sweet in heaps : Dec, 1745, XV, 640 : Dr. Hales' method to keep corn sweet in sacks: July, 1745, -W, 354; An Account of several methods to preserve corn well hy VENTILATION : June, 174G, XVI, 315.

=" " An Account of the good Effects of Ventilators, in Newgate and the Savoy Prison." G. M., February, 1753, XXIII, 70.

" A further Account of the Success of Ventilators etc." G. M., March, 1754, XXIV, 115.

•^'G. M., March, 1754, XXIV, 114. See also G. M., August, 1750, XX, 379.

="P. T., X, 641.

The last of the articles which have "just been enumerated was accompanied with plates and contained a careful and mimite description of the construction of granaries, with calculations regarding the size of the ventilator and tiic amount of air required for drying a certain amount of a given kind of grain in layers of such a depth in granaries of such a size and so forth, all this showing his painstaking accuracy and his detailed knowledge of the subject.

The ventilator which was invented by Sutton, the coffeehouse keeper above mentioned, was " of another construction," " being designed " to draw off the foul air on board ships by means of the cook-room fire." ^ Sutton did not fully recognize the importance of his idea, so that it would have l)een forgotten had it not been for Dr. Mead, who brought it to the attention of the Eoyal Society. The method was so simple and satisfactory that it could not but replace in part at least the method of Hales. But, as the editor of the Gentleman's Magazine says, " The public, however, is not the less indebted to the ingenuity and benevolence of Dr. Hales, whose ventilators came more easily into use for many purposes of the greatest importance to life, particularly for keeping corn sweet, by blowing through it fresh showers of air, a practice very soon adopted b}' France, a large granary having been made under the direction of Du Hamel, for the preservation of corn in this manner, with the view to making it a general practice." ^ Here the editor refers to Duhamel du Monceau,^ F. R. S., the celebrated French botanist and agriculturist, who, at the suggestion of Hales, equipped one of the public granaries with a wind-mill and ventilators to draw up air through the grain.

It was probably through Duhamel's influence that Hales persuaded Louis XV to introduce his system of ventilating into the French prisons in which British soldiers were confined.'° On this occasion, writes the chronicler, " the venerable patriarch of Teddington was heard merrily to say ' he hoped no body would inform against him for corresponding with the enemy.' " "

Among Hales' numerous contributions to the literature of stone in the bladder and kidney, one is of special interest as showing his method of dealing with this question and his zeal in exposing quackery. It is a letter to the editor of the Gentleman's Magazine^ which runs thus:

" Mr. Urban, If you please to put the following Remarks on the Liquid Shell Into your next Magazine, you will do good service to the publick. I am. Sir, &c.

" gome Remarks on the boasted Liquid Shell. The newspapers having frequently repeated a long advertisement in praise of the Liquid Shell, as a powerful dissolvent for the stone and gravel, 1 thought it of importance to enquire, by proper tryals, whether it had that boasted efllciency or not; and, if not, to caution

" P. C, page 275.

^ Henri Louis Duhamel du Monceau, 1700-1782. -"See Michaud: Biographie Universelle, article on Hales by Lefebvre Cauchy. "F. D. =»G. M., October. 174G, XVI, 520.

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[No. 159.

people against throwing away their money, and hazarding their lives, by the use of an uneflScacioiis medicine.

"Having therefore procured some of the Liquid Shell, which is a clear transparent liquor. 1 pul into it a human wtono formed in the urinary passages, ujion which a very white sediment precipitated; and there was a lilve white sediment when a few drops of spirit of harts-horn were dropped into the same liquor; which fully proves that it was in both cases the lime of burnt shell, and not the parts of the dissolved stone as is pretended; for there was no stone put in with the spirit of harts-horn. Besides this precipitated matter is much too white for any part of dissolved stones.

" And, whereas, it is said in the advertisement, ' That, if the stone be put into a vial of the Liquid Shell, in a moderate sand heat, it will in a few hours be dissolved or broken to pieces:' On the contrary, it has been found, that, on putting human stones, of different degrees of hardness, into a vial of the Liquid Shell, they have not been dissolved, nor broken in pieces, though they continued in that state, not a few hours only, but many days; the last four hours of which time, the vial of Liquid Shell was put into scalding hot water, . . . . "

" Soap lie," lie then states, is a powerful solvent of stones, but on evaporating the medicine to dryness only a minute quantity of this material was obtainable, and he therefore concludes thus:

" Hence we see how improbable it is that this Liquid Shell ' given every four hours in the quantity of 70 drops in a dose,' should have any efficiency to dissolve stones in the body," especially since it has been shown that " three pints of lime water a day, with a considerable quantity of soap, have been found necessary to be taken, in order for any probability of success, (as may be seen in the Edinburgh Medical Essays) . . . . "

Among the book notices for the following year is " Dissertation on the Liquid Shell pr. 6 d." °° This pamphlet, like the article in the Gentleman's Magazine, was anonymous.

Dr. Holmes ha.s made us all familiar with the subject of Biishop Berkeley's " Tar Water." In the words of a wag writing in the Gentleman's Magazine,"

" To ev'ry med'cine is assigned its part, " Sena is purging, saffron warms the heart; " Blood sweet'ning juice to sassafras is given, " To tar drink — every virtue under heaven."

On the subject of tar water Hales shows a praiseworthy caution. He docs not deny its efficacy, but he does not advocate its use. His only publication in the Gentleman's Magazine" is a letter received by him from Bishop Berkeley, upon the contents of which he makes no comment. In the book which he wrote on this subject, he confines himself entirely to the chemistry and preparation of tar water. This book, which bears the following title : "An Account of some Experiments and Observations on Tar-Water Wherein is shown the Quantity of Tar that is therein. Which was read before the Eoyal Society. By Stephen Hales, D. D., P. K. S.," closes with the following paragraph: "It is hoped that the Light given by

"G. M., November, 1747, XVII, .'548. ""G. M., February, 1747, XVII, 81. "G. M., February, 1747, XVII, 64.

these Ecsearches, may be of use in Skillful Ihunls, for regulating and adapting the due Proportions of the acid and the oily Principles, to different Cases and ('onstitutions. 'J'liis is the proper Province of the Physician, uliich I am in no ways (jualified to meddle in."

Among the subjects wliich Hales regarded as of great importance was the liquor question. In a letter dated 1758, written by him to Mark Ilildesley, Bishop of Sodor and Man, he speaks of having for the last thirty years borne public testimony against drams "in 11 different books and newspapers," and adds that this circumstance " has been of greater satisfaction to me than if I were assured that the means which I have proposed to avoid noxious air should occasion the prolonging the health and lives of a hundred millions of persons." '"

His most important pamphlets on this subject are entitled "A Friendly Admonition to Drinkers of Brandy and other Distilled Spirits" (published anonymously), and later, " Distilled Spirituous Liquors the Bane of the Nation." In his treatment of even these topics, the scientific bent of his mind is seen, for in the second of these pamphlets, he tries to arouse the interest of the landed gentry and the farming population on the ground that dram drinking decreases the appetite and lowers the demand for food. Then, not contented with anything but quantitative statements, he declares that according to his calculations the country loses £600,000 per annum owing to the distilleries in London alone.'"

We have considered Stephen Hales as a scientist and as a philanthropist, but the question now arises. What was going on in Teddington all this time ? Did the charity of Dr. Hales begin at home ?

History does not record any murmurs of neglect coming from his flock. It is even said that he made some of his women parishioners do public penance for irregular behavior." We are told that the little church of St. Mary owed much to his care. He enlarged the church yard " by prevailing on the lord of the manor." " He superintended the building of a new tower and aisle, for which he contributed £200 out of the £592 which it cost.'°

Under his supervision the water supply of the parish was greatly improved, and Hales records in the parish register in a manner quite characteristic that the outflow was such as to fill two quart vessels in " 3 swings of a pendulum, beating seconds, which pendulum was 39 -J- 2/10 inches long from the suspending nail to the middle of the plumbet or bob." "

"Peg" Wofiington," the celebrated actress, was one of his parishioners, and built and endowed an almshouse at Teddington, and at her death a tablet in her memory was placed in the north aisle of St. Mary's."

Hales' connection with the smallpox hospital is shown in

=' Butler: Life of Hildesley, 179!). F. D.

"P. D.

" Parish register, F. D.

"•L. L., Ill, 505. note 14.

""Margaret WofTinglon, l)orn in Dublin, 1714, died, 1760.

" L. L., II, 500.

June, 1904.]

191

the title of an account of this institution which appeared in the Gentleman's Magazine.^ This title reads as follows :

" Middlesex. Of the County Hospital for the small ros, the Duke of Marlborough and the Lord Bishop of WorCESTER, Presidents, Sir Hugh Smithson and Sir Eover Newdigate Barts. the Hon. Col. Bockland and the Rev. Dr. Hales Vice-Presidents.

" For several years Hales was honored with the esteem and friendship of his Eoyal Highness Frederick, Prince of Wales, who frequently visited him at Teddington, from his neighboring palace at Kew, and took a pleasure in surprising him in the midst of those curious researches into the various parts of nature which almost incessantly employed him." "

His contemporaries admired his " social virtue and sweetness of temper " and " the constant serenity and cheerfulness of his mind." *° Pope, who was his neighbor and of whose will Hales was one of the witnesses," was heard to say, " I shall be very glad to see Dr. Hales ; I always love to see him ; he is so worthy and good a man." "

To the end of his long life his mind was ever actively planning scientific experiments and benevolent enterprises. In November, 1760, his signature appears on the parish register for the last time. On Sunday, January 4, 176J., he died after a slight illness. His death was the occasion of the following article, which appeared in the January number of the Gentleman's Magazine : "

" The following Character of the late Dr. Hales, may be relied upon in every particular, and it is to be regretted that we have not more particulars concerning his useful Life from the same hand. On Sunday the 4tli instant, died, at his parsonage-house at Tedington, universally lamented, in the S3rd year of his age, the Hev. Dr. Stephen Hales, F. R. S., member of the royal academy of sciences at Paris and clerk of the closet to her Royal Highness the Princess Dowager of Wales. If any man might ever be said to have devoted his whole life to the public, to all mankind, it was Dr. Hales. He possessed a native innocence and simplicity ot manners, which the characters of other men, and the customs of the world, could never alter; and though he often met with many unworthy objects of his kind and charitable ofiBces, yet they never once lessened his natural and unwearied disposition of doing good and relieving distress. His temper, as well as the powers of his understanding, were happily fitted for the improvement of natural philosophy, possessing, as he did, in an uncommon degree, that industry and patient thinking, which Sir Isaac Newton used modestly to declare, was his own only secret by which he was enabled so fortunately to trace the wonderful analysis of nature. Dr. Hales began his inquiries into natural knowledge very early in life, and he continued it uniformly as his darling amusement, being engaged in experiments until within a few weeks of his death. His industry had this farther excellence, that it was always pointed at the general good of his

'« G. M., June, 1747, XVII, 270.

"P. C, 277.

• °F. D.

"Courthope: Life of Pope, F. D.

"F. D. In the phrase "Plain parson Hale," (Moral Essays, Epistle II) Pope doubtless refers to Hales whose correct name unfortunately could not be made to rhyme with " fail " in the preceding line.

"G. M., January, 17G1, XXXI, 32.

fellow creatures, agreeable to the almost unlimited benevolence of his heart; and being animated with the success of some of his more useful discoveries, his knowledge appeared to everybody near him to feed his mind with a nourishment which gave him, in the decline of his life, and even in its last stages that vigor and serenity of understanding, and clearness of ideas, which so few possess, even the flower of manhood; and which he used often to say, he valued as the most perfect of human pleasures.

" There are two things in his character, which particularly distinguish him from almost every other man; the first was, that his mind was so habitually bent on acquiring knowledge, that, having what he thought an abundant income, he was solicitous to avoid any farther preferment in the church," lest his time and attention might thereby be diverted trom his other favorite and useful occupations.

"The other feature of his character was no less singular: He could look even upon wicked men, and those who did him unkind offices without any emotion of particular indignation; not for want of discernment or sensibility; but he used to consider them only as those experiments which, upon trial, he found could never be applied to any useful purpose, and which he therefore calmly and dispationately laid aside."

In accordance with his own directions he was buried in the vestry under the tower of St. Mary's which he had built eight years before. The tablet over his grave tells us that —

"Here is interred the body of Stephen Hales, D. D., cleric of the closet to the Princess of Wales, who was minister in this parish 51 years. He died the Jftli of Jan., 1761, in the SJfth year of his age."

In the September number of the Gentleman's Magazine of the following year we find this notice : "

" Thursday the 2nd was opened in Westminster Abby, a fine new monument," erected by Mr. John Wilton, statuary to her majesty, at the expense of the Princess Dowager of Wales, to the memory of Stephen Hales, D. D. & F. R. S., Clerk of the closet to the Princess Dowager, minister of Teddington in Middlesex, and rector of Farrington in Hants; grandson of Sir Robert Hales, of Beakesbourne in Kent, Bart. & uncle to the present Sir Thomas Hales. He died in January, 1761, aged 82 years."

There is, then, a monument to Stephen Hales in Westminster erected by the mother of George II, but it is not by means of this piece of marble that the memory of Stephen Hales is kept green among us. He has left us a memento more unique and enduring in the " Statical Essays " and the Hales manometer.

Bibliography.

The more important sources which have been consulted in the preparation of the foregoing article, together with such abbreviations as have been used to designate them in the footnotes, are the following:

1. The separate publications of Hales.

2. Numerous articles bv or referring to Hales in the Phil

" The King offered Hales the canonry of Windsor which the latter, however, declined. L. L. and P. C. " G. M., September, 1762, XXXII, 444. "For epitaph see L. L., Ill, 50", note 19.

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[No. 159.

osophical Transactions of the Royal Society of London, abridged, London, 1809. Designated P. T.

3. Numerous articles by or referring to Hales in the Gentleman's Magazine, London. G. M.

4. An especially important article in G. M., June, 1764, XXXIV, 273, entitled, "Some Account of the Life of the Late excellent and eminent Stephen Hales, D. D., F. B. S., Chiefly from Materials communicated hy P. Collinson, F. E. S." P. C.

5. D. Lysons: Environs of London, London, 1795, Vol. III. L. L.

6. In a niimber of instances the author has been unable to reach the original sources and has quoted from the very excellent account of Hales given by Francis Darwin in the Diet. National Biography, XXV, 33. Such quotations are designated by the initials F. D. which follow the title of the original source when this is known.

7. Other articles in the Diet. Nat. Biog. D. N. B.

A CASE OF CANCER OF THE MAMMA CURED BY MEANS OF ROENTGEN RAYS.

Communicated by Professoe B. Schiff {Vienna).

The first note on cure of cancer by Roentgen rays was given by Gocht.' It referred to a woman of 54 years who had come to be treated of a cancer on the right mamma, ulcerated and inoperable. Considering the pains and solaminis causa the patient was submitted to a daily treatment. The patient felt relieved and the pains entirely disappeared. The 7th day sudden elevation of temperature and appearance of erysipelas extending from the thorax to the back and to the right arm. After a few days profuse hemorrhages out of the ulcerated cancer and death on the 27th day, caused by cachexy and sepsis.

Another patient, aged 45, suffered from recurrence of cancer of the mamma which had been already repeatedly operated on and for the last time in 1896. Also in this case the pains decreased rapidly and reappeared only when the treatment was interrupted. No influence on the cancerous tissue was to be observed.

Later appeared the publications of Magnus Moeller,' Sioegren and Sederholm," Steubeck,' and of many others.

November 6, 1901, I presented to the Imperial Medical Society of Vienna a man affected with an epithelioma suborbiculare, which had been cured by Roentgen rays. Some time later I presented two other similar cases before the same society and which had also been successfully treated. Recently Mikulicz and Fittig " published a very instructive case, and Exner" described three analogous cases.

If I now insist now with more details on a case of a cancer mammffi cured by Roentgen rays accompanying it with some drawings, I do so for two reasons:

First, on account of the most favorable result of the cure and also because I was enabled to study this case histologically. Mrs. N. N. was sent to me by Dr. Schnitzler on February 7, 1903. She showed the following symptoms: Tlio loft thorax

" Fortschritt auf clem Gebiet tier Roentgenstraliles, Bd. I, Heft 1.

"Bibliofheca Medica. 1900.

° Fortschr. a. d. Get), d. Roentgenstrahles, IV.

• Archives d'filectricite m6dicale, 1901.

'Beitriige zur klinischen chirurgie, Bd. 37.

"Wiener klinische Wochenschrift, 1903.

was invaded by a tumor with large basis and of a very solid consistence. This tumor extended from the left sternal margin to the axillary cavity where it reached the glands and formed a hard bunch. On its greatest wideness the tumor had 8 centimeters and its highest elevation was 5 centimetersThe surface was ulcerated, giving issue to a fetid matter, very slightly bleeding even when slightly touched. The inferior periphery showed ten or twelve small tumors of about the size of a hazelnut, also very slightly bleeding. On the back of the patient were five similar noduli. Beneath the above-mentioned bunch of the armhole existed a crateriform cavity wide enough to admit a pigeon egg. The edges were gangrenous and the basis necrotic and full of purulent matter. The glands, both supra and infraclavicular, hard and resistent. The patient said that she suffered since 11 years from pungent pains. Dr. Schnitzler's diagnosis was: Inoperable cancer en cuirasse of the left mamma with lenticular metastases of the cutis.

Although I was for a long time anxious to catch a case of this kind in order to try a Roentgen cure, I confess that the present case left me very little chance of success. Solatii causa, I nevertheless decided to proceed, and already, after the third sitting, the pains considerably decreased and the purulent secretion diminished. I then took the photograph of the patient (Fig. 1), which already shows a modified appearance of the state on February 7. The ulceration was considerably cleaner and scarcely purulent, the tumefaction of the heart nearly wholly reduced and the cutaneous metastases in way of full reconstitution and their volume considerably lessened.

During the treatment I could observe nearly daily an improvement. In the interval appeared slight j^henomena of reactive inflammation of the surrounding skin, and so I interrupted the Roentgen treatment. The pathological process showed evidently favorable modification.

June 5 I noticed that, excepting some superficial excoriated parts, a flat scar crossed by some enlarged capillar vessels had taken the place of ilio former tumor. The cufancous metastases had disappeared and the groups of glands on the supra

THE JOHNS HOPKINS HOSPITAL BULLETIN, JUNE, 1904.

PLATE XXVlll.

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Fig. 1.

Fig. 3.

Fig. •.'.

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Fui. 4.

June, 1904.]

193

anil infraclavicular region had greatly decreased and were soft ( Fig. 2) . The general state of the patient had very mnch improved.

In order to know exactly the histological condition of the case, I requested Dr. Stoerk, of the Pathological Institute of the Vienna University, to make a microscopic examination of some excised parts. The examination included :

1. A fragment of a lenticular nodulus of the back which by the treatment was notably diminished in its size.

2. Fragment of the granulated surface of the cancerous ulceration.

3. A fragment of the region in course of reconstitution surrounding the ulcerated surface and excised near the precedent fragment.

Dr. Stoerk gave the following account :

1. The greater part of this fragment consists of a tissue of large fibers very poor of nuclei and of the type cicatricial tissue; it consists of threads of homogeneous fibers. In the interstitials of these fibers mono- and polynuclear leucocytes; in the deeper part of this fragment remains of cancerous tissue in shape of small bundles of solid cellules, among which is seen a stroma of very thin fibers distinct from the larger fibers above mentioned.

2. Section from the fragment of the ulcerated surface showing the normal appearance of a granulated tissue with a great number of new-formed capillary vessels ranged in typical order.

3. In the part where the epidermis begins to be repaired it is of course very delicate. Underneath a large layer of cutis and in the basis exists still a small hearth of cancerous tissue composed of six or seven cones pressed togetlier.

THROMBOSIS OF THE INTERNAL ILIAC VEIN DURING PREGNANCY.

By F. C. Goldsboeough, M. D., House Officerj The Johns Hopkins Hospital.

{From the Obstetrical Clinic.)

Thrombosis of the vessels of the lower extremities during pregnancy is of such infrequent occurrence and the statements concerning its etiology in the few cases reported in the literature are so scanty and unsatisfactory that it seems advisable to place every case of the kind upon record, particularly when definite statements can be made regarding the etiological factors concerned.

It is my intention in this paper to report a case of thrombosis of the left common iliac vein and its branches, which occurred in the obstetrical department of the Johns Hopkins Hospital, in the service of Prof. J. Whitridge Williams, to whom I am indebted for the privilege of this report.

After carefully reviewing the literature, I have been able to collect but ten cases of phlebitis occurring during pregnancy, though, unfortunately, the reports of three of them, Bradford, Commandeur and Dickinson, are lacking in many important details.

