The Dandridge Volume Being a series of papers presented at various times in the meetings of the CINCINNATI RESEARCH SOCIETY and dedicated by it to the memory of its distinguished member Nathaniel Pendleton Dandridge, M.D. ^^^^^ ^ p^ Cincinnati, Ohio 1913 THE LANCET-CLINIC PRESS CINCIXXATI library :Biodrapby NATHANIEL PENDLETON DANDRIDGE was born in Cincinnati, O., on the 16th of April, 1846. His parents were Dr. Alexander Spots woode Dandridge, a physician of high pro- fessional and social standing in his day, and Martha Eliza Pen- dleton. Both the Dandridge and the Pendleton families were among the early settlers of Virginia, of English and Scotch stock, and are identified in many ways with the most important events in its history. ■ Dr. Nathaniel Pendleton Dandridge received his elementary education in a private school in Cincinnati, and later entered Kenyon College, Gambler, O., from which he was graduated with the class of 1866. The scholastic year of 1866-67 was spent as a student in the jMedical College of Ohio. In the summer of 1867 he went abroad, where he studied medicine in Paris in 1867-68 and in Vienna in 1868-69. At that time these were the most famous medical schools in the world. Returning to the United States with what was at that period much more than an ordinary medical education. Dr. Dandridge entered the College of Physi- cians and Surgeons of New York, and, after taking the winter course of 1869-70, received his degree of Doctor of INIedicine from that institution. Returning to his home in Cincinnati, in 1872, he was appointed pathologist to the Cincinnati Hospital, a position which he held for eight years, during which time he taught pathology as he had learned it from the lips of the great masters in Paris and Vienna, and enriched the museum of the hospital with many specimens intelligently and carefully prepared by his own hands. This appointment, coming so soon after his pathological and clinical studies abroad, laid a sure and broad foundation for that remark- ably comprehensive knowledge of general surgery which later brought the profound admiration and respect of his colleagues and the profession at large. 5 HN 2^07259 6 DANDRIDGE MEMORIAL In 1880 he was appointed surgeon to the Cincinnati Hospital, and in the same year was made professor of surgery in the Miami Medical College (recently merged with the Medical College of Ohio to form the Medical Department of the University of Cin- cinnati). It is as the incumbent of these two positions that he will be most vividly remembered by his juniors in the medical profession of Cincinnati and the surrounding States. His lectures were clear, concise, illuminated by the sound common sense that characterized his argument, and, when the occasion permitted it, enlivened by a glow of that genial humor which always rose spontaneously from his heart to his lips. In 1887 he was appointed to the Board of Examiners of the recently reorganized Police Department. This position he held until 1896, when he resigned. It was during this period that the present high standard of physical development of the members of the police force was set. Although Dr. Dandridge's position as surgeon to the Cincin- nati Hospital brought him, justly, a wide fame and membership in many learned societies, such as the Southern Surgical and Gynecological Association, the American Surgical Association and the Academy of Surgeons of Philadelphia, it is probable that the professional appointment in which he took the keenest pleasure, and to which he unselfishly devoted the greatest amount of time and eftort, was his service at the Episcopal Free Hospital for Children. His gentle and kindly disposition was seen at its best in the wards of this most excellent charity, to which he was one of the surgeons for many years. Although no lectures to students were conducted in this institution, surgical literature was enriched by Dr. Dandridge by many papers on the surgical diseases of the bones and joints, the necessary observations for which were acquired in the wards and operating room of this hospital. In 1909 he resigned his position as surgeon to the Cincinnati Hospital, and accepted an appointment on the Board of Medical Directors of that institution. Twenty-five years previously hi-5 father had been a m.ember of the governing body of the hospital, having served on the Board of Trustees for a number of years. In addition to the professional appointments and honors al- BIOGRAPHY 7 ready recorded, Dr. Dandridge was at the time of his death, in 1910, a member of the Cincinnati Academy of Aledicine, the Ohio State Medical Society, the American jMedical Association, the Southern Surgical and Gynecological Association, and an Hon- orary Fellow of the Academy of Surgery of Philadelphia. He was also a trustee of Kenyon College, and, by right of descent, a member of the Sons of the Revolution and the Virginia Chapter of the Society of Colonial Wars. Christian R. Holmes. (Contents PAGE Biography 5 S. P. Kramer, ]\I.D. The Pathogenesis of Gail-Stones 13 Paul G. Woolley, B.S., M.D., and L. H. Xewburgh, A.B., M.D. Aortic Aneurism with Rupture into the Pulmonary Artery 19 Creighton Wellman, M.D., and Wm. B. Wherry, A.B., M.D. Some New Internal Parasites of the California Ground Squirrel (Otospermophilus Beecheyi) 27 Sidney Lange, B.S., M.D. The Pathology of Mastoiditis as Revealed by the X-Ray 33 Otto V. Huffman, M.D. Miners' Consumption 43 Oscar Berghausen, A.B., M.D. The Wassermann Reaction 47 Oscar Berghausen, A.B., M.D. The Significance of Ehrlich's Aldehyde Reaction in the Urine.... 55 Otto V. Huffman, M.D. Impetigo Contagiosa Transmitted by Machine Oil 67 Albert H. Freiberg, M.D., and Paul G. Woolley, B.S., M.D. Osteochondritis Dissecans : Concerning its Nature and Relation to Formation of Joint Mice 69 Otto V. Huffman, M.D., and Wm. B. Wherry, A.B., M.D. A Description of Four Filaria Loa from the Same Patient 81 Otto V. Huffman, M.D. The Embryos of Filaria Loa 91 William Ravine, M.D. The Successful Treatment of a Case of Illuminating Gas Poison. 99 J. L. Tuechter, M.D. Unequal Pupils as an Early Sign in Phthisis 105 Paul G. Woolley, B.S., M.D. Acute Tuberculous Endaortitis 109 S. P. Kramer, M.D. The Function of the Choroid Plexuses of the Cerebral Ventricles and its Relation to that of the Pituitary Gland 115 9 10 DANDRIDGE MEMORIAL PAGE Paul G. Woolley, B.S., M.D., and L. H. Newburgh, A.B., M.D. The Effect of Injections of Indol and Tyrosin in Experimental Animals 119 Paul G. Woolley, B.S., M.D. Amyloid Degeneration Localized in the Adrenal 123 Arthur D. Dunn, A.B., M.D., and Paul G. Woolley, B.S., M.D. Acquired Diverticula of the Sigmoid with a Report of Six Cases. . 127 William H. Peters, M.D. A Simple Method of Cultivating the Morax-Axenfeld Diplobacillus 145 John E. Greiwe, M.D. The Electrocardiogram 147 Paul G. Woolley, B.S., M.D., and Otto V. Huffman, M.D. The Ova of Schistosoma Japonicum and the Absence of Spines.. 161 M. L. Heidingsfeld, M.D. Hairy or Black Tongue 163 William H. Peters, M.D. Hand Infection Apparently Due to Bacillus Fusiformis 177 Otto V. Huffman, M.D. The Kurloff-Body, a Spurious Parasite 185 Alfred Friedlander, A.B., M.D. Involution of the Thymus by the X-Ray 191 Oscar Berghausen, A.B., M.D. The Role of Acidosis of the Tissue as a Factor in the Production of an Attack in Paroxysmal Hemoglobinuria 207 L. H. Newburgh, A.B., M.D., and Paul G. Woolley, B.S., M.D. The Effects Produced by Numerous Injections of Indol and Tyro- sin in Experimental Animals : A Contribution to the Study of Chronic Intestinal Indications 215 Martin H. Fischer, M.D. Contributions to a Colloid-Chemical Analysis of Absorption and Secretion 225 Henry Louis Wieman, Ph.D. The Relation between Cyto-Reticulum and the Fibril Bundles in the Heart Muscle Cell of the Chick 263 Charles Goosmann, M.D. A Method of Demonstrating Spirochstae and Tr3'panosomes by Means of Nigrosin 277 CONTENTS 11 William H. Strietmann, A.B., ^\i.D., and Martin H. Fischer, M.D. On the Contraction of Catgut and the Theory of Muscular Con- traction 283 Paul G. Woolley, B,S., M.D., and Herbert A. Brown, M.D. An Anomalous Duct Belonging to the Urinary Tract 303 Eugene S. May, M.D. The Germicidal Action of Basic Fuchsin 307 Paul G. Woolley, B.S., MD., and Wm. B. Wherry, A.B., M.D. Notes on Twenty-two Spontaneous Tumors in Wild Rats (M. Norvegicus) 313 A. E. Osmond, M.D. A Computing Chart for Making a Differential Leucocyte Count.. 325 The Cincinnati Research Society 328 THE PATHOGENESIS OF GALL-STONES. BY S. P. KRAMER^ M.D. The ultimate cause for the formation of gall-stones has, not- withstanding the large amount of investigation on the subject, remained a subject for speculation. The earliest view was a purely mechanical one ; that the formation of the stones was the result of concentration due to stagnation. On account of the fact that bile may be concentrated to a thick mass without the precipitation of the products found in gall-stones, this view had to be abandoned. There then followed the so-called chemical theory, the chief exponent of which was Thudichum.^ Cholestearin, bilirubin and the calcium salts are soluble in alkaline solution, especially in solutions of sodium glycocholate, and concentration does not bring about precipitation, li, however, according to Thudichum, as the result of decomposition due to prolonged standing or as the result of abnormal secretion of mucus, the bile becomes acid, the cholestearin and bilirubin calcium are precipitated as the re- sult of the decomposition of the solvent, sodium glycocholate, into glycocoll, cholaic acid and a sodium salt. In reading the work of Thudichum, it is well to remember that the work was done a half century ago, and, of course, without bacterial investi- gation. Another chemical explanation was offered by Dochmann- in 1891. He analyzed both liver and bladder bile, the latter ob- tained after ligation of the cystic duct, and found a great increase in calcium and diminution in sodium in bladder bile as compared with liver bile. According to his view the increase in calcium diminishes the solubility of bilirubin and leads to a precipitation '"f bilirubin calcium and cholestearin. Prolonged intervals be- tween meals and stasis cause a stagnation and precipitation of bilirubin calcium and cholestearin. * Reprinted from the Journal of Experimental Medicine, May, 1907, 13 14 DANDRIDGE MEMORIAL Opposed to these chemical theories are the morphological and bacteriological theories. Dujardin Beaumetz' ascribes the forma- tion of gall-stones to a desquamative cholangitis and biliary stasis, thus reviving the "Steinbildende Katarrh" of Meckel.* Naunyn^ denies the chemical theory of Thudichum. Even when greatly concentrated, bile contains sufficient solvent to keep the cholestearin and bilirubin calcium in solution. The decompo- sition of sodium glycocholate to sodium cholate does not explain the precipitation, since this product is also a solvent for chole- stearin and bilirubin calcium. He also ascribes the formation of gall-stones to a desquamative cholangitis. This inflammatory process leads to a desquamation of epithelial cells which degenerate and form cholestearin and calcium salts. The bilirubin unites with the calcium. The precipitation of bili- rubin calcium is aided by the albuminous character of the products of cellular degeneration, alluding here to the general tendency of albumen to precipitate calcium. In this way are formed small particles which form the nuclei of gall-stones. The cholestearin is deposited later, partly on the outside and partly infiltrating the mass through the so-called in- filtration canals which are found in gall-stones. The mere excess of calcium will not cause a precipitation of bilirubin in calcium and cholestearin. Even the presence of foreign bodies as centers of crystallization will not bring this about. There is lacking the explanation of some biological process which brings this about, and this, according to Naunyn, is fur- nished by the degeneration of epithelial cells the result of an infective cholangitis. We have still, however, no explanation as to the process by which cholestearin and calcium salts, which are normally soluble in bile, are precipitated in cholelithiasis. To say that it is the result of degenerative changes in epithelium, produces more mystery, but no explanation. If now we leave the realm of speculation and search for some exact knowledge, a very curious chain of thought will arise. We have, heretofore, exact knowledge of the formation of stones in one instance and in one only. I refer to the formation of phos- phatic urinary calculi. We know that this is due to chemical de- KRAMER 15 composition, the direct result of bacterial growth. If now we apply this knowledge to experiments, having for their object the clearing up of the subject of gall-stones, it may be that some suc- cess will follow. It has been abundantly proven, that bacteria are at all times present in gall-stones. The literature on the subject is so well known that it is not necessary to burden this article with it. The colon bacillus is the organism most frequently found in gall-stones. The one next in frequency is the typhoid bacillus. It is very probable that it will be found that infection by one of these two micro-organisms is responsible for most cases of chole- lithiasis. Now while this has been commonly accepted, it seems strange that there should be no investigation published, showing the effect of these organisms on bile when grown in it. It would appear a priori reasonable, that possibly the growth of these organisms in bile, or a solution of bile, would effect the precipitation of some of the biliary constituents. Accordingly, for the past year, I have been carrying out such an investigation with most gratifying results. Culture tubes were prepared containing a mixture of one half human bile obtained at autopsy and one half ordinary alkaline pepton bouillon. This mixture or solution was repeatedly ster- ilized and filtered, until a perfectly clear medium was obtained. Such tubes were inoculated with the colon bacillus, the typhoid bacillus and staphylococcus pyogenes aureus. All of these micro- organisms grow readily in this medium. The staphylococcus forms a copious growth which sinks to the bottom of the tube, the medium showing no apparent change. Not so, however, with those inoculated with the colon or ty- phoid bacillus. Here in a few days the medium became cloudy and a precipitate is seen at