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 0«-'<^-4->VLAA- f] ' • 
 
 UPON THE 
 
 EXISTENCE OF A MINUTE MICRO-ORGANISM 
 
 ASSOCIATED WITH CASES OF 
 
 PROGRESSIVE PORTAL OIRHHOSIS 
 
 BY J. G. ADAMl, M.A., IW.D., F.R.S.E., 
 
 PROFESSOR OF PATHOLOGY, McGILL UNIVERSITY, MONTREAL, 
 
 IlKPHINTED PROM THK MONTRKAI- MEDICAL JOURNAL, JULY, 1898. 
 
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 - 4! . 
 
UPON THE EXISTENCE OF A MINUTE MICRO-ORGANISM 
 
 ASSOCIATED WITH CASES OF PROGRESSIVE 
 
 PORTAL CIRRHOSIS.' 
 
 BY 
 
 .1. G. AnAMi, M.A., M.D., F.R.S.E. 
 Professor of PatholoKy, McGill University, Montreal. 
 
 It will be known to members of this Society that, working in 1894 
 and '95 in Nova Scotia, I was not only able to confirm the previous 
 observation of Wyatt Johnston, that a very interesting disease 
 occurring among the cattle in a district to the north of the Peninsula, 
 was infectious and epizootic, but further, obtained from cases of this 
 so-called Pictou Cattle Disease, a characteristic micro-organism patho- 
 genic for rabbits and guinea pigs. This organism I found constantly 
 in the cultures from the livei-s and abdominal lymphatic glands, and 
 fairly frequently in cultures made from other organs. 
 
 The main feature of this Pictou Cattle Disease is a peculiarly exten- 
 sive cirrhosis of the liver accompanied by swelling of the periportal 
 and retroperitoneal lymph j^lands, with some ascites and a condition 
 of multiple follicular ulceration of the fourth or true stomach. The 
 ulcers aie generally found in a cicatrised condition. 
 
 The first recognisable symptoms (of which the most marked is the 
 rapid diminution in the amount of milk given off together with a 
 peculiar bitter taste and odour of the same when heated) occur only 
 from 24 hours to ten days before death ; evidently therefore the 
 extreme ciirhosis of the liver must have been advancing for a long 
 period without symptoms. Death occurs most frequently with pro- 
 gressive weakening and paresis ; in some few cases there is a period 
 
 > Read before the Montreal Medico-Chirurgical Society, June 20th, 1808. 
 
of intense excitement almost maniacal foUowt'd liy exhaustion and 
 death. 
 
 The micro-organisms present in this disease are most difficult to 
 stain in the tissues ; indeed, the difficulty that I have found in deter- 
 mining any method whereliy they can with certainty he demonstrated, 
 has prevented me so far from publishing an extended description of 
 my results.' Apparently they stain easily, hut lose their stain with 
 extreme facility. With practice I have been able to i-ecognize them 
 in an unstained form in the tissues and in this condition they have a 
 faint brownish tinge and a halo is faintly but definitely recognisable. 
 For a long time it appeared to be almost a matter of chance whether I 
 was able to stain them or not, or more correctly, oidy if I was fortun- 
 ate enough to clear the sections with sufficient rapidity did I get the 
 microbes stained. Yet another difficulty in staining this micro- 
 organism has been its minute size within the tLssue.s, so that with the 
 ordinary 15th inch immersion which I have used until the last year or 
 two, unless they were stained to the right extent, neither under nor 
 over stained, they were recognisable with great difficulty. Still, there 
 they were, and under the proper conditions they could be found in 
 great numbers in the liver and abdominal lymphatic glands. 
 