In the cases of Bonnet-Laborderie and Gripat the thrombosis occurred in both legs. In the former, the left internal saphenous vein was affected, while the location of the lesion in the right leg was not stated, the author designating the condition as spontaneous phlebitis. In the latter, the right femoral vein was thrombosed, but no mention was made as to which vessel was involved on the left side. The author ascribed the condition to toxemia of pregnancy, associated with chronic anaemia resulting from paludism.

Of the five cases in which only one leg was affected, the left femoral vein was involved in the patients of Brindeau, Audobert, Saint-Ange and Bacon, while in Beaudry's case the right saphenous vein was the seat of the lesion. In no instance was the etiology perfectly clear, although several of the authors

did not hesitate to suggest a definite causative factor for individual cases. Thus, Brindeau supposed that his patient had suffered from an infectious process, such as la grippe or a gastro-intestinal toxemia during the seventh month of pregnancy, to which he believed the thrombosis and albuminuria which occurred in the following month could be attributed. Bacon's patient had complained of frequent and painful uterine contractions for ten days preceding the appearance of the thrombosis, and the author concluded that " the long-continued uterine contractions may have dislodged placental masses that formed rudimentary emboli, or perhaps altered the blood composition."

In connection with these data it is interesting to ascertain the effect of a thrombosis upon the course of the subsequent labor. No information upon this point is available in the reports of Bonnet-Laborderie and Dickinson. In two other cases the pregnancy terminated spontaneously at the fifth and eighth months, respectively, while the remaining patients went on to full term and were delivered normally and spontaneously. Moreover, it is interesting to note that in only two instances did the patients suffer from fever.

In all the cases in which it was mentioned, the treatment consisted in rest and immobilization of the affected part during the acute stages of the affection; which, as far as the reports show, led to the complete recovery of all the patients.

Our case occurred in a white woman, 29 years of age, who was admitted to the obstetrical department of the Johns Hopkins Hospital on Saturday, June 6, 1903 (Obst. No. 1499), complaining of constipation, nausea and vomiting and swelling of the left leg. Her family history was negative. The patient had always been healthy except for scarlet fever at 14

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and diphtheria at 20 years of age. Menstruation first appeared when she was tliirteeu and a half years old, after which it recurred regularly and without any disagreeable symptoms; the last period having begun on the 10th of September, 1902.

The present pregnancy, which was the first one, had been practically normal until four days before admission to the hospital. There had been no nausea or vomiting, headache or visual disturbances, and the bowels had been regular until about a week before admission, though a slight leucorrheal discharge had occasionally been noted. The patient, who was employed in another hospital, had been able to attend to her usual duties until one week before admission. Up to that time she believed that no one had suspected her condition, which she successfully concealed by wearing a specially constructed corset, which enabled her so to compress her abdomen as to conceal its enlargement, simply giving the impression of being a vrell-developed woman with a broad waist. A week before entering the Johns Hopkins Hospital she was compelled to go to bed on account of marked oedema of her left leg. During this period the bowels did not move, and four days later she began to suffer from nausea and vomiting.

On admission the patient was foiind to be a large-framed woman with no puffiness about the face or eyelids. Nothing abnormal could be made out in the heart or lungs. On inspecting the abdomen, the uterus was seen to be deflected toward the left side, where it reached as high as the costal margin. The epigastrium and upper right abdominal quadrant were greatly distended, and coils of intestine could be clearly distinguished, which could be seen to be going through vigorous peristaltic movements. The stomach was greatly distended and occupied the epigastrium. The child was of moderate size and lay in the right occipito-iliac transverse position, with its head freely movable above the superior strait.

The left leg was enormously and symmetrically swollen from the toes to the groin. There was no increase in its surface temperature, nor was it painful on pressure. The skin was white and glistening, firm and tense, and pitted readily under the finger. In the fold of the groin tliere was an excoriation 5 cm. long by 5 mm. broad, apparently resulting from a blister; while in the region of the knee there were several blebs, which varied from 1 to 5 mm. in diameter. On careful palpation one . could not detect thrombosed vessels either in the groin or at the location of the external saphenous vein. The pulse was 80 to the minute, well sustained, with moderate tension. The vessel walls were nalpable. The urine was amber in color, with a specific gravity of 1020 and an acid reaction. Sugar and albumin were not present. On standing, a moderate amount of flocular sediment was deposited, which under the microscope showed only a few epithelial and pus cells;

'J'he patient was put to bed and the leg wrapped in cotton and elevated. 'J'he bowels were moved by an oil enema and subsequently kept well open by the use of purgatives by the moLitli, though these were only partially retained, and then only with the greatest difficulty. The nausea and vomiting, however, persisted during the succeeding 48 hours, and all

means employed to check it were ineffectual, so that no nourishment was retained. In spite of her low pulse and the absence of increased temperature, the patient made the impression of being very ill, so that it was determined to induce labor in the hope of relieving her.

Accordingly, at 5 P. M., June 8, a Champetier de Ribes balloon was introduced into the uterus. Four hours later labor pains supervened, which were fairly effectual and recurred at short intervals. Unfortunately the balloon burst at 3 A. M. the next morning, though the pains continued several hours longer, when they completely disappeared. At 10 A. M. the temperature was 100° F. and the pulse quite rapid, while the patient appeared considerably worse than when the bag was first introduced For this reason it was determined to deliver her at once rather than to complete the dilatation of the cervix with another balloon.

Examination under chloroform anaesthesia showed that the external os was soft and about 5 cm. in diameter, while the cervical canal was between 2 and 3 cm. long; the presenting part was still freely movable above the superior strait. The cervix was then dilated manually without great difficulty by the Harris method, after which the child was turned and extracted. The operation, however, was extremely difficult, as the uterus became tetanically contracted as soon as the hand was introduced into it, necessitating the use of considerable force in completing the version. Owing to the difficulty in extraction, the child was born dead, when it was found to be a well-formed female, 50.5 cm. long and weighing 3330 grammes. As the patient was much shocked by the operation and had bled very freely, the placenta was removed manually and a perineal laceration speedily repaired.

After being placed in bed, the jjatient responded fairly satisfactorily to stimufation and toward evening her condition seemed quite favorable. About midnight, however, the pulse became rapid and of poor quality, the patient became irrational and did not respond to stimulation; vomiting set in and death ensued at 3 A. M., 15 hours after delivery.

An autopsy was performed 8 hours after death by the resident pathologist. Dr. W. G. MacCallum, to whom I am indebted for the following notes : The body was that of a large, well-nourished white woman, rigor mortis present. The left leg was much enlarged and could be indented with the finger. On careful palpation a hard cjdindrical mass could be felt in the inguinal region. On opening the abdomen no fresh adhesions were found in the peritoneal cavitv, but many old adhesions were present about the uterus, and bound the left tube and ovary into a single mass. The stomach was much distended with gas. The pleural and pericardial cavities appeared normal and contained no excess of fluid. The pulmonary arteries were opened in situ, but no thrombi were found in them, nor in any of their minor branches.

On macroscopic examination, the heart, spleen, adrenals, pancreas, bladder, stomach and intestines appeared normal, while the liver and kidneys showed some evidences of degenerative changes. 'J'herc was no consolidation of the lungs, whicli, however, were moist, purple in section, a good deal of

JuxE, 1904.]

195

fluid and frothy blood exuding from the cut surface. The vessels were clear and normal ; the bronchi were blood-stained and contained a little mucus.

Microscopical examination showed that all the organs were considerably congested. There was marked fragmentation of the myocardium. The lungs showed evidences of oedema. There was considerable degeneration of the liver cells with signs of chronic passive congestion. The renal epithelium was extensively degenerated, but particularly in the tubules.

The lumen of the left common iliac vein was completely occluded where it was crossed by the right common iliac artery. From this point, as far down as the dissection was carried, the vessel was filled by a thrombosed mass, which extended into the external iliac and from it into the femoral and saphenous veins. On the other hand, it stopped abruptly at the point of compression, above which the vessel was perfectly normal. In places the thrombus was of a pale color and showed definite lamellae ; elsewhere it was purplish black, but even here a lamellated structure was visible. The intima of the veins was destroyed, the thrombus being firmly adlierent to the vessel wall.

Microscopic sections through the thrombosed vessel showed practically no change in its walls, except for the absence of the endothelial lining. There were no signs of marked inflammatory reaction, the entire lumen being merely filled by a blood clot which was firmly adherent to its wall.

Cultures taken from the heart's blood and the thrombus at the time of autopsy were absolutely negative; nor could the most thorough examination of appropriately stained hardened specimens reveal the presence of bacteria.

The comparison of the clinical history of this case with the autopsy findings would seem to leave no doubt as to the sequence of events, and apparently shows quite definitely the causative factor in the production of the thrombosis. The negative results of the cultures made from the heart's blood and from the thrombus at the time of autopsy, as well as the absence of bacteria in suitably stained sections through the thrombus, would appear to eliminate the possibilitj' of a bacterial origin, and therefore force ns to seek some other cause.

After carefully considering all the possibilities, it seems to us that this factor is to be found in the pressure which was brought to bear upon the retro-peritoneal structures by the corset which the patient wore to disguise her condition. As the uterus enlarged, it was forced with increasing intensity by the binder downward and backward against the bodies of the lumbar vertebra; and the structures in front of them. This naturally interfered with the return of the blood from the lower extremities, which was particularly marked at the point where the right common iliac arten- crossed the left common iliac vein. As the pressure increased, the latter vessel became compressed between the artery in front of it and the vertebral column behind it, so that eventually its lumen became completely obliterated, when effectual stagnation was brought about. Subsequently coagulation occurred and the thrombosis resulted with the effects already mentioned.

It would, therefore, seem more than probable, in view of the mechanical conditions present and the negative results of bacterial examination, that we have to deal in this case with thrombosis resulting from pressure. Such an occurrence is rare under any circumstances, and as far as I have been able to learn has not as yet been described as a causative factor in a thrombosis occurring during pregnancy.

»

aJ

i

p

Affected

Effect on

6

<

si

Part.

Labor

Etiology.

Reported by.

1

33

3d p.

8th

Lt. femoral vein.

None.

Intercurrent infection.

Brindeau.

f)

-'

1st p.

sth mo.

Lt. internal saph. vein right les.

None.

Spontaneous phlebitis.

Uonnet-Laborderie.

a

L'«

2nd preg.

mo.

V

Rt. internal saph. vein.

None.

?

Beaudry.

i

y

•'

Term; ?

Rt. leg and thigh. Rt. femoral

Very incomplete account.

6

32

7th

End ;

At Sth mo.

Anaemia and

G ripat.

preg.

of 3rd mo.

and left leg.

child stillborn.

albuminuria.

6

M

Istp.

Sth rao.

y

Left leg and thigh.

?

?

Dickinson.

V

40

2nd ] tsi2 iyJLeft femorpreg.l mo. i 1 al vein.

None.

y

Audebert.

»

y

?

1

mo.

~

Left femoral vein.

Miscarriage at .'ith mo.

^

Saint^Ange.

9

y

3rd preg. 1st p.

Sth mo.

Rt. leg.

None.

Commandeur.

10

23

Sth

+

Left femor

None.

See abstract.

Bacon.

mo.

al vein.

il

29

Istp.

Term +

Left common iliac vein.

Operative delivery.

Pressure thrombosis.

F. C. Goldsborough.

Eeferences.

Audebert: Phlebite pendant la grossesse. Echo Med. Toulouse, 1901, XV, 12-1-126.

Bacon: Phlegmasia Alba Dolens during Pregnancy. Am. Jr. Obst, 1903, XLVIII, 518-519.

Beaudry : Phlebite traumatique suivie de la guerison spontanee de varices durant la grossesse. Union Med. du Canada, Montreal, 1875, IV, 388.

Bonnet-Laborderie, A. : Phlegmasie alba dolens survenue an huitieme mois d'une grossesse normale. J. de Sc. Med. de Lille, 1903, 1, 341-347.

Bradford, T. : A Singular Case of Phlegmasia Dolens, occurring before delivery and effectually arresting the progress of parturition. St. Louis M. & S. J., 1858, XVI, 210.

Brindeau : Cas de phlegmasia alba dolens pendant la grossesse. L'Obstetrique, 1900, V, 417-420.

Commandeur: Phlebite de la grossesse compliquee d'embolies pulmonaires ; traite par la methode des abces de fixation. Echo Med. Toulouse, 1900, 2s, XIV, 356-358.

Dickinson : Some observations and examples of phlegmasia dolens in the puerperal, gravid and unimpregnated states and also in the male. Med. & Chir. J., Lond., 1819-1820, II, 116131.

Gripat: Observations de grossesse; albuminurie; phlegmasia alba dolens double. Bull. Soc. de Med. d'Angers, 1889, n, s. XVII, 84-90.

Saint- Ange, L. : Un cas de phlegmatia alba dolens pendant la grossesse. Arch. Med. de Toulouse, 1896, II, 193-203.

196

[No. 159.

CHANGES IN THE NERVOUS SYSTEM AFTER PARATHYROIDECTOMY.

By Colin K. Rdssell, M. D. (McOill).

It has been shown by Gley, Vassale and General! and others that dogs after the extirpation of the parathyroid glands die usually in the course of a few days of a generalized tetany. Vassale and Donaggio made a series of examinations of the spinal cord of seven of such dogs. In six of these after the cord had been kept in Miiller's fluid for 3-5 months, they found a macroscopical alteration tliought to be a degeneration in the crossed pyramidal tracts identical in situation with that following ablation of the motor cortex, and also a similar change in the posterior tracts. This degeneration so clearly visible to the naked eye could not be demonstrated microscopically with Marchi's stain or with the Weigert-Pal method. With a 1 per cent solution of nigrosin they were able to distinguish a swelling and granular appearance of the axis cylinders, and the m3'eliue sheath showed atrophy and did not take the stain well. They did not examine the cortex and left the question open whether this was a primary degeneration of these tracts or whether it was secondary to an atrophy of the respective cortical ganglion cells.

Through the kindness of Dr. W. G. MacCallum, I have been able to examine the brain and cortex in several of the animals of his series of experiments which he published lately and which he is still carrying on, with the object of determining if this degeneration were primary in the cortical cells.

The method used was as follows :

The motor cortex, medulla, and a section of the cord were hardened in 95 per cent alcohol for three days. They were then imbedded in paraffin and cut in sections 10 /x thick.

The sections were stained with iSTissl's methylene blue, the temperature being very gradually raised until steam was given off. They were then decolorized with aniline oil 10 per cent in 95 per cent alcohol, until the stain ceased to be given off. Oil of cajuput followed by xylol and mounted in neutral balsam.

A control was obtained by killing an animal very quickly by opening both carotids and crural arteries.

The following is the synopsis of the histories of the experiments taken from Dr. MacCallum's notes with 'die histological findings:

Case 1. — Dog 128. Four parathyroids removed— violent tetany two days later. Thyroids then removed under ether. Violent exacerbations of tetany and death about GO hours after first operation.

Sections made through the motor cortex show some indefiniteness in the outline of the pyramidal cells. The processes are long. In a great many cases the cells are surrounded by numerous neuroglia cells.

The cell Itself shows marked chromatolysis, staining much more deeply and diffusely about the nucleus, owing to the chromophile granules which ordinarily stain distinctly having become broken up and exceedingly fine. As we approach the processes, the chromophile granules become more sparsely distributed although they extend for a very considerable distance and

are frequently so placed along the margin as to give the process a roughened appearance.

The nucleus is centrally placed and as a rule has a fairly sharp outline. It takes a faint bluish tinge.

The nucleolus stains deeply.

The cord fixed in Miiller's fluid shows macroscopically on cross sections pale areas confined to the crossed pyramidal tract. Although this was stained with the Weigert-Pal, Marchi and Stroebe methods and also with nigrosin 1 per cent, it has been found impossible to demonstrate any degenerative changes microscopically. This same difliculty has been found by Vassale, in his experiments.

Cutting longitudinal sections through these tracts was also tried to see if any swelling of the axis cylinders could be demonstrated but I could not satisfy myself that this was present.

Case 2. — Dog 133. Two parathyroids on right side and left lobe of thyroid together with parathyroids removed, followed by sickness and depression for 26 days before the onset of a moderate grade of tetany. Dog killed in order that blood might be transfused into another dog, 27 days after first operation.

In this dog there were found on examination scattered through the cortex and often side by side with well preserved pyramidal cells, numerous shrunken twisted pyramidal cells with tortuous processes; these cells may be very much diminished in size and are sometimes extremely narrow and dense looking. In the more intensely affected examples the chromophile granules are no longer to be made out at all, but the whole protoplasm takes a dense blue stain sometimes so intense as to completely hide the nucleus. The nucleus itself is shrunken and deeply stained. The nucleolus is frequently no longer visible. Neuroglia cells accumulated about these nerve cells seem very abundant.

In the cord there are also two conditions of the cell to be seen often side by side. In the one the Nissl's bodies are distinct and evenly scattered through the cell. They are large and irregularly shaped and extend a short distance down the processes; here they are long with the long axis parallel to the axis of tho; process. The nucleus and nucleolus are centrally placed, the nucleus takes a faint bluish tinge, the nucleolus staining deeply. These are practicaly normal cells.

In the second type there is a slight degree of chromatolysis especially marked in the body of the cell in the neighborhood of the nucleus. The nucleus and nucleolus are unchanged.

In the cord fixed in Miiller's fluid there was no degeneration of the crossed pyramidal tract made out either macroscopically or microscopically.

Case 3. — Dog 138. Four parathyroids removed. Violent tetany two days later. Both thyroids removed with no effect. Tetany increased; bled to death under ether two days after primary operation.

The pyramidal cells show a degree of chromatolysis similar to Case No. 1. There are practically none of the shrivelled cells that are seen in Case 2, although one or two are visible.

In the medulla stained with Nissl's method, there is a slighter degree of chromatolysis than is seen in the cortex. The chromophile granules have a distinctly finer appearance than is seen in the control specimen.

The cord shows nothing abnormal except that the processes can be followed for a longer distance than they can in the control specimen.

In the cord fixed in Miiller's fluid, no macroscopical degeneration can be made out nor could any be demonstrated microscopically.

June, 190i.]

197

Case 4.— Dog 139. Four parathyroids removed, followed by marked depression, very severe tetanic convulsions on Tth day and death.

Pyramidal cells of cortex show a chromatolysis similar to Case 1. There are a few shrivelled, distorted cells such as are seen in Case 2, but these are not at all numerous.

In the cord, while some of the ganglion cells are perfectly normal, most show a greater or less degree of chromatolysis.

The cord fixed in Muller's fluid shows no macroscopical degeneration of the crossed pyramidal tract; and in longitudinal sections through this tract I could make out no swelling of the axis cylinders.

Case 5. — Dog 141. Left motor cortex removed, followed by paresis of right side. 10 days later three parathyroids were removed from left side and the right thyroid lobe together with Its parathyroids. Seven days later violent tetany, more marked on left side; noticeable on right side also. Died under ether.

The cortical pyramidal cells from the right side show a degree of chromatolysis similar to Cases 1, 3 and 4.

In the cord the cells seem perfectly normal.

There is a marked degeneration in the crossed pyramidal tract on the right side of the cord. Left side is normal.

Case 6.- — Dog 148. Two parathyroids removed from right side and the thyroid lobe together with the parathyroids on left side. Tetany quite violent on the second day following. Intermittent tetany during eleven days after the operation at the end of which the dog was found dead.

In the cortex the pyramidal cells have a rather indefinite outline. There is also a marked chromatolysis, not confined as a rule to the neighborhood of the nucleus but general. Some of the cells are quite broken up.

There are very few shrivelled, distorted cells as described in Case 2. In a great many cases numerous neuroglia cells are seen surrounding the ganglion cells. The cell processes may be followed for some distance as a rule.

The nucleus in a great many cases has disappeared, in some others it is somewhat swollen and may be dislocated more or less to one side of the cell. Nucleolus stains darkly.

In the cord the cells show a fairly well marked chromatolysis. The processes can be followed for some distance from the cell. In some cases the cell is more or less surrounded by neuroglia cells. In some vessels in the posterior horn there is a marked outwandering of leucocytes and many of the cells in the immediate neighborhood are shrunken and stain very deeply and diffusely.

Case T. — Dog 132. Two parathyroids removed from right side. Whole thyroid lobe with its parathyroids removed from left side. Great depression. Intraperitoneal injection of two thyroid glands. Cachexia and emaciation. Death 15 days after primary operation.

In the cortex the pyramidal cells have a diffuse finely granular appearance, showing marked general chromatolysis. In a few, the nucleus is somewhat literally situated. Processes are fairly long.

In the cord, the ganglion cells show a marked chromatolysis especially about the nucleus, while near the periphery and at the beginning of the processes a few irregularly shaped Nissl bodies can be made out. A few stain diffusely throughout; no chromophilic bodies can be made out. In one of these the nucleus is protruded from the cell entirely; in others it is somewhat displaced laterally. Many cells are surrounded by unusually abundant neuroglia cells.