the bottom of the tube. This precipi- tate increases greatly until in about four weeks a very well marked, closely packed, semi-solid mass is seen at the bottom of the tube. If allowed to incubate longer, say for six months, care being taken to prevent evaporation by rubber caps, this precipitated mass be- comes firmly packed and the super-natant fluid may be poured off and we have a kind of very soft "gall-stone" as it were, taking the form of the bottom of the tube. If we examine the precipitate, we 16 DANDRIDGE MEMORIAL have no difficulty in recognizing all the constituents of gall-stones as well as masses of bacilli: Amorphous calcium phosphate, mag- nesium phosphate, calcium carbonate, biliary coloring matter and a few crystals of cholestearin. Crystals of ammonio-magnesium phosphate are formed very late, usually after many weeks of growth. In order that the precipitation of cholestearin might be made more manifest, and since, normally, bile contains comparatively little of it, culture tubes were prepared in which cholestearin was added to the solution of bile and bouillon. This readily dissolves therein and the medium was carefully filtered and examined microscopically before inoculated, so as to be sure that all the cholestearin present was in solution. Such tubes v;hen inoculated with colon or typhoid bacillus, give a precipitate very rich in cholestearin crystals. Another thing which was remarked, was the markedly pre- servative action of bile upon colon and typhoid bacilli. I have at present tubes in which the precipitate was separated and allowed to dry out completely, and yet the bacilli present are still viable and readily resume growth when inoculated upon fresh media. This corresponds with the findings that viable typhoid bacilli have been found in the interior of gall-stones years after the individual had passed through the attack of typhoid fever. Thus Droba'' reports a case in which he obtained the typhoid bacillus from gall-stones removed seventeen years after the patient had recovered from typhoid fever. It appears to me that these experiments indicate very clearly then that gall-stone formation, just as phosphatic urinary stone formation, is due to a chemical decomposition of the bile, the direct result of the growth of micro-organisms therein. Bacillus coli communis and bacillus typhosus are the micro-organisms usually concerned. Just what the exact chemical nature of the decomposition is, remains to be shown. It is rather significant, however, that the two micro-organisms which cause this precipita- tion in vitro, produce an acid reaction in the media. \\'hereas, the staphylococcus, which requires and retains in alkaline reaction, does not cause the precipitation. It may be then that the decomposition theory oi Thudichum KRAMER 17 will prove to be true in a modified form. His work on the de- composition of bile was done, of course, before the days of pure culture, and was without bacterial control. A repetition of his analyses of bile decomposed by pure culture of these organisms may give us the exact chemical nature of the process. REFERENCES. 1. Thudichum, Quarterly Journal of the Chemical Society, 1862, xiv, 114. 2. Dochmann, Wien. med. Presse, 1891, xxxii, 1198. 3. Dujardin Beaumetz, Bui. Thcrap., 1891, cxxi, 291. 4. Meckel von Helmsbach, "Mikro-geologie," 1856, Berlin. 5. Naunyn, "Klinik der Cholelithiasis," 1892. 6. Droba, Wien. klin. IVoch., 1899, xii, 1141. AORTIC ANEURISAI WITH RUPTURE INTO THE PUL- MONARY ARTERY. r.V PAUL G. WOOLLEV, M.I)., A.XO I.. 11. NEWBURGII. M.I). Perhaps the best reason which can be given for a new review of the cases of aortic aneurism that have ruptured into the pul- monary arter}^, is, that in spite of the fact that some forty-nine such ca.ses have been reported, a correct diagnosis has been made in but three, A subsidiary reason is that although an extensive study of the cases in the literature has been made by Kappis. there is no comprehensive review of them in English. To the series of cases already reported we wish to add another, the history of which is as follows : Case No. 152,041. — The patient was a colored laboring man, forty years old, who was admitted to the medical service of the Cincinnati Hospital complaining of pain in the left side and shortness of breath. He died three months after admission. The patient gave a history of the usual diseases of childhood, of smallpox, rheumatic fever, gonorrhea and syphilis. Shortness of breath commenced five weeks before admission. The symptoms gradually became more pronounced, and were associated with cough and night sweats. On admission his temperature was 96.8°, pulse 96 and res- piration 32. The tho-rax was symmetrical. The respiration was labored, but the respiratory movements of the thorax were of normal extent, except in the right axillary region, where they were diminished. The percussion note was flat in the left ax- illa. There was a friction rub on the left side, and in this region, low' in the axilla, the breath sounds were distinct. Tlie outline of cardiac dullness was increased both vertically and transversely. The apex beat was felt in the sixth intercostal space, close to the axillary line ; it was forcible, strong and reg- ular, and fairly well circumscribed. At the apex an inconstant, soft, systolic bruit of varying intensity could be heard. At the level of the junction of the fourth rib and at the sterno-costal 19 20 DANDRIDGE MEMORIAL junction a rough, svstolic and a prolonged and somewhat smooth diastolic bruit were heard. Both of these varied considerably in physical properties, at times being almost inaudible and again loud. The aortic diastolic bruit occasionally disappeared. Per- cussion showed an abnormal area of dullness above the base of the heart. The pulse was regular, full, large and strong — a typical Corrigan. At the time of entrance there was no edema of legs. Later the patient became more and more short of breath to the extent that sleeping was inter fered^ with. Still later dyspnea made it nec- essary to assume a sitting position at night, and vomiting com- menced and continued intermittently. The respiratory symiptoms gradually increased in severity, the systolic murmurs at the apex became quite regular, soft and smooth. To the right of the nipple a rough systolic and a dias- tolic murmur could be heard. The aortic diastolic murmurs be- came less intense, and a pericardial friction developed. The legs became more and more edematous ; the edema constantly ex- tended toward the body, and gradually the patient became weaker, sank and died. At no time was sugar or albumin present in the urine, though the specific gravity reached 1,030. Clinical Diagnosis. — Syphilitic aortitis; aortic stenosis and regurgitation; passive congestion of the kidneys. The autopsy was done two hours after death. The report is, briefly, as follows : The body was that of a poorly nourished, middle-aged negro. The lower part of the body, from the um- bilicus down was enormously swollen, edematous, and presented numerous large and small blebs. Post-morten rigidity slightly evident in feet ; absent elsewhere. The peripheral lymph glands were not enlarged. The prepuce was edematous and phimotic. The glans penis showed numerous shallow, small ulcerations and scars. The abdomen contained about 100 c.c. of a reddish brown, but clear fluid. The pleural cavities were filled with a similar fluid. The pericardial cavity contained a considerable amount of a clear, straw-colored fluid. There were no pleural adhesions. The lungs collapsed partially when the thorax was opened. The left weighed 700 gms. ; the right weighed 975 gms. Aside from a moderate edema at the posterior parts, these organs showed nothing remarkable. The liver weighed 1,525 gms. It was of firm consistence, elastic, and of a pale brownish color. Section showed a gener- ally mottled appearance, due in part to the presence of small W O O L L E Y A N D N E W B LJ R G H 21 hyaline "bacony" areas, which became brown after treatment with iodine. The spleen was a typical "sago" spleen of moderate size. The kidneys weighed 185 gms. each. They were firm and elastic, the cortex generally increased in thickness, and the glo- meruli visible as small, hyaline, shining points. Treatment of the cut surface with iodine gave the amyloid reaction. Both organs were purplish-red in color. The heart was enlarged, pale and flabby. Under the visceral pericardium, near the base on the right side, were very numerous petechial and a few very minute grayish, translucent spots that resembled in a general sort of way miliary tubercles. Both cavities were dilated. The left ventricle was both dilated and hypertrophied. At the apex the myocardium was generally and almost completely replaced by fibrous tissue. The papillary mus- cles were somewhat fibrotic. The cardiac valves showed no evident abnormalities. The tricuspid orifice admitted tlie tips of four fingers, the mitral three, the aortic almost two. In diameter, the tricuspid valve meas- ured 6 cm., the mitral 5 cm., the aortic 3 cm. The aorta was the seat of a well marked, extensive and se- vere grade of arteriosclerosis, of apparently syphilitic origin, as indicated by the bluish hyaline thickenings. Just above the mouth of the left coronary artery was the opening of an aneur- rismal sac, that measured 5 cm. in diameter. The sac itself was 7 cm. in its largest diameter. In it were no clots. The walls were irregularly sclerotic, with scattered hyaline plaques and athe- romatous ulcers. The aneurism projected laterally to the left, and was adherent to the pulmonary artery, into which there were two openings at a point about 1 cm. above the junction of the posterior and left pulmonary leaflets. The openings measured 1x2 cm., and 1x2 mm. in diameter. The margins of both were smooth, and showed no evidence of recent rupture. The pulmonary artery show'cd both fatty degeneration and hyaline sclerosis, especially in the immediate neighborhood of the aneurismal openings. The openings in the pulmonary artery were 1 cm. above the junction of the posterior and left pulmonary leaflets. Anatomical Diagnosis. — Aortic aneurism znth perforation inio the pulmonary artery. Syphilitic aortitis; amyloidosis; pas- siz'e congestion of the liver, kidneys and spleen; hypertrophy and dilation of the heart; pleural and p erica rdnal effusion; edema of the lungs. In order to make comparisons easier and perhaps more odious, we have composed the following tabulation of the cases of which 22 D -\ X D R 1 D G E AJ E AI O R I A L we have been able to find records. In this tabulation the cases discussed by Kappis are included as well as others, which, for one reason or another, were excluded from his records. An analysis of these cases brings out several interesting points. 1. Perhaps most striking, is the frequency with which the per- foration was not the immediate cause of death. The character of the perforation was noted in twenty-eight cases. Thirteen times (Nos. 5, 6, 12, 15. 18, 19, 25, 30, 34, 36^ 39, 42, 49) the edges are described as smooth and rounded, and twice as thickened ( Xo£. 27. 28.). In all but eleven cases, then, the perforation was pre- sumably old; that is, it was not the im'mediate cause of death nor did it even cause enough mischief to make its presence suspected. This seemingly remarkable fact is explained without much diffi- culty. When one considers that the condition produced by per- foration of an aortic aneurism into the pulmonary artery gives rise to a state mechanically very similar to that produced by an open ductus Botalli, and that the latter condition is compatible with years of comfortable and happy existence, the fact under discussion seems quite plausible. There is no reason why the perforation, in and of itself, should be accompanied by stormy symptoms ; for the change in the circulation comes about so slowly that there is time for readjustment. In thirteen cases there was a history of acute symptoms rapidly followed by death (Nos. 1, 2, 4, 9, 12, 17, 19, 23, 31, 41. 44, 45, 48),* and in nine of these the terms "jagged," "laceration," "ir- regular," "recent," and "tear" were used to indicate the condition of the communication between the aneurism- and the pulmonary artery, or ventricle. In No. 19 the opening was described as "healed," and in this case the sudden death should more properly be ascribed to sudden cardiac insufficiency, and not immediately to the aneurismal condition. In three (Nos. 23, 44. 45) the condi- tion of the opening was not described.! * In five cases there was more than one perforation ( Nos. 6, 7, 12, 14. 30), and in but one of these (No. 12) were there acute symptoms, al- though another (No. 30) showed evidence that it was very recent. t The ridiculous variation in anatomic descriptive terminology is no- where, we suspect, better illustrated than in this series of cases. In esti- mating the size of the aneurismal sacs the word oranse is used five times (Cases 1, 2, 21, 45, 4) ; walnut seven times (Cases 10, 14, 17, 20, 22, 35, 40) ; egg seven times (Cases 8, 12, 13, 37, 38, 18, 24) ; fist twice (Cases 4, 31), and so on. In but four cases are the measurements given in terms of inches or centimeters (Cases 29, 29, 30, 48). W O O L L E Y AND N E W^ B U R G H 22> The complete diagnosis was made in only three cases (12, ZV, 48), and only eight times was aortic aneurism diagnosed ante mortem. This was undoubtedly due to the absence or masking of the classic symptoms of aneurism. And they, in turn, were ab- sent so frequently on account of the smallness and position of the aneurism. As pointed out by Kappis, the sac was frequently described as the size of a walnut, and was almost always close to the heart. The perforation opened below the bifurcation of the pulmonary artery in all but six cases (Nos. 16, 18, 23, 25, 31, 49), in which it opened into the right branch, and one case (No. 3), in which the com.munication was with the left branch. Hence, in most cases, it was not large enough to cause distinct pressure symptoms, and whatever dulness it produced must have fused almost imperceptibly with that of the heart. The sacs presumably remained small because they were re- lieved of the brunt of the high aortic pressure earlier than in the commoner forms of aneurism, because of the fact that the sacs in the cases pointed in such a direction that erosion and rupture of the pulmonary artery occurred at an unusually early stage of the development of the aneurism. It is also quite possible that had the conditions in the pulmonary artery been described, evi- dence of preparation for rupture on the pulmonary side would be available. Unfortunately, however, the condition of the pul- monary artery is described in but two cases ; in one it was pitted and rough, in the other normal in appearance. Howe\^er this may be, there is evidence that the rupture occurs slowly, and that a little blood is diffused from the aorta into the pulmonary artery through the unruptured wall because of its increased per- meability; then a minute opening forms, and this enlarges rap- idly and sufficiently to relieve the high pressure. The walls of the aperture become smooth and healed, because there is no fur- ther mechanical occasion for enlargement, and the process of rupture comes to an end. In such a way an event which ordi- narily causes the most disastrous results when it occurs in other locations becomes a salutary one. The patient goes on living for weeks or months until death comes as the result of myocardial degeneration, valvular lesions, or, associated with these and with a more severe arterial condition, another perforation or rupture. 