 If thus an extreme condition of cirrhosis of the liver is brought 
 about in animals by the proliferation in the tissues of a micro-organism 
 which sets up the chronic and progressive hepatic disturbance, it has 
 seemed to me possible that a similar result may be produced in man. 
 As a matter of fact, for some yi-ars past Hanot and the French 
 school of Pathologists have insisted that one form of cirrhosis — the 
 large, smooth, cirrhotic liver with jaundice, the form now frequently 
 spoken of as Hanot's cirrhosis — is of infectious origin, though they 
 have not been able as yet to declare wlnit is the microbe causing the 
 infection. To the be.st of my knowledge liowciA er, no one has so far 
 ventured to .state that the more common or so-called atrophic cirrhosis^ 
 the ordinary hobnailed liver, is ol' microbic causation. While the 
 time has gone pa.st when it was taught that such hob?iailed livers are 
 directly caused by alcohol, the prevailing opiniim is that alcohol or 
 other irritant l)y setting up a condition of chronic gastroenteritis 
 and destruction of the mucous memVtrane of the upper portion of the 
 intestinal canal, permits the altsorption of toxic substances from the 
 food, and thesr toxic sub.stances taken up by the portal blood induce 
 
 ' StateiiiPiits concerning my invcstipit ions in Nova Scotia and early studie.s 
 of the niicni-oiganisnis associated wiMi tlie disease are |)ul)iislied in tlie Rei)orts of 
 tlie Department of Agricnltnre for tlie years 1804 and 18!)3. At tlie Montreal meet- 
 ing of the British Medical Association last year, I also read a paper upon the suhject, 
 of which epitomes were published in \\ni British MedivalJournal, Lancet, &c. 
 
8 
 
 a snrroujuling chionic phlebitis with or witliout direct action upbn 
 the liver cells. 
 
 During the last four years I have carefully studied all cases of 
 hepatic cirrhosis which have come to the post-inortein room at the 
 Royal Victoria Hospital to observe whether I could make out the 
 existence in them of micro-organisms to such an amount and so con- 
 stantly that we may safely conclude that the disease is associated 
 with the presence of these micro-organisms. Here again the same 
 difficulty pursued me as was present in the earlier stage of my studies 
 upon the Pictou Cattle Disease ; at times I could distinguish in sections 
 the presence of numbers of minute diplococcus-like bodies, but further 
 sections from the same case did not stain well, and there has been the 
 added difficulty that the liver contains so many fine granules that in 
 the unstained condition it is extremely difficult to make oneself 
 positive that what one sees is not of the nature of some cellular pre- 
 cipitate or fine deposit. In two cases in 1895 and 1896, 1 thought 
 that I had gained cultures from the liver, but upon growing these 
 they were overrun with the colon bacillus and I lost them. In a / 
 more recent case, during last month, I was able to gain from an agar 
 tube of the liver juice an extremely minute diplococcus staining with 
 great difficulty, and scarcely visible. The tube was reported to me as 
 being sterile and only upon the 4th or 5th day of the growth did I 
 examine it myself, and found there this presence of small micro- 
 organisms in small numbers, but when I tried to make further growths 
 tiie microbe had already died out, if indeed, what I savv was anything 
 beyond the rnicrobes already present in the juice, upon inoculation of 
 the tube, which ha<l not proliferated,. 
 
 In connection with this case, which was one of atrophic portal cirr- 
 hosis with pigmentation, I have been able to find micro-organisms in 
 considerable quantities in the tissues. Dr. Abbott, who has been 
 working on this case more especially in connection with the pigmen- 
 tation of the organs, showed me some sections of the abdominal lymph 
 glands which she had stained by Weigert's fibrin stain, and which 
 under the high power had a peculiarly granular appearance. Upon 
 examining with the i8th inch immersion, I found that the fine gran- 
 ules resolved themselves into great numbers of minute microbes of 
 the character which I had learnt to recognise in connection with the 
 Pictou Cattle Disease ; namel3^ the micro-organisms present were 
 extremely minute, even smaller than those seen in the Pictou Cattle 
 Disease : in the main they were present as diplococci with a slight 
 halo round them, very much smaller than the diplococcus of pneumonia, 
 but like that organism certain of those present were longer and more 
 distinctly in the form of diplo-bacilli. 
 
tfUJi, 
 
 Many of the forms presont rcscinlilc closely inimiti' ('(litions of the 
 gonococcus. Further, the micro- oigiinisniH vary to sonit^ extont in 
 size ; this may be a matter of imperfect staining or may he another 
 evidence of the polymorphism to which 1 have already drawn atten- 
 tion. On the whole inasmuch as certain examples are distinctly 
 bacillary, the organism then should be placed among the bacilli rather 
 than the diplococci. 
 