From the study of these brains it seems evident that when after parathyroidectomy the dogs succumb with symfitoms of tetany, etc., there are to be found fairly tiniform, if slight alterations in the cells of the central nervous system. These alterations consist in:

1. Chromatolysis in which the chromophile granules especially in the immediate neighborhood of the nucleus become reduced to such a fine state of division as to give a diffuse blue stain with Nissl's method. In the cases in which the tetany is of longer duration, the change may be such that isolated chromophile bodies are no longer to be distinguished in the cell. Associated with this alteration there may be a dislocation of the nucleus or even in extreme cases its expulsion from the cell. Sometimes it is possible in these cases to trace the protoplasmic processes to a great distance from the cell.

2. In most severe cases there is in many of the large pyramidal cells a change which leads to their great shrinkage and distortion, the cell protoplasm becoming so densely stained as to hide the nucleus.

3. The small neuroglia cells, of which one or two are usually associated with the pyramidal cells, may become more numerous so that each nerve cell is surrounded by a group of them. This is evidently the appearance described by Quervain and others as due to an accumulation of leucocytes in the spaces about the nerve cells. The function of these neuroglia cells is not understood, but it is thought by many that they may be of a phagocj'tic nature.

In the medulla and cord the alterations are similar, although far less intense than in the cortex.

Since the general conditions of life of these dogs were the normal ones and no pathological alteration was observable in the other organs, it is thought justifiable to ascribe these changes to the influence of the toxin which appears in the body after parath3Toidectomy.

The macroscopic change which Vassale and Donaggio observed in the spinal cord of parathyroidectomized animals after protracted treatment of the tissue with chrome salts is described by them as an alteration not recognizable by the methods of Marchi or Weigert, although by the use of nigrosin they were able to discern a swelling of the axis cylinders and an atrophy of the medullary sheaths in the pyramidal and dorsal tracts. In only one case of this series was such a change evident, possibly because in all the others the tissue had not lain for 3-5 months, as Vassale recommends.

In conclusion, therefore, it seems that we have in the cortical cells anatomical alterations which, although very slight, are still sufficiently well marked to afford a basis for the functional changes which led to the tetany. It seems probable further that the degenerative changes in the pyramidal tract of the spinal cord observed in one case and noted so often by Vassale may represent the analogous condition of the axis cylinder processes of these same cells. Probably in time this alteration of the axis cylinder processes which is possibly secondary to the change in the nerve cell, would be associated with alterations in the myelin sheath recognizable by the usual methods.

Bibliography.

W. G. MacCallum: Medical News, K Y., Oct. 31, 1903. Vassale and Friedman: Arch. Ital. de biol., 1898, XXX. Vassale and Donaggio: Ibid., 1897, XXVII. Quervain : Virchow's Ai-chiv, 1893, CXXXIII.

198

[No. 159.

THE RELATION BETWEEN CARCINOMA CERVICIS UTERI AND THE RECTUM AND ITS SIGNIFICANCE IN THE MORE RADICAL OPERATIONS FOR THAT DISEASE.

By John A. Sampson, M. D., Resident Gynecologist, The Johns Hopkins Hospital; Instructor in Gynecology, Johns Hophins University.

The invasion of carcinoma cervicis uteri into the surrounding tissue manifests itself in the large percentage of cases admitted to this hospital in which the disease has extended so far that palliative treatment alone is indicated and also in the still larger percentage of cases in which the disease returns after operation, showing that at the time of the operation the growth had already invaded the surrounding tissue and that hysterectomy alone seldom cures this disease. In October, 1902, our cases were reviewed, and at that time in over threefifths of the patients admitted to the hospital the growth had extended beyond operative treatment. Of 143 patients in which hysterectomy had been done, 21 died as a result of the operation, giving a primary mortality of 14.6 per cent. Three years or more had elapsed since the operation in 69 of the cases which we had been able to follow, and at the end of that time 20 were living, but 6 of these later had recurrences, thus giving a percentage of recurrences after three years and more of 78.2 per cent. When we considered those cases in which five years or longer had elapsed since operation we found that there were 49 whom we had been able to follow, and of this number the growth had returned in 43, or 87.7 per cent. We realize, however, that five years is not long enough, for two of our patients had died at the end of six and seven years from general carcinosis without a return in the vaginal vault, and a third was living, with a small growth in the vaginal scar, five and a half years after operation, there having been symptoms referable to it for only two months. We reviewed our cases again in May of this 3'ear and found that after three years or more, in 76.5 per cent the growth returned in 94 cases whom we were able to hear from, and that after five years or more the percentage of recurrence was 79.1 per cent in 67 cases heard from. This improvement over the review made in October, 1902, can be explained in two ways: first, that physicians and patients realize more and more the importance of an early diagnosis, and secondly, the operations have become more radical each year.

The importance of a more radical operation in these cases has been emphasized in previous publications' and also the relation between the gi-owth and the ureters ' ° ' and bladder,' ' as well as tlie efficiency ' of tlie blood supply of the ureter and also the complications ' arising from freeing the ureter from its sheath and injury to its blood supply. The dangers* of ascending renal infection from post-operative cystitis have also been considered and a possible way of controlling the bladder infection has been suggested.

The relation between the rectum and carcinoma cervicis uteri should be considered, for in many instances it has a very important bearing in these operations. This relation mani

fests itself clinically in the posterior extension of the disease, thus involving the anterior wall of the rectum and with the necrosis of the cancerous tissue a recto-vaginal fistula is formed. Another manifestation of this relation is injury to the rectum, which may occur in hysterectomy for the disease. The object of this paper is to see what may be learned from anatomical and pathological studies as well as clinical experience in regard to the relation between cancer of the cervix and the rectum, and if these results have any bearing on the more radical operations for this disease.

Fig. I. — View of the Inside op the Right Half of the Pelvis of a Woman Standing, x y%. (Spalteholz).

a-a Represents a borizontal plane passed through the body from the top of the symphysis.

b-b Represents the plane at which the section shown in Fig. II was cut

Anatomical Relations between the TJtekus and Rectum UNDER Normal Conditions.

While much may be learned about the relation between the uterus and rectum from dissections and a study of the conditions found at operations, nevertheless, a stiidy of cross sections of the pelvis probably indicates this relation more clearly than any other method. Fig. II is a drawing made from a cross section of the pelvis of a woman 30 ( ?) years old. The section is indicated by the line b-h. Fig. I, and is higher on the right than on the left side. Fig. Ill is a reconstruction made from the sections made in this ease, and line V indicates the section from which Fig. II was drawn. In this case the rectum was situated in the left side of the pelvis and one can see that the relation between the two is dependent on the position of the uterus in the pelvis and that in this instance nearly

Jdne, 1904.]

199

the entire uterus is situated to the right of the rectum. As the uterus under normal conditions is a relatively freely movable organ, it adapts itself to the space in the pelvis in which there

each ureter, as far as the fixed structures are concerned, as, for instance, the walls of the pelvis in Fig. II, is the same for each, but that their relation to such structures as the uterus

Ltvafor- ant

Venous Jit ttuii ''«> Vcijtnalatit/ vtficcilj

\; - ^

OoUyUss Cul-cie-sac

Jcji o^ Coccyx

.Venous /iltxus (u^e>-ine.,

/y, Va^ifjalaiirt htsifal)

6 rea d alia yf iy ^^oea'e/i

litems.

Fig. II.

Anf-f^oH line. 6/see'fi lit jjelvis

1. Section representeu by the line b-b.

»

-Cross Section of the Pelvis of a Multipara 30 (?) Years Old,

Fig. I, AND V, Fig. V.

Uterus is in retroposition, adherent, and in the right side of the pelvis.

Notice what an important factor the position of the cervix in the pelvis is in determining what tissue may be invaded by an extension of carcinoma cervicis uteri. The relation of the uterus to other structures in the pelvis is dependent on the position of the uterus in the pelvis.

is the most room and its position in the pelvis is in a measure determined by the position and size of the rectum. By referring to Figs. II and III again one may see that the coiirse of

and rectum is dependent on the position of the uterus and rectum in the pelvis. So the relation between the uterus and the rectum is dependent on the position of the uterus in the

200

[No. 159.

l)elvis whether in the right or left lateral position, and also whether forward or in retroposition and whether high in the pelvis or in descensus. A study of sagittal sections of the pelvis also aids in understanding the relation between the two organs. A line bisecting the uterus shown in Fig. Ill would cut the rectum only below the cervix, while a line bisecting the pelvis would bisect the rectum at the level of the top of the uterus, but at the level of the internal uterine os it would almost serve as the boundary line between the uterus, which is in the right side of the pelvis, and the rectal pouch,

rated from the rectum by the cul-de-sac with its uterine and rectal peritoneal lining and in descensus the posterior vaginal wall is interposed between the two organs. In addition, there is adipose tissue between the anterior rectal wall and the vagina and rectal peritoneal covering of the cul-de-sac. The amount of this adipose tissue varies in different cases, as can be seen by comparing Figs. II and IV.

A result of these anatomical studies shows that a direct invasion of the rectum by carcinoma cervicis uteri must extend either through the cul-de-sac, which may have become

Vertical lin <

II

Fio. III. — Reconstkuction Showing the Relation between the Cekvix and Othek Pelvic Stkdctures, from Cross

Sections of tfe Pelvis op a Multipara 30 (?) Years Old, x 1. ReoonstructioD from cross sections of the pelvis of a woman, with the uterus in retroposition, adherent, and in the right side of the pelvis. Fig. II represents one of the cross sections. One may see what an important factor the position of the uterus in the pelvis is, in determining the relation between that organ and other pelvic structures, and what structures are likely to be flrst Involved in a direct extension of the growth.

which is situated in the left side of the pelvis. The posterior surface of the uterus is covered by peritoneum and the reflexion of this peritoneum over upon the uterus forms the bottom of the so-called cul-de-sac of Douglas. The bottom of this cul-de-sac is situated at a lower level than the lower portion of the cervix when the uterus is in its normal position, and as is well known the peritoneal cavity can easily be opened by an incision through the vaginal vault posterior to tlie cervix (see Fig. IV). While there is a relatively broad attachment between the bladder and cervix anteriorly, the cervix is sepa

obliterated by adhesions, or indirectly through the vaginal wall, which may have become involved by the growth, or else the parametriiun of one side, which may be situated directly in front of the rectum, as the left parametrium is situated in Fig. II.

Relation betayeen Carcinoma Cervicis Uteri and the

Eectum.

It is difScult to understand why the growth in one ease may extend in a certain direction, while in another case the direc

June, 1904.]

JOHNS HOPKINS HOSPITAL BULLETIN,

201

tion may bo differpnt. In one specimen the growth may be confined to the anterior portion of the cervix, the bladder soon becoming involved ; on the other hand, in another case the posterior portion of the cervix may be involved and the rectum may soon become invaded. There seem to be as many types of the direction in which the growth may extend as there are possibilities. We are unable to determine why the direction of the invasion of the growth may vary in different cases. The most important factor, aside from the direction of the growth, in determining the parts involved by the extension of the .growth, is the position of the uterus in the pelvis. By referring to Figs. II and III, where the uterus is in adherent retroposition in the right side of the pelvis, one can see how easily the right ureter could become involved by the growth, while the growth would have to be verv extensive in order to com

FiG. IV. — Sagittal section showing the relation between the

UTERUS AND rectum, x 1.

From autopsy specimen. Pelvic contents were removed in one mass and then hardened in formalin. Notice the large bladder attachment and that the cervix is separated from the rectum by the cul-de-sac. Carcinoma cervicis uteri must reach the rectum either through the obliterated cul-de-sac or through the vagina, which may become involved (see Figs. V and VI).

press the left ureter. The rectum could be involved by the extension of the growth to the left, either through the cervix or indirectly through the vagina or left parametrium. On the other hand, when the uterus is in the left lateral portion of the pelvis or in anteposition, its relation to surrounding parts has chaugcd, and so the portions of the pelvis invaded may be difEerent.

In Fig. V is represented a sagittal section of a specimen (Gyn. Path. No. 7419) in which the growth in its posterior oxtension has obliterated the cul-de-sac anil invaded the tissue

to the right of and also anterior to the rectum. The uterus was in retroposition and in the right side of the pelvis, as in Figs. II and III, so that the posterior extension of the disease for the most part after obliterating the cul-de-sac invaded the adipose tissue lateral to the rectum.

Fig. VI (Gyn. Path. No. 7370) represents how the vagina may become involved and the growth in its posterior extension may invade the rectum. The vagina is separated from the rectum by a layer of adipose and fibrous tissue and the thickness of this layer varies in different cases, depending on the amount of adipose tissue. In some cases it is very thin, while in other cases it is quite thick, as in the specimen shown in Fig. IV. When the growth has invaded the vaginal wall there is very little to hinder its invasion of the wall of the rectum.

Fig. v. — Sagittal section of cancerous uterus, showing now the

GROWTH MAT EXTEND TOWARDS THE RECTUM THROUGH THE OBLITERATED cul-de-sac, X 1. Gtn. No. 11193, Gtn. Path. No. 7419. The growth has involved both the anterior and posterior walls of the cervix and in its extension posteriorly has obliterated the cnl-de-sac and invaded the adipose tissue anterior and lateral to the rectum.

Effect of the More Kadical Operation' for Carcinoma Cervicis Uteri on the Eectum.

In removing the uterus with the upper portion of the vagina, the anterior wall of the rectum is exposed, the amount of surface varying with the length of the vagina removed. Ordinarily the rectum is not injured by this; occasionally it is torn or a hole is cut into it by scissors or knife, but usually the vagina may be separated from the rectum through the adipose tissue between the two parts without inflicting any injury upon the rectum.

Recently I removed the uterus with pelvic lymphatics from a patient (Gto. No. 11192) in whom the growth had extended

202

[No. 1.59.

posteriorly, obliterating the cul-de-sac as high up as the level of the internal os (see Pig. V). The uterus was in retroposition in the right lateral part of the pelvis, the rectum being in the left lateral portion of the pelvis. The growth in its posterior extension had invaded the adipose tissue lateral to the rectum and in order to obtain a wide excision of the growth the adipose tissue about the wall of the rectum near the growth was removed, together with the uterus. The result of the above was that the right side of the wall of the rectum was exposed in places injuring its outer muscular coat. The convalescence of the patient was uneventful until

Fig. VI. — Sagittal section op cancerous dtekus, showing how the growth may extend towards the rectum through the i'osteuior vaginal wall, which is involved by the growth; x 1, Gyn. No. 11134, Gyn. Path. No. 7370. The growtli is restricted almost entirely to the posterior wall of the cervix. The cul-de-sac is intact, but the growth has extended out to the peritoneum, covering the anterior surface of the cul-de-sac. This drawing shows how tlie rectum may become invaded by the growth, which has involved the posterior vaginal wall.

the sixth day. The gauze drains, two in number, whicli extended from each side of the pelvis out through the vagina, had been started on the third day and complctoly removed on the fourth and replaced by fresh ones. On the morning of the sixth day the patient's temperature rose to 103°, but there were no subjective symptoms. The patient was placed in the

elevated Sims position and the vagina exposed by a Sims speculum. On removing the gauze drains in the right side an opening about 1 cm in long diameter was seen in the right side of the rectal wall, from which there was a discharge of fecal matter. At the present time. May 4, the opening still exists, and unless it heals spontaneously an attempt will be made to close it.

Bearing of the Above on the More Radical Operations FOR Carcinoma Cervicis Uteri.

A wide excision of the primary growth is most important in all forms of cancer and especially so in cancer of the cervix, for it soon invades the surrounding parts. While one wishes to avoid injury to the rectum, the first requisite is to remove the growth. It is most important to determine before operating the position of the uterus in the pelvis and its relation to surrounding parts. If the cervix is in the right side of the pelvis and fixed, and the rectum is situated to the left, one may see how easily the rectum could be involved by the extension of the growth either through the cervix to the left or through the left parametrium, which may have become involved by the growth (see Fig. II). By making a careful bimanual examination before the operation a definite plan may be formulated, and one may know just where a wide excision is needed most.

A very good plan is to insert a rectal tube in the rectum just before the operation and let it remain there during the operation. This serves two purposes : first, it gets rid of any fecal matter or gases which may be present and keeps the rectum empty during the operation ; second, it is easilv palpated during the operation and serves as a means of locating the rectum, in the same manner as the renal catheter does the catheterized ureter.

At the close of the operation the peritoneum which is reflected from the rectum over the bottom of the cul-de-sac should be sutured to the posterior vaginal wall in order to cover the raw area thus exposed. The operation ° has been described fully in a previous publication.

Conclusions.

1. The relation between carcinoma cervicis uteri and the rectum may manifest itself in the recto-vaginal fistulas which result from a necrosis of the growth which has involved the rectum in the posterior extension of the disease, and also in accidental injuries to the rectum occurring during hysterectomy for the disease.

8. The relation between the uterus and the rectum varies under different conditions and is dependent on the position of the uterus in the pelvis, whether in normal antepositiou or retroposition, and especially the left and right lateral positions of the uterus. Descensus of the uterus also changes the relation between the two organs. The position of the uterus in tlie pelvis is a most important factor in determining what surrounding tissue may be invaded in the extension of the growtli from the cervix.

June, 1904.]

203

3. The rectum may be invaded by a direct extension of the growth either through the cul-de-sac, the two surfaces of which have become adherent, or the posterior vaginal wall may become involved and the rectum secondarily invaded from the vagina, or in the lateral positions of the uterus the gron-th may extend across the obliterated cul-de-sac from the parametrium which lies in front of the rectum and which may have been invaded by the gro'n'th.

•1. The first demand in the more radical operations for carcinoma is a wide excision of the primary growth, and portions of the rectal wall may be sacrificed and repaired if involved by

the growth.

Eeferexces.

1. Sampson: Ligation and Clamping the Ureter as Complications of Surgical Oi^erations. American Medicine, 1902, IV, 693-rOO.

2. • The Importance of a More Eadical Operation in

Carcinoma Cervicis Uteri, as Suggested by Pathological Findings in the Parametrium. Johns Hopkins Hospital Bulletin, 1902, XIII, 299-307.

3. The Advantages of the Sims Posture in Cysto

scopic Examinations. Johns Hopkins Hospital Bulletin, 1903, XIV, 194-196.

4. Ascending Renal Infection; with Special Reference to the Reflux of Urine from the Bladder into the Ureters as an Etiological Factor in Its Causation and Maintenance. Johns Hopkins Hospital Bulletin, 1903, XIV, 334-352.

5. The Efficiency of the Periureteral Arterial Plexus

and the Importance of Its Preservation in the More Radical Operations for Carcinoma Cervicis Uteri. Johns Hopkins Hospital Bulletin, 1904, XV, 36-46.

6. The Relation between Carcinoma Cervicis Uteri

and the Ureters, and Its Significance in the More Radical Operations for that Disease. Johns Hopkins Hospital Bulletin, 1904, XV, 73-84.

7. Complications Arising from Freeing the Ureters

in the More Radical Operations for Carcinoma Cervicis Uteri, with Special Reference to Post-Operative Ureteral Xecrosis. .Johns Hopkins Hospital Bulletin, 1904, XV, 123-134.

8. The Relation between Carcinoma Cervicis Uteri

and the Bladder, and Its Significance in the More Radical Operations for that Disease. Johns Hopkins Hospital Bulletin, 1904, XV, 156-162.

OBSEllVATIONS OX A STUDY OF THE SUBCLAVIAN ARTERY IN MAN.'

By Robert Bexxett Beax, M. D., The Johns Hopkins Medical School.

The work on which these observations are based was undertaken at the suggestion of Dr. Harrison and carried out under the direction of Dr. Mall, in the anatomical laboratory of the Johns Hopkins University. The dissections were made by the students working in anatomy, and some of the drawings were made by them, but nearly all of the drawings were made by myself on Bardeen's Outline Record Charts.' One hundred and twenty-nine dissections of the subclavian artery were recorded, but fourteen of these were so incomplete as to be of no service in summarizing the work. Eighty per cent of the dissections were made on negro subjects. The arten' was found to be divided naturally into five types, depending upon the origin of the large branches. The distribution of these branches was practically the same in all cases.

Type I was found in thirty per cent of the cases, and showed the internal mammary artery, rising from the first part of the subclavian, the vertebral rising from the first part of the subclavian, and the inferior thyroid and supra-scapular arteries rising from a common trunk which came of? from the first part of the subclavian artery; also, the costo-cervical trunk arose from the second part of the subclavian artery.

' Abstract of a paper read before the Johns Hopkins Hospital Medical Society, March 21, 1904.