24 DANDRIDGE MEMORIAL Now that we have accounted for the possibihty of the absence of signs of aneurism, let us briefly consider the cases in which these signs were not absent. Tumor is mentioned but four times (11, 14, 32, 38) ; tracheal tug twice (Nos. 32, 41) ; recurrent laryngeal paralysis (No. 32) and the metallic cough (No. 14) each once. Irregularity of pulses or pupils is not recorded once. Of the remaining signs we find thirty-two cases (Nos. 5, 7, 8, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, 39, 42, 47) in which there were murmurs, thrills or pulsating tumors over the upper chest, either along the left border of the upper sternum, over the manubrium, or occasionally along the right side of the upper sternum. If we exclude those cases which died too shortly after entrance to a hospital to have received suf- ficient study, we find that three-fourths of the cases presented signs referable to disease of the valves at the base of the heart or the root of the aorta and pulmonar}^ artery. Kappis states that the combination of sure signs of aortic aneurism with continuous murm.urs or thrills is pathognomonic of two conditions — the one under consideration, and perforation of aneurism of the aorta into the right ventricle. The latter is much rarer than the former, and in the present series existed coincidently with the pulmonary lesion in four cases (7, 12, 33, 35). When continuous murmurs or thrills occur in the absence of sure signs of aneurism, open ductus Botalli should be con- sidered first. This can be excluded frequently by obtaining a careful past history. Unfortunately, continuous murmurs were noted in only ten cases (Nos. 7, 12, 19, 33, 37, 39, 10, 28, 38, 42), Two of these were cases in which a correct diagnosis was made (12, 17). Can we find no aids to the correct diagnosis when the murmur or thrill is not continuous? It will be seen by an inspection of the pathological material that in a considerable number of the cases (8, 13, 19, 27, 29, 32, 37, 38, 35, 43, 47) the pulmonary artery or valves were afifected as well as the aorta. Many of the systolic murmurs and thrills, especially those over the manu- brium and along the right border of the sternum, must have sug- gested lesions of the pulmonary valves. Since acquired pulmo- Tabulated Record of Forty-nine Cases of Aortic Aneurism with Rupture into Pulmonary Artery WooUey and Newburgh. »™,j™ -..;*,,. .-„„„,.».».,..«.., .™ J.„ ,».. » J..1.1. , , , A.»a„ " *'"'" uitni 4)<[»n 'Xhuiuiii aour tithi '"" '*"" « IS >Uk vnrkn] imol iKiiwtn «d]ns KOQIDI u " > I 1 . ' ' ' '•iit. • «„.. .■.Jg „..>.„,„,..„„. ,„,.„„„. .™^,., ** « f™.i. ■ ■ ' U-..„. .,. I 1 cm. Inns. L r)ll(tl»ii • h iluthi hjptftrophx; pillmon»r» r.w .ml«l»n. on mursl, l(jp.nropl» Md^llswiion: potwrior pulmo- Lrll diliUlion; tinbl hyp«lfo»hy. Hyptnrotin and dfUlIcin. ll>p..lro»h» Md dililioo. Hmnroiifc,. :; ■■ Taylor. (*/ ai Kin»^ XXXUL ette»,aa). THE PATHOLOGY OF MASTODITIS AS REVEALED BY THE X-RAY.* SIDNEY LANGK, M.D,, B.S. The X-ray study of the mastoid region, which was begun in March, 1908, has undergone a slow, but gratifying, metamorpho- sis. Undertaken with grave doubts as to its practical vahie, it has developed into a method which rivals in its accuracy other recog- nized methods of physical examination. At the inception of the work, it promised at best to show the anatomy and the grosser chronic changes in the mastoid region. Then the graver acute changes were registered on the skiagr.^.ni, and later it was found that the milder acute mastoid affections yielded roentgenologic evidence of their presence. Within the last few months it was discovered that in acute otitis media with- out clinical signs of mastoid involvement, the X-ray would often ohow clouding and falling up of the ma.stoid cells just back of the antrum, which changes may either recede or progress as the patient either recovers, or goes on to what is chnically termed mastoiditis. The X-ray method is presented, then, as a method of studying intra vitam the gross pathology of the mastoid. A correct roentgenologic technic is, of course, the sine qua non in this work, and all conclusions should be based upon tech- nically good plates. The method employed for correctly skia- graphing the mastoids was presented before this section one year ago.^ Further details of the X-ray technic were outlined by me in a previous paper- and need not be repeated here. In no instance has a technically good plate failed to give valuable and accurate information. Barring those uncommon cases in which the cortex over the mastoid is excessively thick, or in which the mastoid cells are poorly developed, the X-ray method should * Read in the Section of Laryngology and Otolopy of the American Medical Association, at the Sixty-first Annual Session, held at St. Louis, June 10, 1910, and reprinted from the Journal of the American Medical Association, September 3, 1910, vol. Iv, pp. 819-822. 33 34 DANDRIDGE MEMORIAL in every case reveal in a gross way the pathologic status of the mastoid process. The question of excessive distortion of the relations of the mastoid as a result of the obliquity of the rays was answered by making a series of tests on the dried skull. Lead markers were placed on the tegmen, groove for lateral sinus, and mastoid tip, and measurements made from the skiagraph were compared with the actual distances. In no instance did the discrepancy exceed 3 mm., which difference for practical purposes may be disregarded. The interpretation of the skiagram is always based on a comparison of the diseased with the opposite normal mastoid. After repeated comparisons in normal individuals, in no case did I find essential difierences between the two normal mastoids of the opposite sides. While there may be variations in the size, number and arrangement of the cells of the two sides, the mas- toids as a w^hole were closely similar in type. That is, if there is a pneumatic mastoid on one side there vv^ill be a pneumatic mastoid on the other, or if the one mastoid is of the diploetic type, the opposite one will be of the same type. Plageman says : "On a basis of 85 skiagrams of normal skulls, we find that as a rule the two mastoid processes of healthy individuals are almost identical." Where both sides are diseased, more difficulty is en- countered in reading the plates, but after a study of many plates a fairly accurate interpretation may be made of a single plate without a comparison with its fellow of the opposite side. Previous inflammation in a mastoid usually leaves permanent alterations in the bone, either in the form of more or less exten- sive absorption of the mastoid process or sclerosis of same, and if this inflammation occurs in early life the development of the mastoid may be so retarded as to result in a diploetic or even sclerotic type. Therefore, in interpreting mastoid plates the pre- vious aural history must be ascertained. On the mastoid skiagrams of children under ten years the mastoid appears entirely spongy or diploetic, there are few visi- ble cells, and the tip is undeveloped. The tip at this time con- sists simply of an inner and outer table, with little cancellous bone between, and shows little structure on the skiagram. From L A N G E 35 the age of ten to fifteen the mastoid takes on the pneumatic char- acteristics ; large cells appear and grow downward toward the tip, its diploetic structure finally giving way to the more or less pneumatic adult type. The development of the mastoid may be beautifully demonstrated by a series of successive skiagrams. In order to study the mastoid relations more graphically, stereoscopic skiagrams may be made. For this purpose I have devised a small stereoscopic platform by means of which the two stereoscopic exposures may be made on a 5 x 7 plate. When developed and dried this plate may be placed directly without printing or reduction in a cheap parlor stereoscope and viewed by transmitted light. This method has not been used as a routine, because of the fact that four exposures (two for each mastoid) are required. A reluctance to make repeated exposures has in- terfered also in following the clinical cases at various stages from onset to cure. While the danger of the temporary Roentgen alo- pecia is a remote one, even though the exposures be repeated, provided an aluminumi and leather filter be used, it was thought best not to take the chance of embarrassing the work at this time by any such untoward after-eflfects. Therefore, in most of the patients examined but one exposure of each side was made. Just one caution should be given in regard to the character of tube best suited to this work. The lowest or softest tube pos- sible should be employed. The higher tube gives crisper and more beautiful pictures, but when we consider the small size of the mastoid cells and the fact that we are attempting to show all the smallest septa and contents of these cells, those tubes which give beautiful bone detail of the heavy cranial bones will often fail to show the slightest changes in density in the mastoid region. CLASSIFICATION OF PATHOLOGIC CHANGES. The pathologic changes which may be noted on a skiagram may be tabulated as follows : 1. Slight haziness of cell spaces or complete filling of same with something denser than air. These changes represent clin- ically otitis media with slight mastoid involvement and the milder forms of mastoiditis. The something which fills the cells is in all 36 DANDRIDGE MEMORIAL probability serum. To show these slight changes the skiagram must be made with a soft tube and slightly underexposed. 2. Marked clouding of cell spaces with loss of distinctness and partial destruction of cell walls. Clinically these changes are found in the more severe grades of mastoiditis with pus for- mation and bone softening. 3. More or less complete loss of structure of the mastoid process occurring (a) either in the form of localized abscess for- mation, or (b) as is often seen in the subacute cases in the form of diffuse loss of structure, indicating advanced necrosis of the entire mastoid process. 4. Increased bone density of the mastoid process with (a) partial or complete obliteration of cells, and (b) with bone de- fects. This class represents the chronic sclerosed cases. These changes will be discussed in the reverse order, the or- der in which they are recognized. CHRONIC MASTOIDITIS. The first report of this work was based entirely on the exam- ination of the chronic cases. The ease with which chronic changes can be shown on the skiagram offers a method of deter- mining in any case of chronic otorrhea the gross pathologic con- dition of the mastoid process. In those cases in which the cause of the continued discharge cannot be determined by the usual methods, the skiagram may give the desired information by show- ing the extent of the sclerosis on the one hand or gross bone defects on the other. The skiagraphic appearance in these cases is a thickening and obliteration of cells. In older cases the entire mastoid pro- cess appears dense and structureless, giving no indication of the presence of cells. From my experience it would appear that this extensive sclerosis occurs frequently after mastoiditis of a mild and not necessarily long-continued type, since the sclerosing process is a healing process. Interesting to note is the fact that, in the examination of supposedly normal cases for purposes of study, every now and then a markedly sclerosed and often under- sized mastoid process would be found, and no history of previous ear trouble could be elicited from the patient. These undersized LANGE 37 sclerotic types probably represent a sclerosis, partial absorption or retardation of mastoid development, consequent to a forgotten otitis media of early childhood. Aside from these occasional exceptions in all of the markedly sclerosed cases, the patients examined had symptoms in the form of intermittent otorrhea. To illustrate different phases, several cases will be cited briefly. Case 1. — Sclerosis. — A. V., aged sixteen, presented intermit- tent discharge from the left ear, dating from an attack of acute otitis media three years back. Examination revealed a thick- ened drum with a small perforation in the antero-inferior quad- rant. X-ray examination showed a sclerotic mastoid on the left side, with very little evidence of cellular structure. Subsequent operation verified the X-ray findings. This history is typical of a majority of chronic cases encountered. Case 2. — Sclerosis zvith Bone Defect. — J. Z., Italian, was admitted to the Cincinnati Hospital because of some pain and tenderness over the mastoid. Previous history could not be ob- tained, except that the affected ear had discharged for some time. Examination of the canal revealed changes associated with chronic middle-ear suppuration. An X-ray examination of the mastoids showed no cells on the affected side. Instead, the bone seemed to be hollowed out just back of the antrum. On opera- tion no cells were found, but a large bone defect in a small scle- rotic mastoid. Case 3. — Suhacitte Case tmth Bone Softening. — This is a sub- acute rather than a chronic case, but is included here because the plate showed typical bone defects in a thickened m.astoid, such as might be encountered in the more chronic cases : r.Ir. C, aged thirty-live, came in from one of the surrounding towns because of continued discharge and pain over the mastoid dating back seven weeks. The case had received practically no treatment. Examina- tion showed a perforation in the anterior inferior quadrant. No bulging of the canal. Temperature was 99.5° in the evening, normal in the morning. Pain was marked especially at tip. The patient was referred to me for X-ray examination, which revealed an apparently thickened and structureless mastoid except for sev- eral irregular areas of apparently more necrotic bone which seemed to honeycomb the mastoid. Operation the following day substantiated the diagnosis in every detail. SEVERE ACUTE MASTOIDITIS. Every case of severe acute mastoiditis has given distinct evi- dence on the skiagram. The changes varied from filling the mas- 38 DANDRIDGE MEMORIAL toid cells with something other than air (serum, pus or granu- lations), with indistinctness and partial disappearance of cell outlines, to circumscribed abscess formation or diffuse loss of structure of the mastoid. Case 4. — Mrs. S. gave a history of a running ear following an attack of influenza. Discharge continued two weeks and then stopped. Two weeks later, or four weeks after the onset, the patient came under medical observation because of pain over the mastoid, especially right. Examination revealed a thickened drum, no discharge, no perforation, marked tenderness over mas- toid, but no redness or swelling. Temperature was 99° to 100° ; X-ray examination revealed a hazy mastoid whose cells were no longer air-filled and septa partially broken down. Operation the day following the X-ray examination verified the skiagram. Case 5. — Miss W., aged twenty-five, had had influenza three weeks previously, with a running ear, but without pain or ten- derness over the mastoid. Discharge continued for three weeks, and patient finally sought medical attention because of an in- creasing malaise. Examination revealed a large perforation in posterior part of drum, with scant or no discharge. There was no swelling or redness over the mastoid, but marked tenderness on deep pressure over antrum, no fever. X-ray examination revealed a small abscess in the mastoid about the size of a hazel- nut. The rest of the mastoid appeared hazy and indistinct. Sub- sequent operation verified this finding in every detail. The following case is typical of a number of cases observed from the onset, in which there were definite signs of severe mas- toid involvement, but in which the operative indications were not clear. Operative interference is often delayed in these cases awaiting spontaneous resolution. The X-ray plate showing the amount of destruction may be a deciding factor. Case 6. — Miss H., a nurse at Cincinnati General Hospital, aged thirty, developed, incident to influenza, intense pain in the ear, which in a few hours was followed by rupture of the drum, and a profuse bloody discharge. Three days later the staff otologist was called to see her because of pain and tenderness over the mastoid. He found a small perforation and enlarged it by incision. Tenderness and pain abated, and it was thought that recovery would follow in a few days. Seven days later there was a recurrence of the pain and paracentesis of the drum was again performed. The pain and tenderness now persisted in moderate degree, and a week later I was asked to make a skia- L A N G E 39 gram. The skiagram showed absolutely positive evidence of a breaking down of the entire mastoid, and the operation the fol- lowing day, almost three weeks after the onset, verified the X-ray finding. MILD ACUTE MASTOIDITIS. In the stud)'- of the milder acute cases, an interesting problem presented itself. By the milder cases is meant those cases in which there are distinct demonstrable changes in the mastoid, but in which there is little or none of the gross destruction seen in the more severe cases. These cases may or may not progress to spontaneous recovery. The first change is that of fluid-filled cells. That is, the cell-spaces, instead of standing out sharply and clear, show by comparison with the opposite side that the air is displaced by a more solid substance, which may be serum, pus or granulations. The cell walls are fairly distinct and not bro- ken down. This appearance of fluid-filled instead of air-filled cells is very characteristic of this stage ; and in the attempt to draw operative indications from the plate, the question as to how much bone change in the mastoid may occur without pre- cluding spontaneous recovery, that is, what amount of skia- graphic bone change makes operation imperative, presented itself. Of course, I did not attempt to decide such a weighty prob- lem. In discussing the same, the fact that each text-book and each specialist has individual ideas regarding the pathology of acute mastoiditis was somewhat confusing. Those of the con- servative school cite many instances of clinically severe mas- toiditis which have recovered under the expectant treatment, whereas those of more radical tendencies advise early operative interference when fairly positive clinical evidence of mastoid in- volvement is at hand. The thought at once suggests itself, would it not be possible by means of the X-ray to decide this point, and by a comparative X-ray study of a large series of cases to deter- mine what amount of bone destruction makes operative interfer- ence imperative, if, indeed, the question can be settled at all? Although my series of cases is far too small and too incom- pletely studied to warrant any definite conclusions, yet I adhere to the following tentative rule: If in an acute case the skiagram shows fluid-filled cells with little or no breaking down of cell 40 DANDRIDGE MEMORIAL walls, an expectant line of treatment is suggested, whereas, if the bone destruction is definite and considerable, operation is rec- ommended. The following two cases are typical of this milder type of mastoiditis. Case 7. — Mrs. E., aged thirty-five, had for ten days suffered with pain in the ear. Examination revealed in addition to in- flamed drum, pain and tenderness over the mastoid. There was some fever, 100" in evening, 99.5° in morning. The drum was incised, but symptoms continued a week unabated. An X-ray examination made at this time revealed the mastoid cells fluid- filled, but little or no bone change. After two weeks, discharge gradually ceased and mastoid symptoms abated. Drum returned to normal, pain and fever disappeared, whispered voice heard at twelve feet. A second X-ra}' examination made two weeks later showed the afTected mastoid apparently normal, the ceils contain- ing air. Case 8. — Mrs. M., aged thirty-three, suffered severe pain in ear, following an acute rhinitis. On examination, drum was bulg- ing, covered with hemorrhagic blebs, mastoid tender over antrum. Drum was lanced and few drops of serum exuded, followed by sero-bloody discharge, which continued three days, and suddenly stopped. Pain returned. Drum was again incised, and mucoser- ous discharge continued. Marked tenderness was present over mastoid and antrum, extending toward tip, but there was no fever. After several days discharge again stopped, and buzzing and throbbing pain was complained of. X-ray examination at this stage revealed a haziness of the cells just back of the mastoid antrum, but not extending over the rest of the mastoid. The slight changes seen in the plate did net seem to warrant any active interference. From this time the case went on to recovery, and a second plate made (two weeks after the first one) showed appar- ently a restoration to the normal. Several cases similar to these were encountered at the Cin- cinnati General Hospital, but as the patients treated here often in- sist on leaving before entirely recovered, and are then lost track of, the ultimate outcome could not always be followed. Of great interest would be some statistics as to how frequently such mild mastoid involvement goes on to ultimate recovery, and what per- centage becomes chronic or give rise to intercranial or other com^ plications. L A N G E 41 ACUTE OTITIS MEDIA. After this succe.-s in detecting the milder changes in the mas- toid a small series of patients with acute otitis media without clinical signs of mastoiditis was examined. To my surprise more than 50 per cent, of the patients skiagraphed gave evidence on the plate of slight mastoid involvement. This involvement was indicated by a slight haziness of the cells just back of or sur- rounding the antrum. The bone contours were, however, sharp and distinct. The X-ray study of the mastoid region is submitted at this time as an aid in the obscure cases. A more extended study of a large series of cases will, it is hoped, put this work on such a firm basis that in any case an X-ray examination may yield results so valuable as to justify the procedure. But the work has a broader application. By repeated exami- nations the course of a single case may be studied. By extended studies over long intervals of months or years some new phases of the pathology of mastoiditis may be brought out. The ultimate results of acute and chronic mastoiditis in early childhood, their influence on the development of the mastoid and the auditory function in later life, the final results of those types of mastoid- itis in which the patients apparently recover without operation, and the relation of mastoid sclerosis to the capsule and functions of the internal ear, are problems on which systematic X-ray work may possibly throw some light. As a preliminary to such studies involving repeated exposures, it must first be determined at what intervals and how many exposures may be safely given without causing alopecia and what form of technic will best guard against it. The cases of acute, subacute and chronic otitis media in young children, aged one to ten, presented such unique appearance on the skiagram as to warrant special consideration. It was my priv- ilege to examine about ten patients of this kind, who presented no marked clinical signs of mastoid involvement. Almost without exception the mastoid showed changes varying from a slight hazi- ness of cells in the earlier cases to more or less bone destruction in the more severe cases, while the chronic ones showed pro- 42 D A N D R I D G E U E ^i O R I A L noiinced sclerosis. Owing to tbei small size of the cells and the immature development of the mastoid, the amount of bone change is often hard to determine in these cases. In evei"y case, how- ever, in which such haziness of the mastoid was evident, if opera- tion was subsequently performed actual mastoid involvement was found, justifying operation. It would appear that in a majority of cases otitis media in early childhood is accompanied by distinct mastoid involvement. As mentioned above, the small size of the mastoid in these cases made it rather difficult to draw operative indications from the plate. referencp:s. 1. Iglauer, S. : The Qinical Value of Radiography of the Mastoid Region. Journal A. M. A., September 25, 1909, p. 1005. 2. American Quarterly Roentgenology, December, 1909, No. 1, ii. MINERS' CONSUMPTION/ BY OTTO V. HUFFMAN, M.D. Miners' consumption is a term used by the miners to designate emaciation associated with anemia, general weakness, shortness of breath and occasionally palpitation. It is distinctly a layman's term for a general condition which may be due to a variety of causes. Whoever has observed a large number of miners must have been struck with the fact that the majority are pale and thin, and that they present the facies of chronic dyspepsia. A low state of health among miners is so prevalent and the use of the term "miners' consumption" so general that the subject mer- its the serious attention of the medical profession. One does not have to look far for causes of ill-health among miners. Most mines and mining towns are without any sanitary measures whatsoever. In the mine urine and feces are disposed of promiscuously. The miner's home is situated anywhere. The outhouse is nearly always on the hillside above the home, and of course the well below. The women and children seem to thrive regardless of filthy practices, however, so we must look into the mine where the miner works for the direct cause of his condition. According to the returns of the twelfth census there were 528,- 822 persons in continental United States reported as "miners" in the year 1900. Of this number 344,205 were reported as coal miners ; 52,024 as gold miners and silver miners, and 132,593 as miners not specified. Analyses reported by the Technological Division of the United States Geological Survey show that the atmosphere at the face of the coal in the mine contains nearly always traces of ethane, me- thane and carbon monoxid gases. In the ordinary management of a mine means are taken to detect these gases before they are present in such a dangerous degree as to become inflammable. Efficient forced ventilation will usually remove the gases in suffi- * Reprinted from The Journal of the American Medical Association, November 26, 1910, vol. Iv. pp. 1891-1892. 