 Examining a series of livers by Weigert's fibrin method, I am in 
 doubt as to whether the bacilli truly resist the action of the iodine 
 solution, for while I get good i-esults in some cases, in others I see a 
 very large number of what I may term ' shadows.' It may be there- 
 fore only that the bacteria are relatively resistent to the action of the 
 iodine. 
 
 To-day I have elaborated a still more satisfactory stain which 
 shows the presence of bacteria with certainty. The method is as 
 follows : 
 
 Taking the sections that have been well hardened and cutting them 
 by the freezing microtome, I pla(!e them for a minute or two in a weak 
 solution of acetic acid in order to clear the cells as much as possible, 
 I then wash out the acetic acid and place in absolute alcohol ; from 
 this I transfer to a .solution of methylene blue in anilin oil. This oil 
 takes up the blue with fair ease and I employ a half saturated 
 solution. In this I leave the sections for half an hour. The methy- 
 lene blue-anilin oil mixture has the advantage over an anilin oil 
 gentian violet mixture in that it does not overstain. At the end of 
 half an hour I transfer the sections for a quarter of a minute into a 
 mixture of two parts of anilin oil to t\^o parts of xylol, then rapidly 
 into xylol. If there is an^ tendency to excessive stain, I treat them 
 for a longer period with a mixture of two parts of anilin oil to one of 
 xylol before placing in the xylol ; they then are mounted. 
 
 The method is not perfect, for the tissue is not completely decolor- 
 ised ; nevertheless, the bacteria are to be seen ciearly in the newly 
 formed connective tissue. Staining by this method I also find that 
 not all the bacteria take the stain completely ; there is a lai'ge pro- 
 portion which has retained a brownish tinge, but these from their 
 diplococcus shape and faint halo, can only be microbes. Many of the 
 microbes are also without doubt within the liver cells. 
 
 I thus come to the conclusion that a large number of the microbes 
 present are probably dead, and have absorbed some colouring matter 
 from t' 3 blood or the bile. So far I have come across this one form 
 if, very considerable numbers in every case of advanced hobnailed 
 cirrhotic liver which I have examined (five cases) with one possible 
 
 I 
 
 
I 
 
 exception, the exception being a case in which the undertaker had 
 embalmed the body, and the crystals and dc'bris of the embalming 
 material cause so nmch dirt in the sections that it is difficult to make 
 out the state of attairs, but even in this case I believe I can detect 
 some of the characteristic bacteria. 
 
 Thus at the present time I would go so far as to say that in a 
 certain number of cases, at least, of hobnailed liver, there is present, 
 more especially in the liver and the abdominal lymph glands, a 
 minute micro-organism resetnbling closely that found pathogenic in 
 the infective cirrhosis of cattle ; a form which is present most fre- 
 quently as a minute micrococcus but sometimes has a more bacillary 
 appearance, and which is thus to some extent polymorphous. 
 
 . Appendix, July 9th, 1898. 
 
 Smce reading this communication, through the kindness of Professor 
 Hektoen and Dr. Flexner, I have had the opportunity to examine 
 fifteen other livers showing distinct evidence of portal cirrhosis from 
 the material at the Rtsh Medical (College, Chicago, and the Johns 
 Hopki.js Hospital respectively. I have not, as yet, examined all the 
 material from the latter source, but in all the Chicago ca«es, as in ten 
 well marked examples from Baltimore, I recognise the appearances 
 above described. More satisfactory staining of the doubtful case 
 above mentioned, show the undoubted presence of diplococci. 
 }?L^ 1^ A fuller description of my observations, together with the descrip- 
 tion of the bacillus, isolated by me recently from a case of cirrhosis, 
 will be communicated to the meeting of the British Medical Associa- 
 tion, at Edinburgh, by Di-. Osier. I would only add here that the 
 methylene blue, aniline oil method of staining described above, while 
 giving very fair results for immediate study, does not in my hands 
 
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