- A complete study of the subclavian artery will soon be published in the American Journal of Anatomy.

and so did the transverse cervical artery. This type was present on the right side of the body in twenty-two per cent of the subjects and on the left side of the body in eight per cent.

Type II was found in twenty-seven j)er cent of the cases, and showed the same origin for the vertebral and internal mammary arteries as Type I. The inferior thyroid, suprascapular and transverse cervical arteries rose from a common trunk which came off from the first part of the subclavian artery. This is the th^Toid axis as usually given. The costocervical trunk arose from the first part of the subclavian artery. This type of the artery was found on the left side of the body in twentj--two per cent of the subjects, and on the right side of the body in five per cent. In the three remaining types the vertebral and internal mammary arteries and the costo-cervical trunk arose from the first part of the subclavian artery as in Type II.

Type III was found in twenty-two per cent of the cases. In this tj'pe the inferior thyroid artery arose from the first part of the subclavian artery, the transverse cervical arose from the second part, and the supra-scapular from the third part. This was the most irregular of all the types. The supra-scapular artery arose from the axillary artery eight or nine times.

Type W was found in twelve per cent of the cases. In

204

[No. 159.

this type the inferior thyroid artery arose from the first part of the subclavian artery. A trunk arose from the inferior tliyroid artery and divided near the outer side of the neclv into supra-scapular and transverse cervical arteries.

Type V was found in ten per cent of the cases. Tlie inferior thyroid and transverse cervical arteries arose by a common trunk from the first part of the subclavian artery in this type. The supra-scapular artery arose from the internal mammary artery about tvco inches below the origin of the latter, and passed above the first rib, and anterior to the scalenus auticus muscle to its normal distribution. Arthur Thomson ' tabulates five hundred and forty-four dissections of the subclavian artery. Classifying these in the same manner as our own cases, we get the five types with percentages as follows: Type I, forty-four per cent; Type II, forty-one per cent; Type III, seven per cent; Type IV, six and onehalf per cent ; Type V, one and one-half per cent.

Four anomalies were encountered freqxiently in the course of this work, and they are given in detail below because they may be important from a practical point cf view. A " lateral thoracic artery " was found five times in twenty-eight subjects where the internal mammary artery was worked out in full. Many of the subjects were dissected after autopsies had been held, and in these the internal mammary artery had been destroyed, hence, the small number obtained. This " lateral thoracic artery " was as large as the internal mammary artery and arose from the latter beneath the first rib, and passed between the ribs and pleura to the diaphragm, sometimes ending about the fourth rib, and sending branches into each intercostal space, its distribution being similar to the internal mammary artery. This anomaly may be of interest clinically in cases of fractured ribs, in resection of ribs or in tapping the pleural cavity. From the position of this artery the indication would point to some posterior part of the thora.x as the place of election for entering the pleural cavity with a trochar, rather than going in anteriorly about the sixth rib.

The second anomaly is Type V, which was found twelve times in one hundred and fifteen cases. Quain * found it present four times in two hundred and sixty-four eases (two per cent), and Arthur Thomson found it nine times in five hundred and forty-four cases (one and one-half per cent). This anomaly should be borne in mind when doing a complete breast operation, or in any operation near the sternal end of the clavicle, or the first rib.

The third anomaly is the middle thyroid artery or " artcria thyroida inia." This was found three times coming from the innominate artery, and, passing to the median line, it supplied the lower lobes of the thyroid gland and the isthmus. Wenzel Gruber' records one hundred and twenty-five anoma

" Second Report of the Collective Investigation of tlio Anatomical Society of Great Britain and Ireland. Journal of Anatomy and Physiology, Vol. 26.

' Commentaries on the arteries, London, 1844.

'Virchow's Archiv., Vol. 54.

lies of this kind, and concludes that the artery rises most frequently from the innominate artery, but also comes from the aorta and the common carotid artery not infrequently. He found it sixteen times in one hundred consecutive dissections. The anomaly should be considered in doing a tracheotomy, in operations on the thyroid gland, and in operations about the manubrium.

The fourth anomaly is the right subclavian artery coming from the distal part of the aortic arch, and passing between the oesophagus and the vertebral column at the third or fourth vertebra, finally going to its normal place above the first rib on the right side. Associated with this anomaly the two carotids arose together as the first branch of the aorta and the left subclavian arose as the second. Beyond this the right subclavian artery arose. The right recurrent laryngeal nerve did not form a loop around the subclavian artery, but passed directly to its normal distribution. This anomaly should have clinical consideration in relation to aneurism, especially with associated " dysphagia lusoria," or slow starvation, in diverticula of the oesophagus, carcinoma of the oesophagus, foreign bodies in the oesophagus, operations on the oesophagus, caries of the vertebrse (Potts' disease), scoliosis," osteosarcoma of the vertebrae, heart disease (possible cause), small pulse on the right side, left-handedness ("causa anatomica"), operations on the tliorax, ligations of arteries, and in bronchotomy in those rare instances in which the artery passes anterior to the trachea. The anomalous artery in its course fairly hugs the trachea and oesophagus, completely encircling them with an arterial band by crossing the right carotid artery Just before passing over the first rib. This causes constriction of the trachea and oesophagus, with bulging of the two, on the one hand, and constriction of the right subclavian artery with dilatation of the latter, before it passes beyond the vertebrse. on the other. Gotthold Holzapfel' collected two hundred cases of this anomaly, including four of his own, and found dilatation of the artery in sixty-four per cent of the cases. Six of the cases had a funnel-shaped dilatation, and six showed a blind sac or pouch at the beginning of the artery, evidently aneurism. In the two cases found in the course of my work one was dilated, and in six other cases found in the literature besides the two hundred cases referred to above, one was reported to be dilated, no mention of dilatation being made in the other cases. Quain found this anomaly present four times in one thousand cases. Holzapfel considers it to be present six times in every thousand, while Tiedemann believed it occurred eight times per thousand. Holzapfel gives the following among many conclusions :

The anomaly is one of origin, of direction and of distribution ; it arises about the second to fourth vertebra, also from the thoracic aorta lower down occasionally, and passes between the oesophagus and vertebral column (one hundred and seven

"Brent: The Lancet, 1S44. ' Anatoniische Hefte, 1897.

June, 1904.]

205

times), seldom between the oesophagus and trachea (twenty times), and rarely in front of the trachea (six times) ; was found sixteen times in persons beyond the age of fifty years; occurs in normal and abnormal individuals (anatomically) ; the right recurrent laryngeal nerve goes directly to the trachea, without its normal loop ; the thoracic duct is transposed to the right side at times; the pneumogastric and phrenic nerves are not influenced, and the large veins have their normal distribution ; the anomaly does not cause lef t-handedness, and dysphagia comes only with aneurism. Three eases of " dysphagia lusoria " have been reported in connection with this anomaly : One by Bayford ' in which a patient sixty-one years of age, who had been suffering with difficult deglutition throughout life, died from inability to swallow. Another by Autenrieth and Pfleiderer,' in which a woman about sixty years of age died of slow starvation. A third by Brewer '° of simple dysphagia. All of these cases were associated with aneurism of the anomalous right subclavian artery at its origin. A case of erosion of the vertebra and aorta was reported by Picard," in which the aorta passed between the oesophagus and vertebrae. A case of sudden death from swallowing a large mouthful, resulting in rupture of this anomalous artery is reported by Kirby."

Three eases of heart disease associated wtth the anomalv

' Memoirs of the Medical Society of London, 17S9, Vol. II.

'Reil's Archiv fiir die Physiologie, 1S07.

" Journal de Chirurgie de Desault, Paris, 1791.

" Bulletin de la Societie Anatomique de Paris, 1840.

"Dublin Hospital Reports, ISIS, Vol. II.

have been reported, one by Walter," in 1785; another by Froudsen," in 1854, and a tliird by Schon," in 1833.

Two cases of the anomaly in left-handed individuals were reported by Oehl.'° Four cases have been reported in righthanded individuals.

Conclusions.

1. The subclavian artery may be arranged into five definite types according to the difference in origin of the large branches.

2. The artery differs on the two sides of the body. Type I being normal for the right side, and Type II for the left side.

3. Type I, without the thyroid axis as given in the anatomies of Quain and Gray, is the normal arrangement.

4. Type II, with the Thyroid axis is found fewer times than Type I.

5. Eighty per cent of the dissections were made in negro subjects, a large number of whom may have been mulattoes or mixed bloods. That hybrids tend toward variation is a wellknown biological law. This may explain the large number of abnormalities encountered.

6. Four of the abnormalities are worthy of note : The lateral thoracic artery. Type V. The middle thyroid artery (" thryroidea ima ") . The anomalous right subclavian artery.

7. These abnormalities may be of some clinical significance.

" Nouveaux Memoirs de I'academie royale des sciences et belles lettres, 17S5.

"Thesis: Arterise subclavise dextrae originis abnormis acdecursus Casus, Kiel, 1854.

'"Thesis: Dissertation de nonnularum arteriarum ortu et decursu abnormi, Halle.

"Hyrtl's Topographlsche Anatomie, Zweite Band, 1882.

THE BLOOD IN PREGMNCY.

By William Lawton Thompson, M. D., From the Obstetrical Department of the Johns Hopkins Hospital.

From the time of Morgagni the constitution of the blood during pregnancy has been a subject of interest to many investigators and lias given rise to a great deal of discussion, which unfortunately has not led to uniform conclusions, even in the hands of those working with modern methods.

Leaving out of consideration the old theories as to plethoric and chloransemic conditions of the blood, the more recent work upon the subject may be roughly classified in three groups :

1. An undoubted diminution in the amount of hfemoglobin and the number of red cells (Couvert, Wicolks, Wiskeraan, Fouassier, Kosina and Ekert, Ingerslev, Meyer, Dubner).

2. A diminution in the number of red corpuscles with a simultaneous increase in the amount of haemoglobin (Cohnstein and Fehling).

3. Ko change (Korniloff, Ehrlich and Limbeck) ; while

Eeinl, Lebedeff and Schroeder hold that the constitution of the blood depends upon the general health of the individual, being poor in red cells and hsemoglobin where the patient is feeble, while it is tmchanged in normal individuals.

With regard to the leucocytes. Since Moleschatt and Nasse, the fact that pregnancy leads to leucocytosis has been constantly observed and confirmed. (Paterson, Maurel, Isambert, Spiegelberg, Fouassier and Mallasez, Halla, Kosina, Ekert, Mochnatscheft", Limbeck, Eieder and others.) This was referred by some to a hypertrophy of the groups of lymphatic glands lying in the neighborhood of the genital apparatus, while others (Wyder, Leopold, Johnstone) referred it to the lymphoid tissue of the endometrium. Mochnatscheff distinguished further differences between the blood drawn from the finger-tip and that taken from the cervix, aud explains this difference by a process of irritation of the womb

206

[No. 159.

whereby a leucocytosis takes place. He concludes that this undoubtedly causes the remarkable increase of colorless elejnents preceding delivery.

Eieder, who performed the largest series of observations, and who examined the condition of j^regnant women after a fourteen to sixteen hours' fast, was able in only a small number of multiparas to note a lack of increase in leucocytes; 21 out of 31 showing unmistakable leucocytosis. He is the only one of the observers who has studied in two cases the differential forms of leucocytes, as distinguished by Ehrlich, and vrhose figures agree with one another. He reckoned the average leucocytosis as 13,000, with a maximum figure of 16,500 and a minimum of 10,300. Others, as Mochnatschefi', place the maximum at 14,000.

Hahl concludes that during the last days of pregnancy the leucocytes are somewhat increased, that with the onset of labor pains a comparatively marked leucocytosis begins ; this hyperleucocytosis (which is characterized by an increase of polymorphonuclear neutrophiles) is markedly diminished during labor, and usually during the first week of the puerperium a return to normal takes place.

Hubbard and White found a polymorphonuclear leucocytosis in 80 per cent of their 55 cases. Their averages 24 hours before labor were for primipara 15,000, for multiparEe 11,700.

As to the theories of a leucocytosis in pregnancy, Virchow referred it to a widening of the uterine and abdominal lymphatic vessels and nodes, and the increase of metabolism in the uterus and its contents. Limbeck supposes it to be due to changes in the breasts, viz. : the round-cell infiltration which many such glands show as an indication of a very active cellular process. Ewing concludes that " considering the behaviour of leucocytes in general, it is hardly surprising that the active cellular processes in breasts, uterus, vascular system and foetus and the associated increase of metabolism should, •when instituted for the first time, find a sympathetic excitement in the blood-producing organs."

With reference to the specific gravity of the blood, Nasse •concludes from his observations on the blood obtained by venesection from 67 pregnant women that the decrease in specific gravity is not marked. Ijloyd Jones confirmed these results, while he found in children and pregnant women the lowest figures and denjonstrated a rise of specific gravity during the act of labor. While Lebedeff admits a falling off of "blood gravity in pregnancy, Blumreich could establish no reason for it. According to Jones and Hammerschlag, who had proved a quite constant relationship between the decrease of specific gravity and that of the hajmoglobin and the count of red blood corpuscles, it must be concluded that corresponding to the drop in specific gravity, a diminution in red blood cells also takes place during pregnancy.

Zangemeister, who carried on observations upon women in the last two months of pregnancy, noted a diminution in specific gravity which he attributed to a loss in certain salts of the blood.

Among the most recent works on the subject of the blood in pregnancy is to be mentioned that of v. Eosthorii, wlio (juotcs

the results of Payer with the conclusion that the blood of pregnancy has a normal number of red blood corpuscles, normal hifimoglobin, moderate leucocytosis, somewhat lessened native allcalinity, and normal molecular concentration. Pray finds a diminution of 80,000 red cells, with an increase of hsemogiobin and a hyperleucocytosis.

Observations.

In view of the unsettled state of this question, and in an endeavor to clear away some of the doubtful points concerning the blood state of pregnancy, we began observations on the blood of pregnant women in the Obstetrical Department of Johns Hopkins Hospital under the auspices of Dr. J. Whitridge AVilliams, to whom we wish to express our thanks for extending to us the courtesies of his department and for his many helpful suggestions and lively interest in this work.

The series includes 12 cases (11 colored and 1 white patient). The women were all of the poorer class, but are living under practically the same hygienic and dietary conditions, suffering from no constitutional disease and having no special pathological affections.

The observations cover a period of seven months, from October, 1903, to Ma}', 1904. Each patient was examined once a month from the time she was first seen until the present date. Two of the cases first came under observation at the second month of pregnane}'; two at the third month; four at the fourth month ; three at the fifth ; while the remaining case was not seen until the sixth month.

Four of the cases have been followed throughout their pregnancy and subsequent delivery, while the other eight are still under observation.

The monthly blood examination of each case includes (1) enumeration of red blood corpuscles, (2) estimation of hsemogiobin percentage, (3) count of leucocytes, (4) differentiation of leucocytes, and (5) determination of specific gravity of the total blood content.

The series comprises 33 separate blood examinations, each examination including 5 parts, or a total of 165 various estimations, whose results are as follows:

(1.) Eed Blood Corpuscles.

The blood drop was in each case taken from the lobe of the ear, the Thoma-Zeiss instrument was employed and the blood diluted 200 times with Toison's solution. Out of a total of 33 cases, the average count in the —

2nd month equalled 5,500,000 red blood cells.

3rd " " 5,600,000 "

4th " " 4,300.000 "

5th " " 5,000,000 "

6th " " 4,600,000 "

7th " " 4,700.000 "

8th " " 4,900,000 "

9th " " 5,800,000 "

The following table gives the figures in detail for each moufli from tlio 2ud to the 9tl) inclusive:

JnNB, 1904.]

207

Oases, i, Sd mo.

No. I

8 9 10 II 12

B,B08,oooi .... !4,71fi.non' ... ! .... 4.fi20.nno' ....

3,4.S(I,1«KI o.SiU.IMII 4.III1»,IKIU 4..>(.ss,(10(l 4 410.00(1

4,4»0,l»K) f),4.S(l,tHHI r>.(«S.OlXI .",,.",'.12.000 4,;«2,000

.... I 4,aOO,lXK) 4,4S.H,(KKI ;t,!l4K.lKX) ....

... ' .... I .... 4,8T6,(KXI o.lM.OIX) 4,(104,000 5,616,000 B,87B,000

5,520,000.5,208,000 ....

.... 4.li28.IKX) 4,800,000; 5,3.S4,000 ... I

.... 7,0(k'<,000 5,464,00(1 .... ' .... '

4.644.000 4,948,000

5,164,000, . . .

4,0li«,000| .... .... 4,540,000 ....

Averages : 6,514.000, 5,614,066| 4,347,3331 5,018.857 4,680,000 4,766,666 4,996,000; 5,876,000

It is clear that in our series the count is high at the extremes of pregnancy (5,500,000 at the second and third months and 5,800,000 at the ninth month) while it is somewhat lower in the intermediate periods — ith to 8th months inclusive — dropping to 4,300,000 at the 4th month, then rising irregularly to reach 5,800,000 at the ninth month. It will be seen from

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the average curve (Chart I) that this drop after the beginning of pregnancy with a low intermediate value and an irregular rise as labor comes on, is quite well marked. By reference to the above table of figures it will be seen that cases No. 1, 4, G and 8 show the initial drop, while case No. 5 shows the terminal rise in red blood corpuscles.

(3.) HiEMOGLOBIN.

As in the case of the red cells, the drop was drawn from the ear and the computation made with Gowers' apparatus, which was standardi/.od against a new Miescher instrument, the two instruments recording the same. The figures obtained (percentages) are shown in detail in the following table:

Cases.

iid mo.

3

4

5

6

7

8

9

No. 1

70

6.5

55

,

2

55

80

55

83

65 80

70 72 80 90

3

4

60

60

65

5

70

65

60 90

85

6...

65

f,5

7

60

65

82

8

7.5

••

60

60

70

9

10

70

11

. .

70

12

..

55

Averages:

67.5

66.7

65

66.3

66

68.8 84

85

The haemoglobin, therefore, as early as the 3nd month of pregnancy is low, continues at this level (65 to 67 per cent) until the 7th month, when it begins to increase, until at the 8th and 9th months it has risen to 85 per cent — a gain of nearly 20 per cent.

(3.) Leucocytes.

Cases.

2d mo.

3

4

5

6

7

8

9

No. 1

11,650 12,600

11.200

10.640

2

.. Il,'2o0'l0.050i 9,960 9,1.50 13,250

10,'

3

. . 10.9.50

11,080 9,250 8,400 13,200 8,5.50l 5,4801 7,600 .. 8,950,10.000; 7,666: 7,050

4

5

12,700 11,000

11,100 11.500

rso

6

8', 132 11,400

9,500

7

9,100

8

9

10

n

12

. . 10,200

Averages:

12,125

11,850 11,033

9,693

8,838

8,759 11,166

10,750

For determining the leucocytes, a blood drop was taken from the lobe of the ear, avoiding pressure, diluted 20 times with Toison's solution, and the leucocytes counted with the Thoma-Zeiss apparatus.

As is seen by the table, in only one of the 33 counts were the leucocytes below 7,000. The minimum was 5,400, the maximum 12,700, while the average was about 9,000.

In only the one case did the leucocytes reach the normal mean standard of 5,500, while most of the cases had a leucocytosis of 10,000 to 12,000. A leucocytosis in any given case is always relative, not to a fixed standard, but to that individual in health. Now, if we take 5,500 as the mean normal number of leucocytes, it will be seen, by referring to the above table, that, not only do all our cases present a leucocytosis relative to the average woman, but, with Grawitz' standard of 10,000 as the criterion, the majority of them, in the diflFerent mouths of pregnancy, show a slight absolute leucocytosis.

208

[No. irjo.

(I.) Differential Count of Leucocytes.

Smears wcru prepared by allovviiig a small drop of lilood to fall upon a cover slip which was l)roughl in cnntaet, with another slip, the two being then drawn rapidly apait and the thin smear of blood dried in the air. They were then stained with Wright's modification of Leischmann's stain. Thirteen differential counts were then made, and in each instance 500 cells were studied, the results being given in the following table:

Cases.

Polymoi phonuflear

neutrophili-s.

Small mononuclears

Large mononuclears

Eosinophiles.

No. 1

364 419 387 426 343 410 357 380 397 300 310

85 51 88 47

103 49

110 92 85

147

1SS

48 23 32 26 53 20 33 38 17 53 46 45 28

3

2

4

3

3

4

1

5

1

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7

20

8

15

9

1

10

11

6

13

367 83

5

13

372

96

4

Averages

371

90

84

5

Percentages

74.2^

18^

6.8^

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small mononuclears are diminished about .5 per cent and the eosinophiles about 2 per cent from the accepted standard for these cells, but practically the differential count is normal.

(5.) Specific Gravity. The specific gravity was determined in 33 estimations.