43 44 DANDRIDGE MEMORIAL cient quantity to minimize the danger of an explosion, but at the face of the coal where the miner is working, there will always be traces of the above-mentioned gases. The stronger the ven- tilation the greater the tendency to exhaust in the rooms and blind entries, with greater liberation of gases from the newly-made cuts, bore-holes and broken coal. In just what way the delete- rioijs effects of ethane and methane are brought about when in- haled in small qua,ntities over a long period we are not prepared to say, but we do know that carbon monoxid has the property of uniting with the hemoglobin of the red blood corpuscles to form a rather stable compound, and that it is not readily replaced by oxygen. In mines where dynamite and other nitroglycerin explosives are used we have another source of poison. In such explosives the nitroglycerin is mixed with inert matter. As a result of an explosion the inert matter is blown into the ore or coal. Adher- ing to the particles of this inert matter are small amounts of nitro- glycerin which have been disseminated without entering into the detonation — being finnly fixed to the particles of the menstruum, like so many tablets of nitroglycerin. Later this dust containing small amounts of nitroglycerin is inhaled during loading or shovel- ing, and, as every physician knows, the most efficacious way of administering nitroglycerin is to dissolve the triturate in the mouth. Another way of absorbing this poison is through the skin. Hence, these miners complain of headache, palpitation and nausea. Sometimes men working on the tipple cut in the open complain, too, as they breathe this dust when the cars or wagons are dumped. During the past year Congress passed a law establishing a Bureau of Mines on account of the great number of miners killed or maimed annually as a result of a lack of safety devices. It may be opportune for the physicians to make some effort to better the condition of the miner from a hygienic and sanitary standpoint. If in one of our naval ships we did not have elaborate sys- tems of ventilation and did not make careful tests for the least increase in carbon dioxid gas for the several hundred men con- fined below — if we did not prohibit promiscuous expectorating, HUFFMAN 45 urinating and defecating, what a deplorable ship and state of health we should have ! It is no less important to have a clean, well-ventilated mine for the several hundred men working in it. The mere fact that the filth is hidden in darkness is no excuse for permitting a lack of sanitary precautions which we would not countenance one mo- ment in the open light. We should provide our mines with better ventilation and more experts capable of analyzing the air. Physicians in mining towns are without authority. It seems as though it might come within the province of this new bureau to make rules in regard to sanitary measures outside the mine as well as inside. Without chronic gas poisoning, typhoid, tubercu- losis, hookworm, chronic nitroglycerin poisoning, and other pre- ventable diseases, as well as fleas and chiggers, perhaps there would be no "miners' consumption." Some physicians jump to the conclusion that the miner has general pulmonary fibrosis (anthracosis). As a matter of fact, the miner of to-day inhales very little dust, much less than the coal- handlers outside inhale, and he does not have evidences of ca- tarrhal inflammation of the respiratory tract to the same degree as the men working in coal dust, who undoubtedly have an- thracosis. Other physicians account for the miner's pallor by the lack of sunshine, without considering real anemia. Many men have continued to work in dark but well-ventilated places other than mines for many years without developing anemia or marked pallor. It is our duty to conduct some serious investigations in regard to the health of our miners. We should have more data at hand obtained from blood-examinations, post-morten examinations, air analyses and other examinations which may give us exact in- formation. THE WASSERMANN REACTION.-^^ BY OSCAR BERGHAUSEN, A.li., M.D. The serum diagnosis of syphilis has stood the test of five years, and is now being universally employed. In a recent German con- gress the question as to the relative value of the original method and its various modifications was brought up, and the discoverer naturally insisted upon his original method being adopted as the standard. The only modification which is being successfully applied is that introduced by Noguchi. Von Dungern has intro- duced the same method into Germany, and is still maintaining its value, despite the criticism of the Wassermann school. That differences should exist in the examination of various sera by different experimenters is not to be wondered at, when the difficulties of the reaction are taken into consideration. Mis- takes are made in interpreting the doubtful or border-line reac- tions when nothing is clinically known of the case. Five variable factors must be worked with, and, unless all steps are properly carried out, errors may follow. This is shown by the various reports sent in by Berlin workers, when serum from the same patient was sent to different men for analysis. A preferred stu- dent of Wassermann was guilty of interpreting a positive case as negative, and on another occasion a negative case as positive. Even the most expert must exercise extreme care to avoid such errors. The reaction is not one for every person to carry out, unless he has the requisite knowledge of hemolysis and the abil- ity to work persistently and constantly. Ordinary help, trained to do the reaction, do the work in a methodical way, without a full realization of the various biological factors which must be taken into consideration. The various products, especially hemo- lytic amboceptor, antigen and complement, must be thoroughly examined before each examination to avoid discrepancies. To perform the reaction with the same amounts on Friday as were * From The Lancet-Clinic, December 17, 1910. 47 48 DANDRIDGE MEMORIAL used on the previous Tuesday would be wrong, unless previous experiment would have shown this to be proper. To avoid errors in interpretation, the writer has employed vari- ous methods of late, in order to give him a wider range and to un- derstand their rela*:ive value. The Noguchi and the original Wassermann method are the only two which need be thoroughly considered. THE COMPLEMENT. Noguchi deserves great credit for establishing clearly the im- portance of taking into consideration the relative values of com- plement and hemolytic amboceptor before each test. Ordinarily, in the original method, one-tenth cubic centimeter of guinea-pig serum is taken as a standard amount of complement for each test. The relative amount of hemolytic amboceptor for one unit of complement is determined and then doubled before using in the final test. In the Noguchi modification, when properly carried out, the process is, in addition, reversed, to determine the small- est amount of complement necessary when the unit of amboceptor has been determined, and this amount of complement is doubled before using. In this way the same amounts, quantitatively speak- ing, of amboceptor and complement ar.e used for each test, and lead to greater accuracy. THE AMBOCEPTOR. Furthermore, the fact that normal human sera may contain natural amboceptor for sheep corpuscles, results in the necessity of testing each serum to be examined for this property. If hem- olysis follow of itself, without adding specifically prepared anti- sheep amboceptor, in the presence of complement, another vari- ety of sheep corpuscle must be used, so that one is employed which is not of itself hemolyzed. This leads to an immense amount of work, which falls away when the Noguchi system is employed, because an anti-human amboceptor and human cor- puscles are employed. The serum to be examined can be readily inactivated at 56° C. when the Noguchi method is used. At first the latter recommended the use of the fresh active serum in smaller amounts. To-day he recommends the use of an active BERGHAUSEN 49 serum when antigen prepared by the acetone method of purifi- cation is employed. ANTIGEN. In the following listed cases, antigen prepared both from syphilitic livers and normal organs was employed, as alcoholic extracts. No essential differences were found. Noguchi's method of purifying the extract by means of acetone is an excellent one. By this means objectionable proteids, which may of themselves bind complement, are disposed of. Furthermore, an uniformly pure product is obtained which can easily be preserved. THE WASSERMANN AND NOGUCHI METHODS. In sixteen cases both methods were simultaneously employed. All positive cases were clinically diagnosed as such. The one negative tabetic case denied previous infection. These interpreta- tions were made by me in an unbiased spirit, since much depended upon my honesty in carrrying out the work. The following table shows relative merits of the two methods : Case Wasser- No. Clinical Diagnosis. Nogtichi. mann. 1 Normal — — 2 Normal — — 3 Normal — — 4 Doubtful previous infection — — 5 Tertiary lues -f + 6 Tertiary lues + — 7 Tabes dorsalis -h + 8 Secondary lues under treatment — — 9 Latent lues — — 10 Tertiary lues -j- + 1 1 Tertiary lues -f- + 12 Secondary lues + "i" 13 Paralytic + + 14 Secondary lues under treatment — — 15 Tabes dorsalis — — 16 Hereditary lues -f + Total number of cases 16; Noguchi, + 50 per cent., — 50 per cent; Wassermann, -|- 43.8 per cent., — 56.2 per cent. Although these cases are relatively few in number, they show us, as previous observers have done, the greater delicacy of the Noguchi system. Case No. 6 was undoubtedly luetic, and not under treatment at the time, and yet a positive reading could only 50 D A N D R I D G E MEMORIAL be made by the Noguchi system. A negative Noguchi is greater evidence of a negative luetic condition than a negative Wasser- mann. THE CLARK METHOD. Clark (Journal of Infectious Diseases, vol. 7, No. 3, May 20, 1910) has descril^ed a simplification of the Noguchi system in that a complete reaction is completed in thirty minutes, and the minimum amount of complement necessary is determined and used as the unit of complement for the final test. In four cases thus tested the results vi^ere identical with those obtained by the Nog- uchi method. Outside of the greater rapidity of execution, I could see no advantage over the Noguchi system, which it essen- tially is. THE HECHT METHOD. In this modification we need only the patient's serum, a sheep corpuscle suspension and antigen. It is dependent upon the fact that the patient's serum may contain sufficient natural amboceptor for sheep's corpuscles. In the few tests made the results were unreliable, and therefore the method was no longer employed. THE NOGUCHI SYSTEM. In the following table are listed those cases which were clin- ically diagnosed by others, and by subsequent course have war- ranted me in making such a classification. Several were con- firmed by autopsies and others by the eflFect of treatment. No of r Noguchi n Cases. Slage. — Percent. -'- Percent. 2 Primary 2 100 (2 weeks and 3 weeks) 7 Latent 3 43 4 57 30 Secondary 2 6.6 28 93.4 19 Tertiary 4 21 15 79 23 Parasyphilitic 7 30.3 16 69.7 4 Con«fenital svphiiitics .... I 25 3 75 50 Non-syphilitics 49 93 1 2 Total 135 ; iiegative 50.4 per cent. ; positive 50.6 per cent. Comparing the results obtained in the second table with those obtained in the first table, we see the constancy of results ob- tained when the Noguehi method was used. Practically one-half BERGHAUSEN 51 of all cases examined were positive or negative. Although the percentage of positive cases in several stages is not quite so high as given by other observers, to one acquainted with the work the slight difference is easily understood. Clinicians will usually in- sist on their being correct in calling one case positive, another negative, despite the laboratory report; especially is this the case in obscure lesions. The results are given frankly and on the basis of clinical diagnosis and evidence. ITS VALUE TO THE INTERNIST. In obscure lesions the Wassermann reaction can be of the greatest assistance to the clinician. Plenty of evidence is at hand to prove this point, but I do not wish to lengthen this report by citing case histories. In liver diseases two out of three cases examined were decidedly positive. The one negative case was one of hypertrophic cirrhosis. In heart lesions its value is un- questioned at times. Past observers have noticed the frequent pos'tive findings in aortic lesions and in aneurism. In the follow- ing table are given results obtained in a few cases. The clinical diagnosis is used as a basis for the correctness of my work, de- spile the fact that I realize that in no other branch of medicine do clinicians vary so much at times. No of I Noguchi ^ Cases. Lesion. -j- Per cent. — Per cent. 8 Aortic 5 62.5 3 37.5 1 Aneurism .... 1 100 3 Mitral 3 100 1 Myocarditis .... 1 100 A positive Wassermann would confirm a clinical diagnosis of aor'itis; a negative reaction would tend more to a mitral lesion or disease of the heart muscle itself. In this connection it is well to call your attention to the possibility of a number of lesions existing at the same time in one individual. A patient with an old mitral lesion on a rheumatic basis might acquire a luetic con- dition at a later date. Such an individual might give a positive syphilitic reaction, and if one were to interpret the results on the basis of the above table, confusion would at once arise. A Was- sermann reaction, like all others obtained in the laboratory, must 52 DANDRIDGE MEMORIAL be interpreted only after thoroughly considering the clinical findings. PARASYPHILITIC CONDITIONS. No. of Cases. Noguchi Per cent. 37.5 25 50* Clinical Diagnosis. -|- P^r cent. 8 Tabes 5 62.5 4 Cerebro-spinal syphilis .... 3 75 2 Endarteritis 2 100 3 Paresis 3 100 2 Paralysis 1 50 1 Idiocy 1 100 Total 20: positive 75 per cent.* Negative 25 per cent. EFFECT OF TREATMENT. No. Kind of Treatment. Duration. 1 Injection 3 weeks 2 Injection 2 weeks 3 Injection 2 weeks 4 Infection a few 5 Injection a few 6 Injection 1 month 7 Injection 5 months 8 Combined 2 years 9 Various many years 10 Various 4 years 11 Internal 3 years 12 Internal 3 years 13 Injection 3 years 14 Various 10 years 15 Various 3 years 16 Various (?) In general, the more prolonged and thorough the treatment, the greater the tendency towards a negative reaction. If not thor- oughly eradicated, the positive reaction may develop again after the lapse of many months, although no symptoms may be pres- ent. At times a distinctly positive reaction may shortly become negative under thorough treatment. This can only be explained upon the basis that the effect is greater in one case than in an- other, or upon the assumption that the original infection was less intense. CONCLUSIONS. In summing up this work the following conclusions were reached : 1. A positive luetic reaction must be looked upon as a symptom Time Elapsed. K foguch + + -- -- 5 months — 4 weeks — 6 weeks — 6 months + 4 weeks 4 weeks — 4 weeks — 9 months + (?) 7 months 6 weeks — BERGHAUSEN S3 and interpreted as such, and as long as it exists the patient is not free from the danger of a renewal of other symptoms. 2. A negative reaction does not necessarily exclude syphilis; it would tend to show rhat syphilis is either absent or latent as far as blood serum manifestations are concerned. 3. A negative Noguchi is greater evidence of the absence of an active syphilis than a negative Wassermann. 4. A positive Wassermann is evidence of an active luetic con- dition, when frambesia, leprosy and acute scarlatina (according to others) can be excluded. 5. A distinctly positive Noguchi has the same value as a posi- tive Wassermann. 6. A slightly positive Noguchi or Wassermann should be in- terpreted with some caution. In the presence of a positive his- tory and positive findings it can be interpreted in a positive sense. In doubtful findings it should be repeated in two weeks for a confirmation of the results. 7. One performing the serum diagnosis of syphilis should have both the Noguchi and Wassermann methods at his disposal and command. The Noguchi method gave only one incorrect result when positively reported, taking the clinician's word as evidence of a negative luetic condition, although the case had previously been treated and diagnosed as a luetic by another phy- sician. THE SIGNIFICANCE OF EHRLICH'S ALDEHYD . REACTION IN THE URINE.* BY OSCAR BERGHAUSEN, A.B., M.D. About eight years ago Ehrlich first noticed that normal urine gave a faintly reddish coloration when treated with a muriatic acid solution of paradimethyl-amino-benzaldehyd, and that th's coloration was remarkably intensified in certain pathologic condi- tions. To Otto Neubauer^ is due the credit of having isolated the particular chemical substances causing the reaction, proving that it was caused by pyrrol derivatives present as urobilinogen substances, the product of the metabolism of blood pigments ; and reasoning inversely, he came to the conclusion the blood pigments themselves were derived from pyrrol derivatives rather than indol substances, as upheld by Nenki. He furthermore contended that these urobilinogen substances, mother substances from which the urobilin was formed, were present in increased amounts when there was an increased breaking down of blood pigments, espe- cially in malaria, lead colic, lobar pneumonia, lung infarct, venous thrombosis, liver diseases and some infectious conditions. The object of the present investigation was to determine the clinical value of the reaction, since it is so readily and easily car- ried out. Undoubtedly the determination of the urobilin in the urine would be more satisfactory, as recently contended by Hil- debrandt,- since by his method of treating the urine with zinc ace- tate all urobilinogen substances are converted into urobilin, so that both substances are determined at once, whereas the aldehyd reagent shows only the presence of urobilinogen, its action on urobilin causing no change in color. The present investigation was begun some nine months ago, since which time the work of Conner and Roper^ and Hildebrandt^ has appeared. My observa- * Read in the Section on Pathology and Physiology of the American Medical Association, at the sixtieth annual session, at Atlantic City, June, 1909, and published in the Journal of the American Medical Association, January 8, 1910, vol. liv, pp. 99-103. 55 56 DANDRIDGE MEMORIAL tions so clearly verify many of the observations and predictions of the former writers that their publication seems unnecessary. The question of the origin of the urobilinogen and urobilin naturally is brought up, and the various theories for the produc- tion of the same called to mind, namely, the enterogenous, hepa- togenous, hematogenous, histogenous and renal theories, recently so well summed up by the writers referred to. At the outset it may be stated that my observations would tend to support the enterohepatogenous theory, namely, that under normal conditions the reduction of the biliary pigments into urobilinogen and uro- bilin takes place in the intestines, in accordance with the views long since expressed by F. Miiller and Otto Neubauer, and that a pathologic urobilinuria or urobilinogenuria results when the liver is insufficient; that is, vv'hen it is unable to excrete an increased amount of urobilinogen or urobilin when absorbed from the intes- tines, or when, through disturbances in the liver itself, it is unable to excrete a normal or even deficient amount of these substances. In infections of the liver evidence would point to the fact that these substances may be locally formed in the liver itself. Al- though the histogenous theory cannot be discardeJ, it would seem that the chief organs concerned ordinarily are the intestines and the liver. CLINICAL APPLICATION. The reagent used was prepared as follows: Twenty grams of paradimethyl -amino-benzaldehyd were dis- solved in 1,000 c.c. of dilute muriatic acid, made by diluting 150 c.c. of the chemically pure acid to 1 liter with distilled water. To about 5 c.c. of cold urine taken soon after being voided, because long standing causes a conversion of the urobilinogen into uro- bilin through the action of air and sunlight, 5 to 10 drops of the reagent were added. The mixture was shaken and allowed to stand a minute or two. Normal urine gave a varying coloration, which was intensified to a distinct cherry-red color on heating, usually associated with a peculiar pungent odor. Neubauer as- serts that the urobilinogen represents various substances, ranging in structure from CgHijN (hemopyrrol) to C30H40N4O7 (uro- bilin itself), and that the more sensitive give the reaction in the B E R G H A U S E N 57 cold, the less sensitive only on heating. When the reaction is distinctly scarlet in the cold, a pathologic condition of the urine is present. Experiment soon showed that the intensity of the reaction varied, even in the normal urine, and the following scheme of recording results was adopted: A negative result, i.e., maintenance of the original color of the urine, or a yellowish coloration after adding the reagent was reported as — 0; a faint reddish color only obtained on looking through the whole columns of urine in the test-tube from above, as -j- 1 ; when the mixture presented a pinkish or faintly reddish hue, on looking at it from in front, as -[- 2 ; when a distinctly scar- let coloration was obtained it was recorded as -{-2, which intensity of reaction alone is of any pathologic significance. Examination of my own urine through a period of twenty-five days showed that the reaction varied from one day to the other, but that it never assumed a -}-3 reaction in the cold, but always on heating. From this it was assumed that an apparently normal individual, with a properly functionating liver, was able to pre- serve a urobilinogen balance ; that is, the liver was able to ex- crete these substances derived from the intestines, only allowing a trace to appear in the urine. It may be possible that in cases of severe constipation, or so-called torpid liver, even in an appar- ently normal individual, the reaction might approach -f-3 in in- tensity, but if this condition persists following free purgation, undoubtedly a pathologic condition is at hand. The reaction was next applied to the urine of a series of nearly 200 cases taken from all wards of the City Hospital. The tables show the distinct degree of reaction obtained in many of these cases. First, as to the color of the urine, this was recorded in a total number of 107 cases. Of the 74 light-colored urines ex- amined, 13 (17.5 per cent.) reacted +3 9 (12.4 per cent.) reacted +2 10 (13 5 per cent.) reacted -"-l 42 (56.6 per cent.) reacted — Of the 33 cases of dark-colored urine examined, 13 <'39.4 per cent.) reacted -j-3 5 (15.1 per cent.) reacted -"-2 2 ( 6.1 per cent.) reacted -f-1 13 (39.4 per cent.) reacted —0 58 DAN BRIDGE MEMORIAL This shows conclusively that the positive reaction was more commonly found in dark-colored urines, 21.9 per cent, more than in light-colored urines, but that it also occurred quite frequently in the latter. In the dark-colored urines a negative reaction was correspondingly less frequent — 17.2 per cent. less. On the whole, then, the reaction is independent of the color of the urine, being more common, however, in dark-colored urines. TABLE SHOWING DEGREE OF REACTION IN ABOUT ONE HUNDRED AND FIFTY HOSPITAL CASES. No. Clinical Diagnosis. Cases. Acute lobar pneumonia 17 Malaria 2 Acute articular rheumatism 12 Scarlet fever 5 Typhoid fever 10 Influenza 5 Erysipelas 2 Simple pulmonary tuberculosis 5 Complicated pulmonary tuberculosis 2 Appendicitis 3 Pelvic cellulitis 2 Tonsilitis 2 Pus tubes 4 Endometritis 1 Cystitis 2 Cirrhosis of liver 2 Carcinoma of liver 1 Miliary abscess of liver 1 Catarrhal jaundice 4 Myocardial insufficiency plus edema 8 Pleurisy with effusion 5 Pericarditis plus diaphragmiatic pleurisy.... 2 Pleurisy, dry adhesive 3 Acute nephritis 5 Uremia 1 Chronic nephritis 5 Abortion 3 Shot wound of chest 1 Shot wound of abdomen 1 Shot wound of kidney 1 Ruptured abdominal aneurism 1 Fracture of femur 1 Hemorrhoids 2 Venous thrombosis 1 Syphilis 2 Lead colic 1 Trichiniasis 2 Diabetes mellitus 5 Chronic alcoholism 2 Carbolic acid poisoning 1 +3 7 2 5 Reaction +2 2 1 — 6 5 5 5 2 2 3 BERGHAUSEN 59 No. I Reaction > Clinical Diagnosis. Cases. +3 -f-2 -\-\ — Diabetes insipidus 2 . . . 2 Burn cases 4 . . . 4 Morphinism 3 1 . . 2 Senile dementia 1 . . . 1 Dementia paralytica 1 Neurasthenia 2 Melancholia 1 Acute gastritis 1 Acute bronchitis 4 To sum up : The reaction is most commonly obtained in diseases of the liver, myocardial insufficiency with edema, pleurisy with effusion, and acute catarrhal jaundice, all conditions in which the proper elimination of the urobilinogen through the liver after ab- sorption from the intestines is interfered with; furthermore, in some infectious conditions, as lobar pneumonia, malaria and artic- ular rheumatism. An absence of a pathologic reaction has been conspicuous in more or less localized septic states, as pelvic ab- scess, pus tubes, tonsillitis, simple pulmonary tuberculosis, acute bronchitis, erysipelas, dry pleurisy and pericarditis, despite the increased temperature. In this series of cases the absence of the reaction in typhoid fever and scarlet fever is to be noted. In localized extravasations of blood following shot wounds, or rupture of aneurism, no in- crease in the intensity of the reaction is to be noticed. Con- valescence from a condition in which the reaction was marked was followed by a return to the normal ; thus, in both cases of malaria the quick response to quinine treatment was followed by a disappearance of the reaction. In incipient cases of dis- turbed myocardial insufficiency, and in suspected cases of gall- stone trouble with a clear history and response to treatment, the reaction was not present. Undoubtedly a positive reaction which persists, in these cases, would indicate a marked disturbance either in the production of the urobilinogen in the small intestines plus increased absorption or a disturbance in the eliminating power of the liver. It must be borne in mind that one section of the liver may be involved and yet the remainder ma}' be efficient, as was demonstrated in one severe case of syphilitic cirrhosis of the liver, in which the reaction was negative, though a diminished formation in the intestine may have been present. The reaction 60 DANDRIDGE MEMORIAL is not a constant one, even in those conditions most commonly the cause. That a positive reaction may be of some assistance in suspected liver involvement was shown in a case of miliary ab- scess of the liver following infectious thrombophlebitis. Case I. — The patient, a young man, first showed symptoms of appendicitis ; later localized peritonitis developed, at which time the reaction was +2 in intensity. These symptoms subsided, but later increased temperature plus tenderness over the gall-bladder my tie the attending physicians suspect gall-bladder or liver in- volvement. The urine showed a positive aldehyd leaction in cold and the presence of leucin and tyrosin in the urine. Operation was resorted to for suspected cholecystitis. At operation the gall- bladder was apparently normal and cultures taken proved nega- tive. The patient collapsed suddenly on the table. Autopsy. — This revealed an enlarged liver, studded through- out with miliary abscesses, along the portal tract evidently, and an infectious thrombophlebitis. Cultures from the portal vein and abscess areas both showed the presence of diplococci and a colon-like organism, evidently the result of infection following absorption from the originally involved appendix. Clinically this case beautifully demonstrates what Fischler* showed experimentally on animals, namely, that under certain conditions urobilin can be formed in the liver itself. He made biliary fistulas in dogs, draining the bile to the outside, and then injected amyl alcohol and phosphorus into the gall-bladder. The liver became involved, and urobilin again appeared in the urine; with the subsidence of the condition it again disappeared. In my case the liver itself became involved through infection along the portal tract. EXPERIMENTAL DATA. Since Muller reported the interesting fact that when the com- mon bile duct becomes occluded the urobilin disappears from the urine, the German school has adhered to the enterogenous theory as to the origin of the urobilin, namely, that when the bile is poured into the intestines and is subjected to the action of the re- ducing bacteria, urobilin is formed and absorbed from the intes- tines ; it is again excreted through the bile and to some extent through the urine. Bile usually contains some urobilin. Neu- bauer^ later asserted that occlusion of the common duct would also be followed by absence of the urobilinogen in the urine, bile BERGHAUSEN 61 and intestines, and that this might be shown by a negative aldehyd reaction in the urine, both in the heat and cold. Kimura^ showed that normal bile always contained urobilinogen, using the aldehyd reaction and the spectroscope to detect the absorption band. With the object of verifying this fact through animal experi- ment, the following investigations were made : It was found that normal rabbit urine reacted toward the aldehyd reagent exactly as does the normal human urine. Rabbits were therefore used, and each experiment conducted under ether anesthesia. Ether was given in minimal amounts, and never exceeded thirty minutes. In two instances the animals died within a few hours following the operation, but no changes beyond the normal were found in the urine. ExPERiMEXT I. — Male rabbit. The common bile duct was ligated with silk and the operation wound closed. The animal died eighteen hours after operation. Urinalysis. — Urine before operation negative in the cold, -j-3 on heating. After operating, the urine taken from the bladder soon after death was reddish. Aldehyd reagent caused a nega- tive reaction in the cold, the reddish