The

gravity of the total blood content (not of its serum) was obtained. We followed the method of TIammerscthlag, using the benzol-chloroform mixture, and obtained the following figures for the several months:

Cases.

!

M mu.

3

4

5

6

7

8

9

No. 1

2

1057 1050

1051 1032 1052

1043 1054 1057

1035

1050 1046

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1045 1033

1030 1042 1043 1039

1050

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1053

1058

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10.50

3

4

5

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8

9

10

11

12

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1053.5

1045

1047.5

1041.5ll04U.8

1049

10.51.6

1053

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As will be seen from the above figures, the specific gravity is, as a rule, high in the early months of pregnancy, diminishes progressively in the ensuing months, to again rise to nearly

JONE, 1904.]

209

normal at tlie termination of the gravid state. In some cases the specific gravity decreases intermittently; in others (Chart ril, Case No. 33'.i2) the decrease is regular, while in all cases 'he gravity is subnormal. The initial fall and terminal rise can be traced in every ease.

If we take the average specific gravity of all the cases for each month, and plot a curve (Chart II), or if each case be examined by itself, the curve will be found the same in either instance — high at the beginning and end of pregnancy, low in the intermediate months.

Nasse, in 1853, pointed out that the blood gravity decreases rather early in pregnancy and rises somewhat at its termination, but he did not demonstrate any regularity in this respect, indeed he stated that the decrease is not marked.

Jones and Hammerschlag conclude that corresponding to the drop in specific gravity, a diminution in red blood cells also takes place during pregnancy. This corresponds with the results of our observations, as will be seen by referring to Chart I, where the curve of red blood corpuscles is shown.

Water enters so largely into the composition of the blood, and as it is, moreover, the most variable constituent, we should expect alterations of the blood gravity under ordinary conditions to be due largely to this factor.

The proportion of salts, on the other hand, is small, less variable, and hence less likely to effect any marked alteration 'n the specific gravity. Zangemeister, however, refers the low .specific gra\"ity to a loss of certain salts.

The albumens of the blood are the last principle to be affected by alterations of metabolism, and, as Ewing remarks, " when the albumens of tha blood are affected, marked and permanent changes result in its specific gravity."

That marked and permanent changes do occur in the specific gravity of the blood and that corresponding to this drop a decrea.se in red blood cells also takes place in pregnancy has been repeatedly demonstrated in our observations. It is possible that the reduction in specific gravity during pregnancy may be due to a decrease in the albuminous elements of the red blood cells.

Dieballa showed that a diminution of 10 per cent hsemo

globin corresponds to a drop of 4.4 'i p. m. specific gravity. Now, if the drop in haimoglobin was proportional to the fall in specific gravity, we might attribute the latter to the former, since, as is well known, the determination of specific gravity is a well-recognized method of determining the hucmoglobin.

Our results, however, tend to show that the haemoglobin is proportionately higher than the specific gravity of the total blood content (as in Case 3322 shown in Chart III), the drop in haemoglobin being only 20, while the drop in specific gravity was 24. It is evident, therefore, that the drop in specific gravity is not due to the drop in hsenKiglobin.

Slemons, in a recent contribution, has shown that the organism, under the influence of pregnancy, stores much more water than at other times, and, moreover, that, preceding labor, a marked diuresis occurs.

In view of Siemens' findings, we are inclined to believe that the low specific gravity of the blood in pregnancy is due to an admixture of water in the plasma — a serous dilution or hydrsemia, and that the terminal rise in specific gravity as labor approaches may possibly be due to the marked diuresis which occurs at that time.

Conclusions.

1. A moderate di^crease is observed m red blood corpuscles rather early in pregnancy, remaining subnormal throughout the middle mouths, to rise again to normal at the termination of pregnancy — not, however, in all cases.

2. A low percentage of haemoglobin, constant throughout the first seven months, rapidly approaching normal as pregnancy draws to a close.

3. A slight absolute leucocytosis exists in every case of pregnancy, but this slight leucocytosis does not support the theory that it is due to any positive chemio-taxis.

4. There is no variation from nomial in the different forms of colorless corpuscles, the leucocytosis affecting all forms of white cells alike.

5. The specific gravity is high at the onset of pregnancy, diminishing by progressive steps, to reach its lowest level in the middle months, rising to normal at term.

A CASE OF GENERALIZED LEAD PARALYSIS. WITH A REVIEAV OF THE CASES OF LEAD

PALSY SEEN IN THE HOSPITAL.

By Henry M. Thomas, M. D., Clinkal Professor of Neurology, Johns Hopkins University.

This patient, from Dr. Osier's ward, has interested us very nmch, because his condition is one of great rarity and because we have seen no exactly similar case. The patient was admitted Nov. 3, 1903. He is a man of 46, and has been at work as an enameller. The process employed in the factory ill whicli he worked is a secret one, but it is quite certain that tlie material used contains a great deal of lead. There is nothing else of importance in cither his family or personal historj', except in relation to his use of alcohol. He has been

a heavy drinker, taking several glassc-: of beer a day, as well as niore or less whiskey, and on Saturday nights, when he had the money, he was in the habit of drinking much more, u.sually going to bed drunk.

He had formerly worked as a stevedore, but last summer became an enamel worker, .\fter working at this new occupation for only two weeks, he noticed that he was becoming weak. This weakness showed itself first in his legs, but it increased and spread so rapidly over his body that in a little

210

[No. 159.

more than a week he hail become bed-ridden and helpless. He gives no history of having had any pain in his stomach or sharp pain in his legs or arms, but certain of the joints have been painful. His mother told us that soon after he took to his bed he wa.s for several days somewhat delirious. The patient was admitted to the hospital about two mouths after he had become paralyzed. Since then he has shown no sign of mental disturbance.

As yon see, the patient is a pale, sick-looking man. His blood count gives red blood corpuscles 3,736,000, white blood corpuscles 3,100, hfemoglobin 40 per cent. After repeated examinations, granular degeneration of the red blood cells was demonstrated. There is a typical lead line on his gums, and under the microscope Dr. Stevens has placed a section of a bit of the gum which shows very. well that the black

h

The picture which he presents is a very typical one of a severe multiple neuriti.s, but the interesting point is that this is apparently due to an intense intoxication by lead. The trouble came on a man (who, to be sure, has a strong alcoholic history) two weeks after he began to work in lead, and who now shows the evidence of lead poi-soning, the lead line and a granular degeneration of the red blood corpuscles. The paralysis has not the distribution that is typical of lead, but similar cases have been described by several authors under the title of " Generalized Lead Paralysis."

Note. — April 15, 1904. The patient has improved slowly and has recovered a considerable amount of power in the muscles about the shoulder-girdle and the hip-joint. His ansemia has decreased. There is considerable atrophy of the muscles.

sulphide of load is deposited in the substance of the tissue itself (see illustration) .

There is no involvement of any of the cranial nerves and an ophthalmoscopic examination showed the fundus to be normal. The muscles of his neck are fairly strong but below these nearly every mu.scle is completely paralyzed. There is slight power in the pectoral muscle, but nowhere else in the shoulder-girdle or arms. You will notice that his respiration is entirely thoracic, the diaphragm being completely inactive. The muscles of the trunk are also affected and in the legs the only motions that are left are slight flexion at the hip and feeble movements of the toes. The reaction of degeneration to the electrical currents is present in the paralyzed muscles. The deep reflexes are all lost. Sensation is everywhere acute. Firm pressure over the various muscle groups in the arms and legs causes pain. The right shoulder joint is somewhat swollen and painful. There is no disturbance in either the bladder or rectum.

I have examined the records of the hospital and the neurological dispensary and have found that 33 cases of lead poisoning have been admitted to the medical wards and 25 have been treated in the nervous dispensary. Four of these 58 cases were seen in both departments and we have therefore the histories of 54 patients. As would be expected, the cases entering the hospital are of very different character from those seen in the out-patient department. In the neurological dispensary we meet only with cases showing definite nervous symptoms, and see none of the cases suffering from the more common effects of lead poisoning, constipation, colic, etc., these cases being referred to the medical dispensary. The patients admitted to the wards are usually those who show the more intense form of gastro-intestinal disturbances, or have evidence of grave intoxication. Of the 33 hospital cases, there was no complaint of muscular weakness in 23; in 6 of these, however, some slight muscular involvement was discovered on examination, and in one case, complicated with

June, 1904.]

211

heart disease, a hemiplegia developed while in the hospital. In 10 cases there was definite motor paralysis.

Of these 10 hospital cases showing paralysis, 5 exhibited the usual form of lead paralysis, viz. : double wrist-drop. In one case the wrist-drop was confined to the right side; in the fonr remaining cases botli the arms and legs were more or less severely affected.

Of the 25 cases treated in the neurological dispensary, 23 of them complained of paralysis. Fifteen of these showed bilateral wrist-drop, 6 paralysis confined to the right arm, and in one it was confined to the left arm. In one case the paralysis was confined to the leg, in the distribution of the right esternal popliteal nerve; this last, however, is a doubtful case, as the paralysis developed in a painter after a long day's work in a squatting position, and the nerve may have been injured by pressure.

If we combine the records of the hospital and dispensary cases, deducting the duplicate cases, we have 31 cases of lead paralysis. Eighteen of these showed the typical distribution of paralysis in the form of double wrist-drop. In 7 the weakness was confined to the right arm and in one to the left, i. e.j the paralysis was confined to the arms in 26 cases. The arms and legs were involved together in 4 cases. The remaining case, in which the right leg alone was alfected, I think should be excluded.

We are particularly interested to-night in these four cases in which the paralysis affected the legs as well as the arms.

Case I (No. 2393) was that of a girl, five and a half years old, who was in the habit of eating the remains of food left in tin cans, and who had had weakness of her arms for three months. Two days before admission her legs became so weak that she was entirely unable to walk. There was a lead line on the gums ; knee jerks were normal. She remained in the wards only two days. It is worthy of note that this is the only case of suspected lead poisoning that we have had in a child, and it agrees with the statement of some authors that in children the legs are particularly apt to be affected.

Case II (N"o. 2617), a tinner, 42 years old, was admitted on account of paralysis of his legs, which had come on suddenly eight days before. There was marked wealmess of his legs and to a less extent of his arms. Deep reflexes were absent. No lead line was discovered, and there seems to have been loss of control of his rectum, which facts throw doubt upon the diagnosis.

Case III (No. 11,733) was a painter, 43 years old, with a history of many attacks of colic and weakness of his arms for several years. He was admitted on account of pains in his arms and legs. There was definite, although not great, loss of power in the muscles of his legs, as well as in his arms. His knee jerks were exaggerated; there was a distinct lead line.

Case IV (No. 13.757) is of particular interest, as it shows an intense degree of intoxication. The patient was a man, 28 years old, an enameller by trade, as is the patient now before you, and had worked in lead for eight years. He came to the neurological dispensary with the history that two

months before he had had an attack of unconsciousness and that six weeks after this had begun to suffer from headache and weakness of wrists. He then developed pain in his knees. He kept on working for a week, his wrists becoming weaker and his legs becoming numb and weak. He then had severe colicky pains in his stomach and began to vomit. This persisting, he entered the hospital on the second day. He was evidently very weak and ill and was at once sent to the wards. There was a general weakness of arms and legs with well-marked wrist- and ankle-drop. Deep reflexes were not obtained in arms and were present but not exaggerated in legs. Sensation was normal. The lead line was present. There was no change in the fundus oculi. On the evening of the day of his admission to the hospital he became delirious, imagining spirits were after him. The next morning he was perfectly rational but again became delirious in the evening of the fourth day, and was more or less unconscious from that time on. On this day he developed fever and in a day or two meningitis was suspected. Lumbar puncture did not confirm this and it was soon evident that he had pneumonia. He died 19 days after entering the hospital. The blood was examined on two occasions but no granular degeneration of the red blood cells was found. Broncho-pneumonia and chronic tuberculosis were found at autopsy.

Of these four cases, the second should not have been included, since, other than his occupation, there is nothing that speaks for lead as being the cause of his paralysis; and we therefore have, with the case you have just seen, four patients in whom the legs were more or less affected. The paralysis in the other three had not this widespread distribution and this is the only case that deserves to be classed as acute geiveralized lead paralyiis. Similar cases have been described by Mme. Dejerine-Klumpke, E. Remak and others. The involvement of the diaphragm, which is so beautifully shown in this patient, makes the case a serious one and we dread for him an extension of the paralysis to the intercostal muscles or any intercurrent respiratory infection, as we fear he would be unable to withstand a further interference with his respiration.

You may have noticed that the enameller who died in the hospital showed maiked mental symptoms before the development of his terminal pneumonia. He was delirious and difficult to control on two different nights, but quite rational on the following mornings. The patient before .you to-night is said to have been delirious at the onset of his trouble. Three of the other hospital patients also showed marked cerebral involvement. Thus, a patient (No. 5608) was admitted with tremor of hands and subjective feelings of weakness of arms and legs. There was a lead line on the gums. He gives the history of having been subject to attacks of vertigo and of having had two attacks of vmconsciousness While under treatment he developed delusions of persecution with maniacal excitement and had to be removed to the insane wards at Bay View. In this case there was also a history of alcohol and syphilis. Still more interesting was the case of a carriage painter (No. 13,677), who came in suf

212

[No. 159.

fering from a severe attack of lead colic. He had had five previous attacks. There was no paralysis but a definite lead line was present and the red blood cells showed the typical granular degeneration. On the second day of his stay in the hospital he became delirious and then unconscious for a short time. Upon regaining consciousness he seemed rational, but complained that he was completely blind. No changes could be seen in his eye-grounds and he regained his sight in half an hour. Two days after this he had another attack of unconsciousness but without visual disturbances. His recovery was rapid and he soon left the hospital. He was readmitted the next year with another attack of colic, with which, however, there were no cerebral sym^jtoms.

Another painter (No. 14,101), with colic and double wristdrop, who showed a marked lead line and granular degeneration in the blood, was more than once delirious during the night, while in the wards.

Among the dispensary histories of patients wlio were not admitted to the hospital I find the mention of cerebral symptoms twice. In one case it was delirium during the niglit in a stereotyper with double wrist-drop, and in another it was an attack of unconsciousness and convulsions in a lad of 18, who had gotten his poisoning while working as a brass finisher.

These patients illustrate the fact that lead at times exerts its poisonous effects on the brain. This has been well recognized ever since Tanquerel's fundamental monograph in 1838. He classes such cases under the term " Lead encephalopathy."

The experience in this hospital in regard to the source from which the poisoning was derived differs ver)' little from that of others. More than half of the patients (28) worked with paints containing lead. The other group is made up of workers in various otlier trades in which lead is more or less used ( brass workers, 4 ; enamellers, 3 ; canmakers, 3 ; tinners, 3 ; stereotypers, 1 ; glass-cutters (putty), 1 etc.), and of those who had taken the poison as medicine or in food. Pour patients had slight lead poisoning after taking lead and opium medicinally for a considerable time; one was severely affected from drinking home-made wine, which had been kept in a cask fitted with a lead pipe, and the little girl who was so severely paralyzed got the lead, we thought, by eating the scrapings of food whicli remained in cans. In four cases we were unable to determine any probable source for the lead.

NOTES ON NEW BOOKS.

The Self-Cure of Consumption without Medicine. By Chas. H. Stanley Davis, M. D., Ph.D. (New York: E. B. Treat & Co., IDOJ,.)

The central idea of this little book, namely, that the cure of consumption is largely in the hands of the patient himself, is

one of great importance, since the cure of tuberculosis is, as the writer remarks, " the most important economic problem that confronts the American people." Its relief, in his opinion, is much less dependent on climatic surroundings than has hitherto been supposed; they are. indeed, but one factor, and can never act beneficially in the absence of hygenic conditions. To secure such conditions, especially in respect to food and exercise, is the great object towards which effort should be directed, and residence In a sanatorium is essential to its accomplishment in a large number of cases. For, although the necessary regulation of life is largely within the patient's own hands, it is only the exceptional patient who can be trusted to carry them out in their Integrity. The description of the methods employed in different sanatoria are interesting, and afford much useful information for those who require it.

The chapter devoted to showing the uselessness of almost all drugs in the treatment of consumption is prudently and carefully written. As a whole, the book contains all that is essential for the information of the public mind on the subject, put with clearness and common sense, and it is, therefore, a work of value, for the education of the public is the one means by which consumption can ever be eradicated, and everything which contributes to this end deserves respect and consideration.

The Blues (Splanchnic Neurasthenia) ; Causes and Cure. By Albert Abeams, A.M., M. D., Heidelberg, F. R. M. S. (New York: E. B. Treat & Co., 190.',.)

The object of this little book is to focus attention upon a special form of nervous exhaustion, characterized by extreme depression, which arises from congestion of the abdominal veins affecting in turn the splanchnic nerves. The writer presents his theory with much elaboration, but the clinical evidence which he brings to support it is inadequate for the purpose. Nevertheless, there can be no doubt that too little attention is paid as yet to the influence of the splanchnic nerves in the human economy and the book deserves attention from a suggestive point of view, since it is more than possible that further investigation along the lines which it follows, will repay effort.

Manual of Clinical Microscopy and Chemistry. By Dr. Hermann Lenhartz; authorized translation from the fourth and last German edition by Henry T. Brooks, M. D. (Philadelphia: F. A. Davis Company, 190Jf.)

In the preface to the first edition of his book the author states that it has been his endeavor to present a work which shall not only instruct in chemical microscopy and chemical methods of examination, but aid in interpreting their diagnostic significance. He is to be congratulated on his success in both respects, but particularly in the second. Practical utility is the book's most striking characteristic, and English speaking, or rather English reading people are fortunate in having access to it through the medium of a good translator. The author has shown good judgment in devoting special attention to the chemical side of the book, for the constantly increasing importance of this side of clinical diagnosis makes its development especially valuable, and in this connection the section on examination of urine deserves particular notice. The book contains a large number of excellent illustrations, and its value is enhanced by a full and accurate index, which in any manual is indispensable to real service.

The Johns Hopkinn Ifoajntal Bulletins are ismted monthly. They are printed by the FBIJBDENWALD CO., Baltimore. Single copies may be procured from the CVSHINO CO. and the BALTIMORE NEWS CO., Baltimore. Subscriptions, \$3.00 a year, may he addressed to the publishers, THE JOHNS HOPKINS PliESS, BALTIMORE ; simjlc copies will be sent by mail for twenty-five cents each.

BULLETIN

OF

THE JOHNS HOPKINS HO

Entered as Second-Class Matter at the Baltimore, Maryland, Postofflce.

Vol. xv.-No"^. reo-^e*^:]-'

BALTIMORE, JULY-AUGUST, 1904.

CONTENTS.

PAGE

The Sensory Distribution of tlie Fifth Cranial Nerve. By Hauvev

CtSBING, M. D -'13

Stephen Hales, the Physiolotjist. By Percy M. Dawson, M. D.,

The Chemical Origin of Leucocytes. By E. Schmoll, M. D.,

Mental Phenomena anil Visceral Disease. By Cahey B, Gamble, Jk., a. M., M. D.,

Proceedings of Societies ;

The Johns Hopkins Hospital Medical Society,

A Simple Method of Obtaiuinsr Uterine Lochia for Bacteriological Examination [Dr. Little] ; — The Dittereutial Diagnosis and Treatment of the So-Called Rheumatoid Diseases (an Abstract) [Dr. Goluthwait); — The Pathological Lesions of the So-Called Rheumatoid Diseases [Dr. Painter]; — Exhibition of Medical Cases |Dr. McCrae] ; — Exhibition of Medical Cases

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[Dr. Cole] ; — An Experimental Study of the Eosinophile Leucocytes during Infection with an Animal Parasite (Trichina Spiralis) [Dr. Opie]; — The Origin (Chemical) of Leucocytes in Leukemia [Dr. Schmoll]; — Myomectomy in its Relation to Pregnancy [Dr. Kelly] ; Observations on the Study of the Subclavian Arteryin Man [Dr. Bean] ; — On the Surgical Importance of the Visceral Crises in the Erythema Group JDr. Osler] ; — Immunization of Bacillus Dysenteric by Growth in Agglutinating Serum [Drs. Marshall and Knox]; — The Treatment of Delirium Tremens and Allied Conditions [Dr. Lambert]; — The Blood in Pregnancy [Dr. Tho.mpson] ; — The Pathology and Treatment of Benign Tumors of Bone with Cyst Formation [Dr. Halsted] ; — Pulmonary Distomatosis in Man I Dr. Stiles].

Correspondence, 263

Notes on New Books, 263

THE SENSORY DISTRIBUTION OF THE FIFTH CRANIAL NERVE.

By Harvey C'ushing, M. D., Associate Professor of Surgery, the Johns Hophins University.

There are several way.s in whicli tlie confines of the trigeminal sensory field may lie more or less accurately determined.