color of the original urine soon disappearing on adding the reagent. On heating, a brown- ish precipitate formed, but no scarlet color developed. The cold urine was then heated, filtered, and the reagent added after cool- ing. Reaction was +1 ; on heating no increase in the intensity of the reaction. The urine drawn before operation and preserved on ice in the dark, when added to the catheterized specimen im- mediately caused a scarlet coloration on heating with the reagent. Autopsy. — This, made about twelve hours after death, showed abdominal wound perfect, no escape of bile, liver enlarged, con- gested, apparently bile-stained. Common duct ligated, severe congestion from this point unward. The aldehyd reaction nega- tive in the heat and cold, but not confirmed by spectroscope ex- amination. Kidneys both showed an acutely congested appear- ance. Experiment II. — ]\Iale rabbit; common duct ligated and op- eration wound closed. The animal died thirty-six hours after operation. Urinalysis. — Urine after operation showed a negative reaction in the cold and -f-l on heating. Addition of the urine obtained on the previous day before operation caused intense reddish color- ation on heating with the reagent. Autopsy. — Thoracic organs normal. Abdomen showed an early 62 DANDRIDGE MEMORIAL localized peritonitis immediately below the operating wound. Liver was bile-colored, gall-bladder dilated. These experiments both show^ that occlusion of the common duct is early manifested by a decided alteration in the normal reaction. On heating with the reagent only the faintest trace of a reddish color was noticed. On adding the normal urine, how- ever, the color immediately became scarlet, showing conclusively the urobilinogen had practically been eliminated ; in reality none had been formed, because the action of the reducing bacteria in the intestines had been excluded. The fact that the reaction on heating was still recorded as +1 would show that, as late as thirty-six hours after the second experiment there was still a slight trace of urobilinogen present, which no doubt was due to residual urobilinogen of the tissues, rhis time interval not being sufficient to cause complete elimination from the system. Several experiments were made of infecting the gall-bladder above the point of constriction in order to observe, if possible, the reoccur- rence of the scarlet color due to changes in the liver through bac- terial action. No results were obtained, however. Complete occlusion of the common bile-duct is therefore fol- lowed by a negative reaction, both in the cold and in the heat, after adding the aldehyd reagent to the urine. There immediately occurs to one the possibility of using this fact as a means of diag- nosis in cases of total obstruction of the duct through a stone, through inflammatory changes in the mucosa, or by compression from without through any source. Are these the only conditions which can cause this change in the reaction? Kimura^ has shown that in severe diarrheas a similar condition is obtained, owing to the fact probably that no bile can be reduced in the intestines under such a condition, or absorption becomes impossible. We must further conceive of the possibility of a patent ductus veno- sus, allowing of the discharge of bilirubin in the intestines, al- though occlusion of the duct be present. In the newly born the same condition is obtained, because bacterial reduction has not as yet begun. In my list of clinical cases two other conditions were encoun- tered which gave a similar result: Case II. — Infant, female, aged seventeen months, died eight days after acute phosphorus poisoning caused by eating matches. BERGHAUSEN 63 The urine examined before death had unfortunately been stand- ing from thirty to thirty-six hours before the aldehyd reaction was tried. It was^ however, found negative both in the heat and the cold. Tyrosin was also found in the urine. Autopsy, made about four hours after death, shov/ed a some- what enlarged liver, distinctly fatty. Heart showed beginning endocarditis. Intestines were somewhat congested. Microscopic examination of the liver showed distinct fatty changes and round- celled infiltration about the vessels; the hver cells were poorly stained and fat globules numerous. The urine obtained at au- topsy showed a negative aldehyd reaction both in the heat and the cold. Case III. — Clinical diagnosis, transverse myelitis. An opera- tion had been performed to relieve any supposed compression of the cord about at a level with the fifth dorsal vertebra, since a distinct traumatic history was given. No relief followed. Im- mediate operation, however, was successful from a technical standpoint. The patient sank rapidly from incontinence of both urine and feces, and at last refused to eat, so that exhaustion ul- timately resulted in death. For several days previous to death profuse hemorrhages occurred from the lower bowel. Autopsy. — There was found an extremely fatty liver, chronic inters" "tial" nephritis, and hemorrhagic condition of the lower colon. The urine obtained at this time likewise showed a nega- tive reaction in the heat and cold. In both tt ese cases it may be argued that post-mortem changes in the urine caused these variations in the aldehyd reaction from the normal. Among numerous cases examined after death, how- ever, these two cases were the only ones which presented such a condition. Hiidebrandt believes that in severe phosphorus poison- ing the general destruction of the liver would lead to such find- ings. He has no direct evidence to support his views, however. Case II was undoubtedly one of acute phosphorus poisoning, and tyrosin was found in the urine ; bile could not be detected by nitric acid or iodine tests Before death, however, the stools were very frequent, quite pale, and grayish in color. To what extent the profuse diarrhea was instrumental in causing the negative uro- bilinogen reaction cannot be definitely told. Likewise in Case III frequent diarrheic stools were present before death, and in addi- tion a severe hemorrhage from the bowel on repeated occasions. In both cases, however, the liver showed marked fatty degenera- tion, which would tend to support the views of Hiidebrandt. In 64 DANDRIDGE MEMORIAL the future severe anemias may be shown to react in a similar way, because of the lessened destruction of blood pigment in late stages. In phosphorus poisoning the variety, whether acute or chronic, must also be taken into consideration. Harnack" has recently shown experimentally that in acute cases following injection of phosphorus into the stomach rapid degeneration and fatty changes are produced in the liver. In more chronic cases, as when sub- cutaneous injections of phosphorus in oil are given, the degenera- tive changes in the liver are still present, but not so intense as in the more acute cases, inflammatory reactions on the part of the liver being more common. Therefore, it may be possible that in chronic phosphorus poisoning the destruction to the liver sub- stance may not be so intense as to lead to a total absence of uro- bilinogen in the urine, as indicated by a negative aldehyd reaction in the heat and cold. The animal experiment was again called into play, to shed, if possible, some light on this subject. Experiment III. — A male rabbit was given phosphorus in oil mixed with the food. About six hours later it began to show signs of being ill, and died some time during the night. Urinalysis. — Before operation, at which time the bladder was emptied, the urine showed a negative reaction in the cold, and a positive reaction on heatinaf. The urine, withdrawn from the bladder some time after death, showed a similar reaction. Autopsy. — Stomach full of food, phosphorus fumes still es- caping. The most dependent part of the organ showed an escha- rotic-like condition of the mucosa. The liver was not particularly enlarged, was distinctly mottled on section, but did not present a fatty appearance. Microscopically the liver showed distinct cloudy swelling of the cells, round-celled infiltration about the vessels, and engorgement of the capillaries. No fatty globules could be detected. The kidneys were enlarged and had a con- gested appearance. The above experiment did not result in such marked fatty changes as to lead to a complete obliteration of the urobilinogen in the urine. It is possible that the death occurred too rapidly for such changes to be caused, and that a more gradually induced toxemia would have produced the desired result. To establish this point a second animal was used for experiment. Experiment IV. — A male rabbit was given phosphorus in oil per mouth. On the three succeeding days the urine was normal BERGHAUSEN 65 in reaction, i. e., negative in the cold and positive on heating. On the fourth day more phosphorus was fed. On the day following the reaction was -f- "^ i" the cold, distinctly positive. This per- sisted for five days, when more phosphorus was given per mouth. On the following day the reaction was negative in the cold, and a brownish coloration only developed on heating. Twenty-four hours later the reaction was negative in the heat and cold. The animal now showed signs of considerable weakness and suffering, and was killed by chloroform. Autopsy. — The liver was somev/hat contracted, pale yellow, with a mottled appearance on section. The liver was still firm. Microscopically there was almost total obliteration of the liver cells; those remaining were pale with poorly stained nuclei. Numerous fat molecules were distributed throughout. There was round-celled infiltration about the vessels, and seemingly a begin- ning formation of connective tissue. The stomach was full of undigested food. The small intestines were nearly empty, the large intestines packed with ordinarily formed stools. The bile was thin, light greenish in color, and showed a negative aldehyd reaction in the cold and in the heat. In this instance the destruction of the liver substance had been so great that no bilirubin was offered to the intestines for reduction. All stages of the reaction were also beautifully demon- strated, varying from the normal to a relatively and at last an absolutely deficient liver, as indicated on successive days by the changes in the aldehyd reaction. CONCLUSIONS. The clinical value of the aldehyd reaction obtained by adding the reagent to cold, freshly passed urine, and then noticing the changes in the color, at first in the cold and then on heating, is manifest, though limited at times. The color reaction in the cold is of pathologic significance only when a distinct scarlet color is obtained. When the reaction persists following free purgation a patho- logic condition is at hand. The reaction is most commonly present in disea.ses of the liver and bile passages, severe grades of myocardial insufficiency, and certain infectious conditions, as lobar pneumonia and malaria. The reaction is not a constant one, even in apparently severe grades of the above conditions, presumably because the liver is 66 DANDRIDGE MEMORIAL still efficient in excreting any normal or increased amount of uro- bilinogen offered it. Localized infections are more seldom accompanied by this re- action, and when it does persist in such conditions the condition of the intestines and liver should be taken into consideration. In early grades of myocardial insufficiency of gall-stone trouble, and of liver disturbances the reaction is often a negative one. The appearance of the reaction in such cases previously negative would arouse suspicions of disturbances in the hepatic function; inversely, the disappearance of a reaction previously positive would indicate improvement. The positive reaction is not constant in localized extravasa- tions of blood into the tissues. When the reaction is positive some care must be exercised in the selection of an anesthetic for operations, since it is well known that chloroform, for instance, can be a direct liver poison. The absence of the reaction, both in the heat and in the cold, would indicate obstruction in the flow of bile into the intestines. This condition is also obtained in cases of severe diarrhea, in the newly born, and in severe grades of destruction of the liver substance. In conclusion I wish to express my indebtedness to the medical and surgical staff officers of the City Hospital for their kind per- mission in allowing me to use the material at hand, to the internes — more particularly Drs. Light, Schlanser, Monroe and Mussey — also to Dr. A. E. Osmond, without whose kind assistance and skill much of the experimental work would have been impossible. REFERENCES. 1. Neubaner, Otto : Sitzungsh. d. Gcsellsch. f. Morphol. u. Physiol, in Miinchen, 1903. No. 2, xix, 32. 2. Hildebrandt: Milnch. mcd. Wochcnsch., April 6. 1909, p. 710. 3. Conner, L. A., and Roper, J. C. : Arch. Int. Merf., Jan. 15, 1909, ii,532. 4. Fischler : Das Urobilin u. seine klinische Bedeutung. Thesis, Heidel- berg, 1906. 5. Kimura, T. : Deutsch. Arch. f. klin. Med., 1904, Ixxix, 274. 6. Harnack, E. : Milnch. mcd. Woch., March 2, 1909, p. 436. IMPETIGO CONTAGIOSA TRANSMITTED BY MACHINE OIL.* BY OTTO V. HUFFMAN, M.D., A BRIEF HISTORY of an epidemic of impetigo contagiosa among the machinists of a local manufactory is of interest because it brings forth some facts not obtainable from individual personal histories and shows the necessity of investigating infectious dis- eases in a comprehensive way, and of enforcing sanitary pre- cautions in machine shops. As long as these patients were treated by their several physicians, a variety of diagnoses were made without discovering the cause of the disease. In March, 1909, quite a number of the machinists working in the screw machine department complained that the oil which they were using caused a rash where it came in contact with the skin. The company sent a specimen of the oil to the laboratory to be examined. It was found that the oil did not contain any chemical impurities, that it was neither acid nor alkaline. It did not seem necessary to look into the matter of organic impurities, as the oil was made from lard which during the process of rendering was heated to a sufficient degree to make it sterile. Upon receiving the report that the cause of the rash com- plained of by their men could not be found in the oil as purchased, the company ordered the complaining men to report for examin- ation and treatment and to bring some of the oil actually used by them. Quite a number had complained, but only six reported. Of these six machinists, five presented inflamed papules and pustules distributed irregularly over the upper extremities, face, and neck, wherever the oil might reach the exposed skin. The sixth man did not have a rash, but said that he had had a "felon" on his thumb which was entirely healed. Upon questioning him, he stated that he had worked at a screw machine supplied by the same oil pump as that which supplied oil to the machines and * Reprinted from the New York Medical Journal, December 31, 1910. 