First of all, morphological studies serve to indicate what the boundary is likely to be, inasmuch as the structures that develop cephalad to the first vi.'^ceral cleft will, in the natural order of things, receive their sensory supply solely from the X. trigeminus.

In the .second jilace, anatomical dissections furnish possibly the most siiiijilc and commonly utilized means of establishing the destination of the liner ramitlcations of this as of any other nerve wiio.se imiiii radicle enters into no plexifonii \v\ations with its neighliors.

A tbinl method is the experimental one in which eom]iarative observations in the lowei' animals are made upon the funelional, rather than the anatomical field of distributiiiii ; eillier by section of the nerve in question ami deter

mination of the resultant field of "no response" to sensory stimuli, or else by section of the adjoining roots leaving intact tlie sensativity of the area to be demarcated. Thus a negative as well as a positive field may be surveyed and the physiological overlap from one side or the other be determined.

There remain, finally and fourthly, the opportunities which are offered by the stuily of clinical cases. The various conditions encountered at the bedside may be conveniently divided into two groups. One of these, the more objective, pre.sents a \isible peripheral lesion resultant upon pathological changes of one sort or another in the posterior root ganglia; the other partakes of the lirinciples involved in the preceding paragraph, the opportunity being grasped of outlining the area of disturbed sensation when, from disease, accident or intent, tiie continuity of the nerve or of its neighbors has been severed.

In this paper, as was the case in the studies which led to it.

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the subject will be approached primarily from the standpoint of this fourth method and the relationship to the clinical lindings which are borne by observations inado after one or another of the iirst three methods will be discussed secondarily.

I. Results of Clinical Observations.

Of those clinical states bearing an apparent relation to the partial loss of trigeminal control and all of which presumably indicate disturbances situate in the ganglion, congenital niuvi, progressive hemifacial atrophy and herpes zoster alone need be mentioned as giving characteristic objective lesions that conform more or less closely in distribution with one or another division of the familiar trigeminal skin-field. Even zoster, however, far the most definite of these states, indicates territorial outlines very roughly at best and valuable as has been the evidence that studies of herpetic eruptions have given in regard to segmental topography, accurate delineation of segmental boundaries is not looked for from data furnished by these cases. The same may be said of some states of a purely subjective nature which similarly are useful and interesting rather as furnishing confirmation of the outlines determined in other ways, than as adding anything more to their definiteness. For example, intra-cranial disturbances may at times, by reflex action through the trigeminus, give pain with hyperesthesia and tenderness over the entire field of sensory distribution of the nerve. I have twice seen patients suffering from the effects of a small extradural abscess of otitic origin in whom it was possible to clearly delineate the trigeminal outline including its auricular portion, by this hypersensitiveness to tactual impressions, though it may be doubted whether the accuracy of the outline would have been recognized without a thorough preliminary acquaintance with the normal boundary. The same statement applies to those cases of severe major neuralgia in which the entire sensory field of the fifth may be included in the paroxysmal wave of pain.

Instances of traumatism, or of progressive involvement of tiie nerve in morbid processes in such wise as to interrupt afferent impulses, have supplied, heretofore, the chief opportunities of determining in man the function and distribution of the ti'igeminus. It would be unusual for a single observer to have for a study a considerable series of such cases and the lesions, unfortunately, arc rarely uncomplicated, sufficiently circumscribed, or if so, possible to authenticate by a post-mortem examination and intracranial lesions of any seriousness are too apt to leave patients in a condition in which it is difficult to properly carry out delicate sensory examinations. It is, possibly, for this reason, rather than because of the supposed great variability in outline of the trigeminal field, that one finds in standard text-books of medicine and neurologv so great a lack of unanimity in the described and pictured bounilaries of this area.

Needless to say, no clinical condifion oIlVi-s ojiporl unities so favorable for subsequent study of the function of the fifth nerve as that su|iplir'(l by a purjioseful Jul racr;inial ncun-e

toniy. In no other way is it possible to obtain for study an uncomplicated group of cases presenting tliis simple lesion alone and from which may be gathci-ed the average normal distribution as well as its variations. It is often said that the conditions are comparable to those of an accurate physiological experiment, but they are much more than that. The stumbling block of the laboratory in studies of sensory nerve distribution has been not only tlu' great difficulty of eliciting responses but of interpreting the animal's sensations, a matter so subjective that verbal communication is necessary. This is possible only between man and nuin, and even here a mind more acute than the ordinary on the part of the subject is desirable since only by the observer's interpretation of the patient's own comment upon his sensations, for which any one has but a small vocabulary, can data of great reliability be obtained. Little has been added to our knowledge of the consequences of this operation from an anatomical and physiological point of view since the publication in 189G of Krause's well-known monograph.' Six of the cases which at that time formed the basis of his studies were therein reported with especial care from the standpoint of the post-operative sensory disturbances and his findings will be commented upon later on. Most of the surgeons, other than Krause, who have had a series of these cases sufficient to furnish material for similar observations, have devoted their reports more to the operative aspect of ganglion extirpation than to the study of its physiological consequences. The observations are, unfortunately, time-consuming and tedious, and only a spirit of investigation would provoke their study. They are, furthermore, as fatiguing to the patient as to the observer, and it is necessary to have the absolute co-operation of the former and the willingness of both to sacrifice time. Happily, those individuals who have been released from the indescribable sufferings of extreme forms of neuralgia quniti major are willing enough to lend themselves to the annoyance and tedium of sensory tests, and happily again, convalescence, as a rule, is so rapid from this operation that observations may be profitably begun on the succeeding day and be corroborated or added to by frequent examinations during the period of hospital residence.

The series of cases of ganglion extirpation or of division of the trigeminal sensory root from which have been obtained the results to be given in this paper are twenty-six in number. Of tlieso, a few of the earlier eases are comparatively of little value, for although the extirpation in the majority of them was total, file anaesthetic areas, as the records and the photo

' Fetlor Krause: Die Neuralgie des Trigeminus nebst der Anatomie und Physiologie des Nerven. Leipzig. F. C. W. Vogel, 1S!)«.

- Freiiuently diagrams or photographs accompany the reports of these operations, showing the resultant area of anaesthesia willioiit comment ui)on the method of testing the same. From I lie configuration of the area which is usually delineated in those cases, in which a total extirpation has lieen assured, one would judge that it represented the outline of total analgesia as it would lie conveniently mapped out by a pin or needle.

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graphs show, were very easnally mapped out, and usually to one form of sensation alone. Subsequent examinations in some of these cases, even after three or four years, have revealed outlines which indicate the crudeness of the earlier delineations. In all of the later cases great pains have been taken to carefully trace the boundary lines of anesthesia to all forms of sensation, and, as will be seen, with the result of determining a definite outline from which in the great majority of cases there is only the very slightest individual deviation. Several of the cases, furthermore, had had no preliminary neurectomies of peripheral nerves so that possible functional overlapping on long-standing patches of anaesthesia was the source of no confusion during the early tests.

Fig. 1. — Diagram showing tlie normal (average) field of post-operativi cutaneous aniesthesia. The shaded area including tragus and anterior wall of meatus remains ausesthetic to tactual (hair iestheslometer) stimuli. The dotted strip gives the impression of touch or pressure to pain stimuli (needle) with few if any actual pain points.

For making the tests the following appliances have been used: for touch, a horse hair arranged like a v. Frey ajsthesiometor, of a length just sufficient, owing to bending on impact, to give tactile instead of a dolorous sensation in case it impinged upon a pain point; for pain, a needle or sharp pin placed obliquely on the end of a light cardboard handle, thus allowing of more delicate stabs of the skin than when held in the fingers ; for thermic tests, a camel's hair brusli wet with ether for cold, and for heat the wanned head of a pin or else tlie convenient hot and cold test-tube. Electrical tests have also been used in the majority of the more recent cases. On the skin there is no more satisfactory way of delineating the outline of tactual anaesthesia. A unipolar electrode of fine platinum wire with the faradic cui'rent has generallv been em

ployed ; this gives the electrical sting or "' whirr " only on a field of tactual aisthesia. In making the tests the field margins were approached always from a known area of anaesthesia. The patient, so far as possible, was always alone with the observer in quiet surroundings and the observations were invariably deferred when evidence of even a slight degree of fatigue was given by uncertainty or delay in the responses. Comment will be made:

1. Upon the field of cutaneous ansEsthesia.

2. Upon the anassthesia of the mucous membranes.

3. Upon disturbances of " muscular sense."

4. Upon the distribution to the meninges.

5. Upon the sensory distribution of adjoining fields.

Fig. 3.

G. Upon the overla]) and permanence of anesthesia.

1. Outline of the Cutaneous Field. — There are two lines which in every case may readily be mapped out as delineating phases of anaesthesia at the posterior boiindari/ of the trigeminal skin field (Fig. 1) ; the more anterior of these lines bounds the area within which anaesthesia is complete to all forms of sensation: the more posterior, outlines the area within which the an;¥sthesia, though complete to thermic, dolorous and delicate tactual stimuli, nevertheless is not absolute since perception for painful stimuli remains, the impulses being interpreted, however, not as pain but as pressure or contact (common sensation). There exists, therefore, a strip of skin between these two lines from which sensory respon.ses may be elicited, and although, properly speaking, the posterior of the lines encloses the functional area of trigeminal distribution for pain, touch and temperature, the anterior represents the line wliicli woidd be mapped out by the experi

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mental method on animals as enclosing the field of 'no response" whatever. This will be commented upon later in discussing Sherrington's findings in the monkey.

In the twenty-six cases of trigeminal neureetoiny from which these studies have been made the great prej)onderanee of one type, occurring as it does in twenty instances with but little variation from case to case, indicates that this stands as the average normal cutaneous distribution. Instances of this normal type are shown in the accompanying pliotographs, taken from eight to ten days after the operation, of patients on whom the field had been mapped out (Figs. 2-T). A comparison with tlie photographs and diagrams of the ampsthesia after cervical nerve lesions (Figs. l-l-]'.() i-endei'S it evident at

Fu.. :;.

once that the border zones between the cranial (trigeminal) and the adjoining spinal field ( second cervical ) either offer an exception to tlie general laws of overlapping which Sherrington has shown to apply to the border ai'eas Ijetween neighboring akin-fields of spinal origin, or else through tlie greater accuracy of the tests which are possible in the liuman subject. the exact anatomical delineation of a segmental skin-field may be. determined, after the section of its dor.sal root, regardless of the possible functional overlap with adjoining segments.

It lias lieen determinc'd on experimental grounds, as is well known, that tlie overlap between adjoining segments is sufficient to leave no area with deficient tactual sensativity after the section of a single dorsal root, the tactual overlap in fact Iteing greater tlian tjiat lor pain and tein|)erature, a florso-ventral stri]) of at least partial analgesia ami thermoanivsthesia remaining after a single spinal root division."

'Sherrington: The S|)inal Roots and Dissociative Anfesthesia in the Monkey. .lournal ot Pliysiolog.v. Vol. XXVIl.

In the case of the trigeminal field in man, at all events, it seems quite otherwise since tiie only observable overlaj) on the trigeminal field, at least of its mandibular portion, after division of the sensory root is for pain alone, although, as already stated, painful impulses from the field of overlap, if it is to bi' regarded as such, when perceived are not dolorous.'

Particular attention has been paid in these cases of trigeminal neurectomy to the delineation of the field of postoperative tactual ancEsihesia inasmuch as points of chief interest have been obtained therefrom ami tiie outline thus plotted seemingly represents the extent of anatomical distribution of the terminals of the nerve. This boundary liiu' nuiy be traced as follows: Starting from the mid-longituilinal line of the

I

Fig. 4. Figs. 2-4. — PLiotoirraphs of patients s to 10 days after the operation sliowing area of tactual aua?stliesia alone.

scalp at a point whicli roughly corresponds with the upper end of the underlvins Rolandic fissure, the line crosses the scalp

'This statement has been restricted to the field of the N. mandiijularis division of the trigeminus since it is possible that the overlap which exists at the vertex between the second cervical field and the ophthalmic division of the trigeminus may be somewhat more marked. This deserves further study. It is not impossible that the first visceral cleft may have furnished a barrier to overlapping ventral to the ear that does not exist in the parts dorsal to it. This may explain the slighter overlap in the ear-cheek-chin portion that exists on the crown. It must be borne in mind, of course, that the Gasserion ganglion represents in all probability a fusion of three separate cranial dorsal root ganglia, the groups of cells corresponding to each division remaining more or less distinct, as the observations, which Dr. Barker and the writer made a few years ago would indicate, the degenerated cells after peripheral evulsion of one or another of the main trunks lying in a definite group and not being scattered throughout the ganglion as might be expected. Sherrington has shown however and clinical observations confirm the fact that the

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with some irregularities but generally in a forward and downward direction much as does this underlying cerebral fissure; it then drops to the anterior attachment of the pinna around the edge of which it curves in a backward direction so as to include a small section of the ascending rim of the helix, togetlier with the entire erus of the same; thence it disappears in the external auditory canal at the upper edge of the meatus ; from this point the line passes into the canal along its upper wall as far as the tympanic membrane, which is included to a greater or less extent in the anesthetic area, returns along the lower and anterior wall of the canal to the lower edge of the tragus, where it once more reappears on the exposed cutaneous surface ; thence it passes at a greater or less angle in a forward and slightly upward direction across the zygomatic region for

y

Fu;.

a distance of from 3 to 5 cm. before turning and sweeping downward across the cheek, still keeping nearly 5 cm. from the posterior edge of the ascending maxillary ramus (about half-way between the angle of the jaw and corner of the mouth) until it drops imder the edge of the horizontal ramus and regains the mid line 1 or 2 cm. below the mental prominence. It is to the auricular portion (Fig. 8) of this " Scheitel-Ohr-Kinnlinie," as it is called by the German anatomists, that the greatest interest attaches, and although through the dissection methods, to which reference will be made later, the trigeminal area has with considerable agreement been made to include a certain ixirtion of the helix together with the

skin-fields of the separate divisions do not run to the mid dorsum. Thus the field of the N. mandil)ularis dops not entirely separate the fields of the 1st and 2d trigeminal divisions from the cervical fields and though its auriculotemporal branch would suggest an analogue with the posterior division of the spinal nerves, it fails to roach the mid dorsal line.

tragus, scant merition seems to have been made, even by anatomists, of the extension of the field into the external auditory canal. It is difficult at times to demonstrate the exact outline unless the meatus be large and in some cases it may be necessary to clip away the hair from the tragus before a satisfactory examination can be made. The deeper portion of the canal, together with the drum, is best examined through an aural speculum. As a rule the tactual anaesthesia of its upper and anterior walls may be easily demonstrated. The patient usually will hear the horse hair when it impinges upon the surface, altiiough the unpleasant tickling sensation which follows upon touching the postero-inferior wall of the canal, just as in the normal ear, is not called out. The drum itself.

Fig. 6.

ordinarily exquisitely sensitive, is as a rule anagsthetic to a greater or less extent. In one patient it was found that the tympanum (to all appearances normal) was divided by the handle of the malleus into an anterior and upper anesthetic portion, touching which with a" horse hair gave only a loud rapping noise without tactual impression, and into a posterior acutely esthetic portion touching which occasioned pain. Dr. Randolph was kind enough to corroborate the results of this finding and was able through his greater skill in intra-aural examinations to accurately map out the boundary line. In other instances I have not succeeded in so clearly demarcating the two fields on the tympanum. It has seemed, in some cases, together with the deeper portion of the posterior wall of the canal to be entirely without tactual sensativity. It may be said, however, that in the great majority of all cases the CPUS of the helix and the tragus, together with the anterior wall of the auricular canal, represent a point of anchorage, as it wcic, wiicrc the cutaneous lines of tactile anassthesia are

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buoyed, no matter at what angle tlicy may bo swept away from this point by the shifting of the sliin over the developing mandible and cranium. (Compare the series of diagrams. Figs. 26-30.)

The anterior of the two lines is much more simple in its configuration and needs no description other than that which the diagram (Fig. 1) itself gives. It for the most part lies parallel to the erown-ear-chin line from which it diverges most widely at the crown and ear and approaches most closely at the temporal region, cheek and chin. Occasionally it also bellies out toward the tragus, though it usually bridges across this auricular irregularity in contour of the posterior line with no attempt at parallelism.

KiG. 7. Figs. .5-7. — Photograjilis showiug combined areas o£ analgesia and tactual anjesthesia ten days after operation.

Variations from the Normal Type. — As has been stated, the above description applies to the posterior cutaneous boundary in the great majority of the ca.ses observed and the variation in outline from case to case is no greater than might be expected from individual differences in the configuration of the underlying skull. In three instances, however, out of the twentysix there was found an outline possessing somewhat different characteristics, and being alil<i' in all throe it may justlv be regarded as indicative of a separate type of distribution. In these cases, as in tlie above, the same double lines were demonstrable. They were, however, set back so that the more anterior corresponded appro.ximately with the more posterior of the normal type, that is, with the line described above in detail, whereas the more posterior of the two included within its boundaries the upper half of the pinna, the aniiliclix and its crura, a portion of the concha and a eonsiderablv greater share

of the cheek. This variation is best shown by the photographs of the three cases" (Figs. 9-11). I have seen one case also, though only one, in which the outline corresponded with the field which Frohse, through the dissection method, has given as the average type (cf. Fig. 23) and in which the ascending portion of the helix, together with the fossa of the antihelix (fossa triangularis), are included.

The median boundary of the anesthetic area, determined by tactual stimuli (horse-hair test), corresponded in all cases exactly with the mid-line of the crown, forehead, nose, lips and chin. There is detectable, however, as in the case of the posterior boundary, a very narrow border strip broadening out slightly at the root and tip of the nose, within which painful stimuli are interpreted as touch or pressure: analgesia as such, however, reaches, as does tactile anaesthesia, to the mid line. This is best appreciated by the examination of those cases in which the trigeminal neurectomy has been performed as the first operation, that is, when it has not been preceded by per

FiQ. s. — Outline of the auricular portion of the trigeminal field determined by the line delimiting tactual aniesthesia.

ipheral operations perhaps often repeated. In the latter cases the slight functional overlap, which time has allowed to take place, from across the mid line and from adjoining posterior fields, may accentuate the width and the sentiency of this border zone, though this is not always the case.

° There is one peculiarity in regard to the stability of these boundary lines that may be mentioned here since in one of these three cases it was more pronounced than in any of the other patients I have examined, although as a matter of fact it is observable to a greater or less degree in all. This consists in a rhythmic shifting of the lines of anjesthesia. If. for example, the line of tactile anipsthesia over the side of the scalp be rapidly marked out. the patient responding promptly the moment he feels the touch of the hair as it passes on to the area of festhesia. it may be found after a few moments, should a second examination be made, to corroborate the line, that it has shifted backward perhaps one or two cm. A short time later it may again be found at its original position, and so on. One of the patients.

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Hoi'oi'c considering tlie iiili'iil)iu-i'al licld of anaestliesia it may not be out of place hero to compare the above results with the observations made by others, notably by Krause, on this cutaneous field. Relative ito six of the eases which form the basis of his earlier (189()) report upon a series of ganglion extirpations, are careful notes in regard to the post-operative anffisthesias. One of his photographs I take the liberty of copying here in outline (Fig. 12), inasmuch as it has found its way into several text-books of anatomy and neurology, having been accepted by the authors as the normal outline of functional ana;sthesia after a trigeminal neurectomy. The figure represents the findings of an examination four weeks after the operation. The chart accompanying it shows that all forms of sensation in the areas A and B were at the time of observation abolished (aufgehoben) ; in C, D and E, greatly reduced (stark herabgesetzt) , and and F sliglitly so (wenig

Fig

herabgesetzt). Doubtless the partial anaesthesia in the areas of the second and third division in this case have some relation

an Intelligent observer of his own sensations, told me that he was himself aware of this slight contraction and expansion of the field of anaesthesia and that it occurred usually with a definite rhythm. It was noted, furthermore, in this same individual that when a watch was placed at a distance at which its ticking could barely be heard, the sound became plain and then scarcely or not at all audible with the same rhythm as that which affected the change in size of the anaesthetic field. It was then easily demonstrable by attaching to the patient's arm a blood pressure apparatus that a slight rise in systolic pressure of six to eight mm. of Hg. corresponded with the period of more acute hearing as well as with that of shrinkage of the anaesthetic field. When sleepy or fatigued the field of anaesthesia was broadest and evidence of the fluctuation of the boundary was no longer apparent.

Such a shifting is doubtless explicable on physiological grounds and although it occurs but rarely to any great extent, it nevertheless must be borne in mind by those making the tests lest it be the occasion of confusion. In the cases in which the rhythm was definite I have endeavored always to plot the i)osterior of the lines.

to the many preceding peripheral nerve resections on these branches, the first of which on the inferior maxillary had been performed as much as thirteen years before the ganglion operation. A later observation (314 years) on this same patient showed considerable shrinkage, especially in the territory of the first (ophthalmic) division, together with partial return of common sensation in the supraorbital region and a shrinkage of the area away from the median line. In some others of Krausc's earlier cases it seems evident from the description that the ganglion cells, particularly of the ophthalmic division, had not been completely removed since sensory perception of the supraorbital territory was relatively so little affected. In two or three of the cases in my series a similar

return of more or less complete sensitivity in the ophthalmic division has taken place. These were eases in which from operative difficulties a complete enucleation of the ganglion with evulsion of the sensory root was impossible. In one of them not only was there a partial return for sensations of pain and touch in the area of the ophthalmic division, but also painful stimuli over the cheek gave impulses interpreted as touch or pressure (area of N. infraorbitalis). The lower twothirds of the ganglion with the intracranial portions of the N. niaxillaris and N. mandibularis were certainly removed in this case and the ophthalmic portion sutfieiently broken up to render its territory completely anesthetic for some weeks. It is presumable that in the fragment of the ganglion left at the operation, cells remained which finally re-established connections not only with the traumatized ophthalmic division, but also in part with the severed N". infraorbitalis. Inasmuch as those cases, in which the ganglion with its sensory root has been removed in its entirety, have had no return of sensation other than an insignificant shrinkage of the border areas of the entire field, it seems much more probable that the partial

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return or persistence of sensation in tliese eases represents the passage of impulses by way of the partially restored trigeminus rather than by an extensive functional overlap with the cervical fields. Zander has attempted to explain the post-operative sensativity of the ophthalmic field in some of Krause's cases by the supposition that the occipital nerves may at times extend forward as far as the palpebral cleft. From the diagrams of resultant anesthesia, I would be inclined to put the former interpretation, namely, that of incomplete extirpation, upon one of Friedrich's carefully studied cases.°^

It will be noticed in Krause's diagrams that although the margin of anaesthesia approaches the ear, it does not include the tragus and doubtless there was no intent to more than roughly indicate the outlines of the trigeminal divisions. Tliis

Fig. 11.

Figs. 9-11. — I'liotograjjlis of the three instances of variation from the normal distribution. I'aticnts ten days after operation. Anterior line, analgesia; jxjsterior line, tac'tual anesthesia.

is the more apparent since he briefly mentions the insensativeness of the anterior wall of the canal in its e.xternal portion and comments in the context upon its inclusion in the trigeminal field since two of his patients found in cleaning their ears with " einem kleinen Loffelchen " that they were apt to occasion pain, owing to the insufficient protection of an anesthetic meatus, by carrying their " lloinigung " too deep, even to the sensative drum. This occurred in one case as late as two and one-third years after the operation.

Krause's observations led him to accept the view of double innervation for otiierwise " miissto ja nach Ausrothung des Ganglion Gasseri das gesammtc Trigeminusgebiet volkommen anasthetesch sein : unsere Untersuchungen lieferten ober ganz andere Ergebnisse." He explains the varialiility of his (iixl '• Friedrieh. Deulsehc Zcitsclirift fiirf'liir., Isflil, Hd, rt'2, ji. :i(J(l.

ings on anatomical grounds, a belief to which the investigations of Frohse and Zander seemed to give support.' It is much to ge regretted that Krause in his more recent paper has not added to the physiological notes which accompanied this earlier work, since a larger proportion of the later cases have been doubtless more perfect extirpations, and what is more important, have, some of them, been carried out on patients in whom no previous peripheral neureotomies had been performed. It is from such uncomplicated cases especially that the most satisfactory data may be obtained.

2. Outline of the Mucous-M emhrane Field. — The boundary of the intrabuccal field of anassthesia may be traced, as has been the skin-field, by beginning at a given point, and for this purpose the muco-cutaneous junction of the lower lip may be conveniently chosen. The line of anesthesia (Fig. 13) to all forms of sensation corresponds exactly with the mid line of lip, frenuin lingue, tip and dorsum of tongue as far back as a point slightly anterior to the foramen caecum ;

FiG. 12. — Krause's " Beobaebtung 3." Showing the results of an examination four weeks after a ganglion extirpation.

thence it passes outward along the row of circumvallate papillae to the lateral root of the tongue where there is some variation from case to case, though in the majority of instances it passes along the j^alato-giossal fold, to the upper portion of the anterior pillar of the fauces ( Arcus glossopalatinus) which it follows to the uvula. The posterior pillar (Arcus pharyngopalatiuus), so far as I have observed, together with the tonsil

" A ease has been reported by Drs. Spiller, Keen and Dercum in which the ganglion was removed, together with an endothelioma of the neighborhood and in which there was only slight consequent hypaesthesia of the face. On physiological grounds it is difficult to conceive of such a condition and that the facial nerve should assume the sensory function of the trigeminus even in an anomalous case seems from a morphological standpoint quite improbable. It is enough to startle the shades of Majendie and Charles Bell into remonstrance. The writer has twice operated on cases of basal tumors involving the Gasserion ganglion (once an "endothelioma" and another time a chondrofibroma) and although the tumor in each instance was entirely extradural and to all appearances occupied the entire Cavum Meckelii, leaving apparently no trace of the second and third rami or of their foramina, only partial anesthesia resulted from the attempleil exUriJalion of the ,s;rowth.

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221

aiul the lower or vertical portion of the anterior pillar, retain their sensation and developed as they arc from the parts posterior to the mandibular arch, are supplied, as would be expected, by the glossopharyngeal nerve. Whether the nasal and pharynjieal areas of anaesthesia arc cut oil' from this intraoral Held by an ffisthetic strip on the roof of the soft palate, from my observations cannot be stated positively, and although there is an overlap here which will be described later, it seems probable that the trigeminal fields of intraoral and nasopharyngeal distribution do so communicate. If this be the case, the line, to continue with its course, curves around the soft palate near its junction with the uvula, gains the roof

Fig. 1:1— Diagram of iutiabuccal ana'sthesia. Other mucous surfaces, the 8chneiderian membraue, dorsum of palate, root of pharyux and half ot Eustachian orifice (?) are also without sensitivity.

of the velum across which it passes to the lateral pharyngeal wall; tlience upward, dividing in its course the pharyngeal ostium of the Eustachian tube, proceeding thence to the mid line of the vault of the pharyn.x; from here it pursues again a median path along the internasal septum, keeping in the mid line of soft palate and uvula, both dorsal and ventral surface, hard palate, gums and upper lip to the muco-cutaneous junction again.

With the exception of the tongue, as will be described, the entire mucous field within these lines is rendered completely devoid of sensation by the neurectomy: the lips, teeth, gums, anterior two-thirds of the tongue, cheek, hard and soft palate, uvula, a i>ortion of the pharyngeal vault, together with the entire Sehneiderinu iiieinln'aiie on one side. Instruments

may be introduced into and through the nasal chamber, the patient being unconscious of their presence. The sneezing reflex is abolished, as well as the gagging rellex produced by irritating the soft palate on the side of anesthesia. The fumes from ammonia, ether and like substances are no longer irritating when inhaled, the irritant quality acting apparently upon the nerves of common sensation alone and not upon these of special sense, for the latter remain unalfected. Some interference with the sense of smell has been described in these cases, but it is probably due to the fact that an abnoriiial dryness of the mucous membraue persists for some time after the operation and interferes somewhat with the acuity ot the sense of smell, for, especially if the membrane be moistened by a saline irrigation, the special sense perception seems equally acute on the two sides.

One portion of this mucous field, owing to its inaccessability, has been less satisfactorily examined than the remainder. This is the field occupying the vault of the pharynx. One observation, however, that has in all cases yielded like results, shows the normal sensitivity of the Eustachian orifice to be much diminished. A Eustachian catheter may be passed through the nares on the aua;stlietic side unknown to the patient and be introduced into the ostium of the tube, where it produces very slight if any sensation, provided it is held away from the outer siile of the orifice and does not enter the fossa of Rosenmtiller.

This observation may be controlled as follows: If the ffisthetic mucous membrane of the other nares is cocainized so that the catheter may be similarly introduced without the patient's being aware of its presence, the usual disagreeable sensation is produced the moment the instrument comes in contact with any part of the Eustachian orifice. So far as my observations go, it also seems that the vault of the pharynx above and anterior to the ostium is likewise anaasthetic for tactual stimuli. Examinations of this sort through the nares without direct visual supervision of the points of contact is, of course, open to criticism, and without great success I have attempted to corroborate the findings by tests carried out through the mouth with the aid of a laryngoscopic mirror. Only in exceptional instances lias this been passible. The main point, however, which it is desired to emphasize is that the pharyngeal opening of the tube, like the external auditory canal, is probably innervated on its anterior (cephalad) half by the trigeminus and posteriorly by the next adjoining cranial nerve liaving aiferent splanchnic fibers, glosso-pharyngeus or vagus.

After a trigeminal neurectomy that portion of the tongue anterior to the circumvallate papillffi is an exception to the rule of total anaesthesia to all forms of stimuli. Simple tactual impulses produced with a horse hair, as well as those of pain and temperature, are completely interrupted exactly to the mid line. Certain forms of common sensation are, however, preserved. If a cotton swab or a wisp of cloth be moved over the antesthctic field, its presence is recognized, localized iiKii-e or less aemirafelv. and its direction of move

222

[Nos. lGO-101.

ment appreciated. There are reasons for believing that certain fibers from this area of the tongue not only as the special sense fibers of taste but also of common sensation, pass to the brain by way of the Chorda tympani and the Nervus intermedins (Wrisberg). This question has been entered into more fully in a previous communication ' concerning the coui-se of the taste fibers. Reasons for believing that the paths for taste fibers were largely, if not entirely, independcnit of the trigeminus, as well as for believing that some other fibers of common sensation passed together with them from the anterior two-thirds of the tongue were then given. Since writing that paper additional opportunities in seven cases have sufficed to further strengthen the conclusions therein sot down. In none of these cases was taste affected in the slightest by the operation ; in all of them there was retained over the anaesthetic portion of tlie tongue this peculiar form of sensitiveness to certain tactual stimuli. An examination, furthermore, of a number of cases of facial palsy, has shown that when the lesion is high enough to interrupt the transmission of gustatory impulses there is an accompanying slight sensory disturbance over the anterior portion of the tongue to these particular forms of stimuli, even though a normal sentiency to touch pain and temperature seems to be present. Thirdly, the good fortune of being enabled to observe a patient in whom both the fifth and seventh nerves were totally paralyzed has shown that no sensation whatever over the anterior part of tongue remained to touch, taste, pain, temperature or to the movement of a swab over the surface. These observations have been sufficient to establish from a clinical basis a personal conviction that there exist afferent fibers of two sorts, common and special sense fibers, which pass from the tongue via the chorda tympani and N. intermedins. It may be seen that morphological studies are in agreement with this.

3. Disturbances of the So-called " Muscular Sense." — Comment was made by Charles Bell upon the apparent slight palsy of the muscles supplied by the facial nerve that followed operative or experimental section of the peripheral branches of the trigeminus. Thus, for example, a slight droop of the upper lip with planing out of the naso-labial fold could be observed after section of the infraorbital bundle of the trigeminus. Sequelae of this sort have since been frequently observed by surgeons after peripheral nenrcctomies of branches of the fifth nerve and are commonly ascribed to associated injuries of terminal twigs of the facial or to division of fibers of the muscles tliemselves. Postural deformities of any consequence, such as usually appear in tlie region of the eyebrow after the customary ganglion incision, are of course due to such an injui-v of the nerves to the frontalis, corrugator supercilii, ami jjossibly in part to the oi-bicularis itself. Quite another matter ai-c the phenomena of senso-paralysis which may oftentimes be observed in these patients, though they might not atli-act the ca.sual glance.

In the period imini'iliatcly following tlii' lunircctomy there

'The Taste Fibers and llicir Iiulcpendenw! of the N. triKomiiuis. The Johns Hopkins lIosi)ilal Unllclin, Vol. 11, liMi:!, p. 71.

may be seen, more marked in some cases tlian in others, a not inconsiderable hemilateral flaccidity of both upper and lower lips and possibly, as Krause has remarked, a slight flattening of the ala nasse and lessening in deptii of the naso labial fold, a condition somewhat emphasized by the temporary fullness of the tissues due to the vasomotor paralysis. At rest, witii the lips closed, the lip margins on the operated side tend in some cases to remain slightly parted; during active movements the asymmetry between the two sides may become somewhat more pronounced, for example, in the effort to whistle when the lips may not be satisfa,ctorily puckered. In one of my cases for a few weeks the postural disturbance was so great as to sinmlate an actual hemifacial palsy, and only after electrical examination could it be proved otherwise. At a later period the flaccidity is frequently replaced by a corresponding degree of overaction in the expressional musculature, namely, by a slightly drawn position of the corner of the mouth, a deepening of the naso-labial fold, and in old people an accentuation of the wrinkles (crow's foot) radiating from the outer canthus. The principle underlying this phenomenon is of quite a different nature and the overaction is never as marked as in contracture of the muscles during recovery of a true motor palsy. There is not uncommonly seen also a slight " tic " or twitching of the muscles, for instance in those comprising the orbicular or naso-labial group. Of this the patient is unconscious. It must be said that all of these phenomena may be so inconspicuous as to be readily overlooked and in some cases may not be observed at all.

The complete absence of postural sense may, however, be easily demonstrated in another way. It has been noted above that faridization is one of the most satisfactory methods of mapping out the field of anaesthesia, the patient being unaware of the contact of the electrode until it crosses the boundary onto the ajsthetic area. If the current be strong enough to elicit contractions in the groups of muscles about the eye, nose or mouth, the movements are not appreciated, provided the patient's eyes be closed so that they cannot be observed, and also jirovided the twitch be not transmitted to the opposite or assthetie side of the face. Similarly, passive movements produced in other W"ays, as by hooking up the ala of the nose or corner of the mouth, are unaccompanied by recognition of the changed position.

The loss of muscle sense may likewise be in a measure responsible for the post-operative postural asymmetry of the tongue and soft palate, thougli I have been inclined to largely account for the condition in another way. During the operative procedure the motor root of the fifth is almost of necessity sacrificed with resultant unilateral paralysis of the masticatory muscles. Consequent upon the loss of function of the pterygoids, the lower jaw, when the mouth is widely opened, deflects towanl the paralyzed side and the protruded tongue remains in the mid line of the deflected jaw, doubtless gaining its sense of position from the posterior attachments to the inferior maxillary bones. The base of the tongue retains, of course, its normal sensitivitv and the loss of muscle

Ji:iA-ArGL'ST, l!.)01.]

223

sense affects the muscle bundles of the anterior portion on one side only, llany patients have some difficulty in placing and especially in retaining the tip of the organ in the mid-line position even of the deflected jaw.

The post-operative asymmetry of the palate, to be discussed more at length elsewhere, may also be attributable in part to disturbances of muscle sense, though I have a-scribed it as due chiefly to the paralysis of the tensor palati (M. tensor veli palatini), which ha.s a motor fifth supply. The degree of postural deformity varies greatly in different individuals. The patient in whom of all the eases it was most marked, a preacher, was the only one to appreciate any inconvenience therefrom. When talking rapidly in delivering an address he finds that the palatal sounds are less distinctly enunciated than formerly. In conversational tones this is not apparent.

Other than the transient paralyses of the ocular muscles attributable to a definite cause, namely, to pressure of the instruments against the third, fourth or si.xth nerves during the operation, I have never observed any ataxia or postural disturbance of movement in the eyeball consequent upon the neurectomy. It is quite possible that these muscles receive their sensory innervation from another source than the fifth cranial.

4. The Sensory Supplji of the Dura Mater. — Since the time of Haller's experiments the dura has been recognized as a sensitive membrane. So far as the writer's operative experience goes, it is less acutely so in man than in some of the lower animals; in dogs especially, even when under deep narcosis, a great " pressor " response through the vasomotor center may be reflexly elicited even by slight dural manipulation. The same reaction occurs in man, though seemingly to a less degree. After a trigeminal neurectomy the dura, so far as it is exposed by the cranial opening, is rendered antesthetie. In a case of basal tumor recently operated upon and in which the ganglion and its trigeminal root were removed along with the larger part of the infiltrating growth, the wound was left open to allow of direct application of the X-rays. The large area of dura of the middle fossa and temporal region thus exposed was found after the operation to be totally without sensitivity.

There is one post-operative symptom, which in a certain proportion of the cases of G-asserion ganglion extirpation has been observed with great regularity. During the later stage of the operation when the superior envelope of the ganglion lia.s been elevated sufficiently well to expose the trigeminal root, an escape of cerebro-spinal fluid almost invariably takes place. In certain cases also, in which there is more than the usual degree of bleeding after extracting the ganglion, it is necessary to insert a drain for two or three days, the cerebrospinal fluid continuing to escape for as many days as the drain remains. This seemingly is the occasion of the dull post-operative headache which chiefly in these drained cases may characterize the first few days of convalescence. The headache, however, in a case of total extirpation is invariably a iiiiilaleral one and referred to the sound or unoperated side

of the cranium. The same peculiarity remains a feature of the headaches which during subsequent months may be occasioned by one cau.se or another, such as chance disorders of alimentation. Only on the few occasions in which the extirpation has been incomplete, owing to operative difficulties, and the o])hthalmic division with its fragment of the ganglion been left in situ, have these post-operative intracranial discomforts been bilateral. In these cases of partial extirpation, of which there have been two in my series, the sensitivity over the skin-field of tbe ophthalmic branch has been only affected in part and it is presumable that the filaments to the dura from the same division likewise continue to transmit impulses.

The hemicranial nature of these symptoms in cases of total extirpation points very strongly toward a dui-al origin for nuvny forms of headache, and offers, furthermore, an interesting suggestion of the relationship between trigeminal neuralgia and its frequent preciirsor, migraine.

The following quotation from a standard text-book of anatomy will show that in the minds of some there exists some doubt as to the sensory innervation of the dura. " Minute nervous filaments, derived from the fifth, tenth and twelfth cranial nerves, and from the sympathetic, enter the dura mater of the brain to be distributed chiefly to the blood vessels and to the bone, but partly perhaps to the membrane itself." Others, however, consider the nerves to be unquestionably sensory. The more important of them, as described by Arnold and Luschka, are the recurrent nerve (N. tentorii) from the ophthalmic division, the recurrent nerve of the superior maxillary division following the meningeal artery and its branches, and two recurrent nerves from the mandibular division, one to the middle fossa and a small branch to the occipital dura, entering the condyloid fossa with the hypoglossal. Charpy. in an excellent chapter on the " Coverings of the Central Nervous System," ° sums up the matter as follows : " Comme on le voit, si on excepte le rameau du pneumogastrique et quelques filets emanes des plexus sympathiques perivasculaires, c'est le trijumeau qui fournit la tolalite des nerfs propres de la dure-mere."

5. Sensory Outline of Adjoining j§'Ann-^(?Ms. — Extensive operations on the neck, in whicli the ventral cutaneous branches of the second and third, or even of the second, third and fourth cervical segments are sacrificed, serve to isolate the trigeminal skin-field within an enclosing area of cutaneous anaesthesia. An opportunity is thus given, by comparing the anterior outlines of the ana>sthetie field so produced with the posterior outlines of the aufesthetic field residtant to a trigeminal neurectomy, of determining the extent iind characteiof functional overlap between these adjoining areas.

The cases which have for the most part best served this purpose have been those of complete extirpation of the cervical glands (Figs. 11-1.5), though operations of other sorts necessitating peripheral nerve divisions have also furnished material for studv. The anajsthesia occasioned bv these lesions is a

'Poirier et A. Charpy: Traite d'Anatomie Humaine, 1901, Tome III, Systeme Nerveux, p. 96.

224

[Nos. 100-1 (11.

much less permanent one than that in the trigeminal area after division of the root of the fifth nerve, and consequently it is advisable to determine the outlines as early as possible

Kii;. 14.

aftei' the operation. Most of the areas liavc been plotted fniiu the seventh to the tenth day, that is, as soon as the surgical dressings would allow of an exposure of the parts.

Fiii. 10. — Average outline of the auricular portion of the ceivicul field (lelimitinK tlic area of tactual an;i'stliesia.

As in the study of the trigeminal field, so here chief stress will be laid upon the outlines related to the ear. The lino delimiting tactual anaesthesia (horse-hair test) (Fig. 16) in the large majoi'ity of cases studied lies nn the temporal region

somewhat farther back than the tactual line of the trigeminal field, strikes the pinna at about its upper mid portion, ascends over the edge of the helix to the outer face of the

Flii. IT). Figs. 14 and 1.5. — Area of transitory anaesthesia after extensive 'glands of the neck' operation with facrifice of ventral branches (CII, III and IV) of the cervical plexus.

ear, which it crosses behind the fossa triangularis to the antihelix; the ridge of this latter structure it follows, passing around the posterior margin of the concha to the in

Fid. 17. — Charted S days after 'glands of neck' operation. Boy of la. Showing medium (average) vagus area.

cisura intertragica, the line usually dipping in somewhat on the inner face of the antitragus; from the incisura intertragica. •"' imii. or more below the point of emergence of the irigi'ininal line for touch, it passes out onto the cheek usually

July-August, 1901.]

in a forward and downward direction instead of forward and upward as does the trigeminal line.

The line of analgesia and thermo-ana?sthesia lies from a few nun. to about one cm. posterior to this tactile outline.

7V"

Fig. is. — Eleven days after ' srlauds-of-ueck ' operation. Girl of 20. Larije vagus area.

There can be detected, also, in almost all cases, a clear-cut boundary on the cheek which corresponds with the anterior of the lines described with the trigeminal field and within which there is an appreciable though exceedingly slight hypa?sthesia to all forms of sensation, to pain, touch and temperature.

Fii.i. I'.K — Eiglit (lays after 'glauds-of-neclc ' operatiou. Small vagus area.

Figs. 17-19. — Show areas of " remaiuing sesthesia " in fields of trigeminus and vagus after section of cervical nerves (N. auricularis magnus and X. occipitalis minor).

Shaded area, within broken line = field of tactual anai-sthesia.

Dotted area, within solid line (Figs. IT and 18) = field of slight hyp;cpthesia to pain touch and tempicrature.

Dotted line delimits anterior maruin of analgesia.

These several outlines may be lictter a])prec-iated by the three drawings (Figs, 17, 18 and 19), which give at the same time some of the variations seen in this area.

It will be seen, in Fig. 17, that tbr mitline of tactile ampstliesia 111' the rervical field. \)itli the exception of tlie concha.

presents almost an e.vact negative of the corresponding line of the trigeminal held. This has been observed in several cases. A photograph of the outline of one of them is here given (Fig. 20), a case in which the posterior root ganglia of the second and third segments on the left side were removed from the intervertebral notches for intractable neuralgia of this region. The concha itself, wholly or in large part, as will be seen, retains its normal sensitivity, and together with the posterior wall of the external auditory canal it represents a field of distribution interposed between the trigeminal and cervical areas. It has been generally conceded by anatomists that this area is supplied by the peculiar aberrant cutaneous branch from the vagus, the Iv. auricularis ncrvi vagi of Arnold.

/ w

%

Fig. 20. — Segmental area of tactual aua-sthesia after removal of 2nd and 3rd posterior root ganglia.

G. Orerhipping and Permanence of Ancesthesia. — What has been said in the preceding section will have shown that the overlap between the skin fields "of the trigeminal and cervical areas is less extensive and functionally less perfect than anatomical and experimental evidence would have led one to expect. If. as seems probable, the strip of hypalgesia (Fig. 1) is to be taken as representing the overlap on to the trigeminal field from the area of C II, it not only is possessed of very slight sensativity in the early post-operative period but also, so far as I have been able to learn from the examination of late cases, never returns to anything like its normal condition of ipsthesia. In only seven cases of the ganglion series has it been possible to make comparative examination after long periods of time: one of them a year, two eighteen months, three two years and one four years after the operation. Ill all iif these cases, with two exceptions, the old outlines

226

[Xos. 1 GO- 101.

have still been clearly demonstrable, the only change being that of slightly increased sensativity in the strip of overlap, though it remains considerably below a normal condition of issthesia. The two exceptions were as follows: one, an incomplete extirpation in which sensation with some hyperalgesia had largely returned in the territory of the ophthalmic division, the other, one of the group constituting the trigeminal subvariety (Fig. 9) and, though a complete extirpation, there had been after two years a shrinkage of the field to the normal or average configuration (Fig. 21) a finding which would have served to make one somewhat skeptical of the accuracy of the original outlines had they not been carefully and repeatedly plotted. This, too, was one of the cases in which the rhythmic shifting of outline mentioned above had been especially evident, the most post

r

Fio. 21. — For comparison witli Fis;. '.l. Areas uf .auii'Sthesia to paiu aud touch two years after the neurectomy.

axial position of the line having been pliotographed in the original. In many of these late examinations on account of the growth of hair I have felt less certain of the persistence of the original lines on the scalp thougli in this case (Fig. 9 and 21) and in one other, owing to baldness, it was possible to trace them to the longitudinal line of the crown.

Tlie median or crossed ovcrhi].), from the opposite side, after the lapse of time remains likewise insignificant and pliysiolngically incomplete, it being possible to demonstrate factual hypiethesia to the mid-line after years, in spite of the slight increase of sensativity wliicli appears especially in the nasal portion of the mesial strip.

The same is true for the mid-line of the mucous membrane field wliei'e tlie functional crossing is trifling. One portion of the intraoral field, however, in several cases seems to have largely regained its sentiency, namely, the anterior pillar of the fauces, the uvula and the margin of the soft palate. It is this return of sense perception along the velum tliat has thrown some donbt upon the communication, mention^ il

above, as a probable one between the pharyngeal and oral portions of the trigeminal territory.

What has been said applies only to the overlap from the adjoining areas on to the trigeminal field in conditions of trigeminal neurectomy. In the cases of cervical nerve lesion the almost complete restoration of normal anaesthesia has probably been due to the fact that the peripheral nerves alone have been sacrificed and nerve reunion ratiier than trigeminal overlap has been responsible for the return of sensation. In one only of the cervical cases was the anaesthesia due to a root division (Fig. 30) and there has been no opportunity of examining this patient since his discharge from the hospital. I am inclined to the opinion, however, that overlap from the

Fig. 33. — Frobse's four types of trigeminal distributiou. mandibular division is dotted. Vagus field solid black.

Field of

trigeminal onto the cervical fields is functionally less than from the cervical onto the trigeminal, for the slight though appreciable dulling of sensation along the posterior edge of the trigeminal area immediately after the cervical lesions (Fig. 17-19) shows the anterior limit of cervical distribution, surprising though it may be that one is able to demonstrate overlap in this way. It is not impossible, however, that what I have considered as a subvariety of the trigeminal area (Figs. 9-11) may be nothing more than the corresponding overlaj) onto the cervical field, demonstrable immediately after the trigeminal lesion and sufficiently noticeable in three cases only though possibly present in inappreciable degrees in all.

The anterior or posterior overlap from the auricular skinfield innervated l)y the vagus, if present at all, seems to be inconsiderable.

IT. .\N-ATOjric.\L Results Givex by the DissectionMethod.

We may now for jnirposes of comparison turn lirii'fly to

July- August, 1904.]

227

tlio considoratidii ol' tlio rcsiiKs ohiiiiiu'.l by oWwr methods tlian tin' rliniciil one. TIhiso imatoniists who have made this area the object of particular study, notably Frohse and Zanger. have devoted their attention largely to the cutaneous distribution. Their painstaking labors seem to have indicated that the variation in outline of the main field, from case to case, is con.siderablc and particiibniy that tlie extent of the fields for the three trigeminal subdivisions shows great individual difl'erenccs; that ev(Mi in the same individual the distribution on the two sides of the face may be very

fiandois and ollirrs. In Pig. 22 are given four types of skinPields as his personal dissections have led him to picture tliem," the first of whicli, inasmuch as it corresponds with the diagram which he had furnished for Krause's (189()) niono1,'raph (cf. also Frohse's outline in Fig. 23), I take to represent the average type as he has foimd it. His four figures all illustrat(^ well the " anchorage" of the field at the external a\ulitory meatus. Excepting the inclusion of the helix about to its mid summit, as well as the fossa of the antihelix, a distribution wliicli I have found to be functionally drnionstrable

___ Vaw GeVvu 'TWo«e_ .

Fio. 23. — Posterior bouudary of the tris;eminftl skin-field as given by various anatomists.

(lifTeront; that there is a wide anatomical overlap, " Verbreitungsgebiet," between the adjoining fields; and, Zanger, especially, that it is possible liy careful dissection to demonstrate fibers crossing the mid-line, more noticeably at the nose and lips. They have both emphasized the absence of trigeminal fibers to the skin covering the parotid and masseteric areas, a condition which had escaped the notice of their predecessors, ;ind, nuiy 1 add, of many of their followers. Froliso in his claliorate monograph " gives not only the variations which lie has found, but compares them with the fields delineated in the familiar diagrams of Striimpell, Merkel,

in one case only, tlic outline in this first figure is practically the counterpart of the skin field demarcated in the great majority of my ca.ses. Frohse also emphasizes the presence of the vagus field its area being somewhat variable in extent though largely confined to the concha.

In Fig. 23 a composite has been made of the trigeminal outlines given in some of the standard anatomical works. Many more types might have been added for there are a great number of them, but these will suffice. Van Gehuchtcn," it will be seen, gives merely a .schematic outline within which the skin

'Fritz Frohse: Die oberflachliclien Nervon cies Kopfes. lin-Prag, 1895.

Ber

'" Bardeleben, Haeekel und Frolisc: Atlas dor topographischen Anatomie ites Menschen. Dritte auflaRo, Jena, 1904.

" Anatomie du SystCsrae Nerveux. Troisi6me Edition, Louvain, 1900, Vol, 2, p. 150,

228

[Nos. 160-161.

covering- the panitiil and iiiasseter regions is incluilnl. Tnldt,'^ incloses the vagus lielil together with the antitragus within the trigeminal area. Thane " gives a still more [jostcriorly placed auricidar line which, like Toldt's, includes the vagus field and also most of the helix and antihelix, the outline corresponding closel_y with the field of the suhvariety wliich has hecn mentioned as occurring in a snudl percentage of my cases. Other authors as Spalteholtz, following Zander," have given a somewhat confused figure with indefinite outline, in their desire to represent the anatomical variations and overlap. Zander's diagram otherwise is for the most part in accord with Frohse's and his excellent article is given up largely to the consideration of anatomically demrmstrahle overlap.

In man) of the newer anatomies, in spite of the omissions of detail in describing skin-fields, there will be touml in the context mention of the finer distribution : as that of Arnold's nerve, of the branch from the auricuio-temporal to the external auditory meatus; of the filament to the tympanic membrane, etc. In Schwalbe and Siebenmann's monographs on the Ear '" will bo found gathered most of the available information in regard to the distribution about the external and internal ear, though I have not found even there comment on the supply to the Eustachian tube. According to Henle, however, certain branches of the superior nasal group from the spheno-palatine ganglion terminate in the neighborhood of the Eustachian orifice. The distribution of Arnold's auricular branch from the vagus has been traced with particular care by Frohse and interposed as it is between the auricular branches of the fifth cranial and those of the second cervical fields the possibilities of complex innervation of the external ear are great. As stated by Soulie '" " c'ost le jiavillion de Foreille qui, en raison des sources multiples de son innervation, presente les anomalies les plus frcquentes; c'est d'aillcurs a cette innervation complexc ipril doit de conserver sa sensabilite presque indemne lors(|u"iine i\v ses sources d'innervation vient a etre supprimee."

Ill i-niisidcralinii, IbiTi'roi'c. of this miillipli' innci'vation, [)articularly of the auricle, and of the variability of field innliguralioM shown by l<'rolisi' and the demonstrable overlap between llic fii'lds according to Zander, it is surprising how much conformity there seems to lie in Ihe clinical outlines in a comparatively large grou|) of cases and how closely the ta.ctiuil-line delineation of these cases corresponds with the average field dclcniiiiicd bv lrohsc"s dissections.

" Anatomische.s Atlas, 1903.

"Quain's Anatomy. lOt.h Edition, ]8i).>. Vol. Ill, Pt, II, -The Nerves."

'* R. Zander: UoitraKe /.iir K'i'inilniss diT llavjlnervcu dos KopfpK. Anatomische Hefto, I8!)7, Bd. IX, p. 1, Merkel's Festschrift Volume.

"' Bardeleben's I laiidliiicli dcr Anatomic des Mensclicn, .Tona, 1897, Bd. V, LieferunK H.

'"Poirier et Charpy's Traite d'Anatomie llumaine, Paris, PJOl, Tome ?,, p. 8?A.

•'5. Tnic Resui/i's ok Anim.m, Expeklmkniai'ion.

Ei'om the slandpoint ol physiological experimentation the investigations made by Sherrington" to determine the segmental skin-fields on the macaque are .so far su|)erior in extent and in accuracy of detail to any similar obscrvaiions wliii-h have ever been made that for purposes of compari.son with our clinical findings they alone need he referred to here. 'J'he metliod chiefly u.sed was that designated by Head as the " method of remaining a'sthesia " in wliicb the extent of a given skinfield is determined, after the intradtiral section of two or three dorsal nerve roots adjoining, both on the cranial as well as caudal side, the particular root whose distribution was the object of study, in this way an a-s(hetic dorso-venlral strip of skin would be left in the midst of an anai.sthotic field. It need hardly be repeated here that the experitm-ntal section of a single dorsal root, at least of the spinal segments, leaves no area from which tactual responses may not be elicited even though there may result only partial loss of sensitivity to some other forms of stimuli. This is due to the almost complete tactual overlap of a single dermatome by the nerve terminals from adjoining root fields, the condition for each unit f)eing that of almost complete double innervation. I have hail an opportunity of corroborating in man tlie accuracy of these laboratory findings in so far as they apply to one of the spinal segments, by the study of a patient in whom a dorsal root in the cervical region had been divided during the enucleation of a tumor of the meninges. This well recognized law of overlap seemingly does not apply in its full force to the cervico-trigeminal boundaries, nor to the field margins of the three trigeminal divisions. If we are to consider the X. trigemintts and its ganglion as representing a fusion of three sensory cranial tmits, the severence of peripheral connections with one of its divisions should not leave a factually anaesthetic field. This is, however, not the case for section in man of the N. mandibularis alone for example, leaves an ansesthetic skinfield whose boundaries in the early post-operative period correspond with the anatomical distribution and with the physiological field which would be determined by the " method of remaining a'sthesia." If the laws of functional overlap were here applicable the other divisions of the fifth and the second cervical fields would so encroach on this area as to mask its factual outlines.

On section of the trigeminal root, it being the most anterior of the sensory nerves of the body, and overlap across the mid line IxMug so slight, llierc naturally results a large area of ana'sthesia. Ihe lield of ihuiblr iunervalion onlv being possible at ils pos(ei-i(M' border. Sherrington fcnind thai such a trigemiiKil seel ion in the inonkm Irft a lii'ld n( (-(uuplete insensitivify within Ihe ,-nit('ri(ir line sIkiwu in Fig. '2 \ c. which at the sanir lime snpposcdl\ rcpi'i'sciits the aiitrrior limit of futu'lioiial (list riliul inn of tlir ecrN'ical se<i-incnls. This line ihudit

" C. S. Slicrrin.i^ton: Exiinrinients in Examination of the Periph<-ral Distribution of the Fibers of the Posterior Roots of some S|)inal Nerves. Part II. Philosophical Transactions of the Royal Soc, London, Series B, Vol. 190 (189S), p. 45-1 8G.

JULY-AUGCST, 190J:.]

229

less corresponds for the macaque with the anterior of the lines determined in man (Fig. 1), and herein lies the chief difference between the experimental and clinical findings. It is almost impossible in dealing with animals to difEerentiate between the character of responses to the various forms of stimuli and all must be set down alike. Hence the entire extent of the trigeminal skin-field, after posterior root division, cannot be mapped out as it can in man by the employment of delicate tactual stimuli. Were communication impossible between the observer and the patient, as is the case in the laboratory experiment, the functional incompleteness of the overlap in man also would pass unobserved, since responses to pain (though not dolorous as stated above) may be elicited from the trigeminal posterior-border-strip. (Fig. 1).

After experimental division of the cervical nerve roots, Sherrington also determined a line representing the posterior border of functional distribution of the trigeminus which, although it includes in the diagram (Fig. 24b) the entire ear and is somewhat more posteriorly placed than in our clinical

section of the trigeminal root and at the same sitting an intraspinal division of the upper cervical roots on the corresponding side. This was accomplished in two instances, an aesthetic field remaining (Fig. 25) which was considered to represent the vagus ( ?) distribution to the skin. A similar field, as has been seen, may be determined in man after trigeminal and cervical root division, owing to the functional incompleteness of overlap. The area in the monkey, according to Sherrington, " includes and immediately surrounds the external auditory meatus. It takes in practically the whole of the concha, the antitragus, part of the tragus and part of the antihelix ; also part of the fossa of the antihelix." He considers that this field receives in part a quadruple innervation being overlapped not only by the trigeminus but by the second and third cervical segments.

So far as it has been possible to carry out the tests, the observation on the field of anaesthesia over the mucous membranes, after trigeminal neurectomy in the monkey, are in close agreement with the clinical determinations given above. Sher

FiG. 34.— Skin-flelds of 2nd and 3rd cervical segments and of 5th cranial determined in the macaque according to the method of "remaining aesthesia." Note that overlap between 5th cranial and ord cervical is suflBcient to completely cover the 2nd cervical. (Sherrington.)

Fig. 25. — \\ ithin dotted lines lies the "completely delimited area of auricular of vagus" determined experimentally for the macaque. (Sherrington.)

cases, nevertheless the posterior edge of the upper field of response as given in his paper (Philosoph. Transac, 1898, Yol. 190, p. 54), is almost in exact accord with that determined in our cases of cervical nerve lesion. Here again the anterior boundaries of hj-pjesthesia found to exist in man would be indeterminable in the animal. In Fig. 24abc, furnished for one of Head's papers, Sherrington has so incorporated his findings as to demonstrate the extent of overlap. It will be seen that the second cervical field practically in its entire extent is doubly innervated. Although our clinical observations cover merely the anterior half of this field they are in accord with the experimental work, however, only in so far as the latter concerns the field of no response to any form of stimuli, for the overlap itself is of a different nature and is functionally possessed of a much lower plane of sensativity than had been pre-supposed.

By the " method of remaining aesthesia " Sherrington succeeded also, for the macaque, in demonstrating the presence of the vagus skin-field although for this purpose a very difficult and severe operation was necessitated, namely an intracranial

rington notes that the anjesthesia extends fully up to the median line across which an overlap from the opposite side " is very slight or non-existent."

To simimarize the question of overlap between the trigeminal and cervical areas, it may be said : That trigeminal root division in man gives a field of total insensitivity which corresponds with that determinable in the monkey, the complete extent of the skin-field, however, remaining demonstrable, owing to the functional insufficiency of the overlap, delicate tactual anaesthesia persisting over the entire field.

Furthermore, that after division of the cervical branches (roots in one case) the anterior boundary of total insensitivity corresponds approximately with the experimental findings, tactual anesthesia to delicate stimuli, however, remaining complete (exclusive of the vagus field) almost as far forward as the posterior line delimited in the same way for the trigeminal field. Thus in clinical cases the "' method of resulting anaesthesia " serves as well for the establishment of the outline as that of " remaining aesthesia."

230

[Nos. lGo-it;i.

i. Embryological Basis for Sensory Distribution.

Without entering into a discussion of the homologies between the cranial and spinal nerves, a subject which has inspired mucli of the recent work on the development of the lower vertebrates and one which still remains in a somewliat discordant state, the generalization is sufficient for our purposes that the X. trigeminus bears in its structure and in its peripheral and central connections a close parallelism with the double system of ventral and dorsal roots of the spinal segments and it is possible to establish for this nerve and for those cranial ones which follow a certain metameric disposition similar to that characterizing the spinal nerves.

So long as it represents the only pathway for all the splanchnic and somatic afferent fibers from that portion of the head which has developed anterior to the first visceral

Fig. 26.

cleft, it is iiiiinaterial for our purposes whether or not the Gasserion ganglion represents the fusion of one or more cranial dorsal root ganglia.

In the early embryo (Fig. 26) this deep cleft .serves to divide the mandibular bar, which is innervated by the N. mandibularis division of the trigeminus, from the posteriorly placed hyoid arch whose main nerve is the N. facialis. Around the dorsal end of the cleft lie grouped the six cartilaginous tubercles (Fig. 26) which according to the investigation of Wm. His, Jr., represent the rudiments of the external ear. Two of them according to his description lie on the mandibular side of the cleft and develop, one, into the tragus, the other into a portion of the helix (its crus according to Schwalbe). The third protuberance (tuberculum intermedium) His places at the upper end of the cleft possibly developing from its mandibular, possibly from its hyoidal side ; it is destined to form the anterior ascending portion of the helix. The fnurtli, fifth and sixth tubercles develop

from the hyoidal arch and are the rudiments respectively of the antihelix, the antitragus and the lobe of the ear. Schwalbe" and Gradenigo have a somewhat different adult destination for these hyoid tubercles, though tlie general plan is much like that of His. Of the helix its