67 68 DANDRIDGE MEMORIAL lathes of the other five men; that he had worked in the oil while the abscess on his thumb was discharging pus ; that this occurred just before the rash appeared upon his fellow workmen; that he had not had any rash but thought perhaps that his abscess might have been due to the oil. This verbal evidence needed only to be supplemented with knowledge of the lubricating system of these six machines to point clearly to the fact that the pyogenic germs discharged into the oil from the abscess on the finger of this man had been the cause of the pustular rash on the other five. At the factory it was found that the waste oil of the six machines at which these men had worked drained to a common reservoir from which after being strained it was again pumped to the same six machines — thus making successive cycles. The identical oil which had been at one time in contact with the abscess had been mixed with all the oil in the reservoir and thus diluted had been splashed upon the arms and faces of the machinists. The men with the rash were cleaned first with tincture of green soap, applied with pledgets of cotton so as not to cause scratches or points of inoculation, then with alcohol to further help dissolve the oil which might be absorbed carrying the pyo- genic germs beneath the skin in the same way as plague bacilli may be inoculated by inunction. The parts were then gently dried and dressed in ammoniated mercurial ointment held by gauze bandages. The men were kept from work and made un- eventful recoveries. It is interesting to note that, although the man who had had the abscess on his finger continued to work in the oil laden with pyogenic germs, he did not develop a rash. He had evidently acquired an immunity to the pyogenic germs of his own pus. As it was clear that the oil pumped to the six machines was laden with pus germs which caused the pustular rash, it was recommended to the company to destroy or sterilize it. Further inquiry in regard to other complainants showed that a few who had worked temporarily at some of these machines had slight rashes and that others presented skin diseases which in no way could be attributed to the oil. The company destroyed the oil and has had no trouble since. OSTEOCHONDRITIS DISSECANS: CONCERNING ITS NATURE AND RELATION TO FORMATION OF JOINT MICE.* BY ALBERT H. FREIBERG, M.D., AND PAUL G. WOOLLEY^ M.D. The formation of loose bodies is one of the most interesting phenomena to be observed in connection with the pathology of the chronic joint diseases. Long known as an accompaniment of certain cases of arthritis deformans, it was also believed that corpora mobilia were frequently the result of traumata. In 1887, Koenig described the formation of these bodies by a process which he considered sui generis and which he named accordingly, osteochondritis dissecans. Unable to satisfy himself either by experiment on the cadaver, or as the result of a large experience, of the relationship between trauma and the production of joint mice, he felt constrained to describe as osteochondritis dissecans, a definite and distinct joint affection, not associated with arthritis deformans nor in his judgment related to it ; nor yet standing in any demonstrable connection with trauma. As the result of a process whose nature was not clear to him, Koenig described the separation from the underlying joint ends of pieces of varying size. These fragments acquire a covering of connective tissue containing some cartilage cells. Usually one is able to find the defect in the joint segment from which the separation occurred although this rapidly fills in with cartilage. According to Koenig also, these joints are otherwise normal excepting some effusion and villous hypertrophy and after the removal of the foreign bodies they remain well. It must not be overlooked that the formation of loose bodies in certain cases by the chondrification or ossification of hypertrophied joint villi is accepted by Koenig also. In 1896, Barth disputed the existence of osteochondritis dis- secans as a distinct process, urging that for chondral and osteo- * Read before the American Orthopedic Association at its twenty-fourth annual meeting, held in Washington, May 3-5, 1910, and published in the American Journal of Orthopedic Surgery, February, 1911. 69 70 DANDRIDGE MEMORIAL chondral loose bodies only two modes of formation could be accepted; namely, arthritis deformans and trauma. According to Earth pathologic-anatomic proof of the existence of osteo- chondritis was lacking; Koenig's clinical and operative observa- tion was of doubtful value and his explanation was purely hypothetical. In 1908, Ludloff described two knee cases in which the diag- nosis of osteochondritis dissecans was made on the basis of the radiogram and confirmed by operation; in both cases the radio- gram showed a body about the size of a date seed which had apparently separated from the internal condyle of the femur opposite the insertion of the posterior crucial ligament. It ap- peared to lie in a cavity hollowed out of the condyle. In his first case the cartilage was intact over the body and it was liberated only by incision; in his second case a part of the bone fragment had already separated as a "corpus liberum." In this case the other and supposedly normal knee presented a similar condition in the radiogram. Most of the cases of osteochondritis dissecans of the knee which have been reported have similarly concerned this particular part of the internal condyle and Ludloft seeks to harmonize the divergent views of Koenig and Earth by a study of the vascular arrangement of this neighborhood. The arteria genu media ramifies over the posterior crucial ligament toward the lateral edge of the internal condyle. It is here a terminal vessel and would appear to be susceptible of injury at this point by forced simultaneous hyperextension and inward rotation of the joint. The circulation being thus cut oft" at this point we should then have following an osteochondritis dissecans of traumatic origin. It is, however, significant in our judgment, that in Ludloff's Case II both knees were affected and that in neither of his cases was the history of trauma forthcoming. Our interest in this subject was aroused by the following clinical observation : A Russian girl twenty years of age was admitted into hospital because of trouble with both knees. She had been having pain and frequent joint locking since her childhood, both knees being affected in like degree. At the age of seventeen an arthrotomy of both knees was done in Russia and loose bodies were removed, FREIBERG AND W O O L L E Y 71 which were afterwards shown to her. A second operation be- came necessary because of the appearance of more loose bodies. No radiograms were made in Russia by her surgeons. These operations afforded her reHef. She asserts that at no time had she any injury to the knees of noteworthy character. She is of decidedly nervous temperament, but seems otherwise in good general health ; is of short stature but well developed and de- cidedly plump. Upon admission she complained of pain in walking, but es- pecially in standing. The right knee was much more troublesome than the left. Has had no attacks of joint locking since the last operation. Both knees appeared swollen to some extent and both had about normal mobility. Some tenderness on palpation of the joint line on the mesial surface of both knees, much more marked in the right side. No muscular atrophy. No crepitation or grating on motion of either joint. Palpation disclosed no abnormality in the contours of the joint segments. Radiograms were now made by Dr. Lange. DESCRIPTION OF X-EAYS. Right Knee. (a) Antero-Posterior View. — The most striking feature of this view is the appearance of the internal condyle of the femur, We see here an apparent defect in the bone 3 cm. long, in which lie two fragments which are respectively 1 cm. by 0.3 cm. wide and 0.3 cm. long by 0.4 cm. wide. The defect in the femur gives the appearance of two cavities corresponding in size and shape to the two fragments which lie in them. The fragments appear to be completely separated from the surface of the bone beneath them. Superimposed upon the shadow of the fragment of the fibular side and to a slight degree upon the end of the internal one also, is seen the lighter shadow of a third mass of oval shape, measuring 1.6 x 1.3 cm. The upper border of this shadow is in great part obscured by the dense shadow of the femur upon which it is superimposed. The joint space itself seems of about normal width, and the tibia and femur appear to be of normal density. One must be struck with the fact, however, that at the joint line, and especially as concerns its mesial half, both the femur and '^l t>A^JDRIDGE MEMORIAL tibia differ from the normal in contour. The inter condyloid emi- nence of the tibia projects upward much less than usual, and the intercondyloid fossa of the femur is correspondingly shallow. The contour of the internal condyle of the femur lacks its usual convexity, being almost straight; the internal articular facet of the tibia is correspondingly shallow. There is but slight indica- tion of the marginal bone proliferation commonly seen in arthritis deformans. Since the most marked changes to be seen in the antero-pos- terior view are found in the internal condyle, it is unfortunate that the lateral view only is accessible, since no plate was made before operation with the mesial side of the joint applied. For this reason the mesial condyle is but imperfectly portrayed and the view of the pathological condition here is very unsatisfac- tory. In this view of the knee, however, it may be observed that at the upper margin of the patella near the posterior surface, there is a blunt, bony outgrowth, and in front of this apparently a loose body of bony texture lying in the tendon of the quad- riceps. Mesial View of the Right Knee (made since operation). — On March 25, 1910, a mesial view of the right knee was obtained. In this view it may be seen that the shell of bone which has sep- arated from the internal condyle is of greater extent, in an antero-posterior sense, than might have been imagined; it com- prises about the posterior three-fifths of the condyle. Left Knee. The same views were obtained of this joint. (a) Antero-Posterior View. — The general contours of the bones are very similar to those of the right knee. The anterior border of the internal condyle of the femur appears to be over- hanging. It gives the impression that it was probably at one time the seat of a condition like that of the right knee, and that a considerable amount of repair had taken place. The condyle has not only lost its convexity below, but has apparently lost some of its bulk in a vertical sense. A loose body appears at the mesial side of the internal epicondyle. (b) Lateral View. — The loose body just mentioned is now FREIBERG AND WOOLLEY 73 seen to "be behind the internal condyle. (It was not seen at the operation.) The patella presents a blunt, thick outgrowth from its upper and posterior margin. There is a suggestion of lipping to be seen at the anterior margin of the upper end of the tibia. Operation, January 19, 1910. By incision at the mesial side of the patella, the right knee was opened. There was unusually great venous hemorrhage from the capsule. The arthrotoniy was done upon the previously flexed knee, as suggested by Robert Jones. A loose body, the size of a cherry was at once seen, attached to the internal condyle by a slender pedicle composed apparently of connective tissue and synovial membrane. This was easily removed, but to our sur- prise nothing was to be seen of the two fragments shown in the radiogram, nor of the defect in the internal condyle, although the exposure of the joint was thoroughly satisfactory. After care- ful inspection the cartilage over the mesial condyle appeared of different color than elsewhere, and pressure upon it seemed to indicate that it was loosened from the underlying bone. A small incision showed this to be the case. Unaware of Ludloflf's ex- perience, related above, it was deemed unwise to further disturb the cartilage. The synovial membrane of the joint appeared thickened, and two nodular masses were excised and preserved, one from the tibia and one from the femur. An arthrotomy of the left knee was now done through a small incision. No loose body was seen. The mesial condyle of the femur appeared unusually flat and somewhat irregular in surface, but covered with cartilage of normal appearance. Here, too, the synovial membrane was thickened and a nodule was excised from the margin of the tibial surface Prompt healing occurred. The patient soon left the hospital, and has since been at work with practically no disturbance of joint function and no pain. The case just reported assumes a greater interest for two rea- sons. The first of these is that thus far few cases corresponding to Koenig's osteochondritis have been reported in which a radio- graphic study has been made. While the radiographic aspect of the right knee made it appear typical of this disease, it differs radically from this in the reappearance of symptoms after the 74 D A N D R I D G E MEMORIAL removal of the loose bodies; indeed this joint affection would seem to have assumed a distinctly progressive character, whereas this has not been true of the cases reported by Koenig and oth- ers- This would appear to strengthen Earth's view, that we are dealing here with arthritis deformans, and especially so since there is in both knees evidence of new bone formation at the margins of the patella. On the other hand it must be noted: 1. That at the operation no degeneration of the joint cartilage was to be seen. 2. That although the disease has been in existence for a num- ber of years, only the slightest marginal proliferation is to be seen in either femur or tibia. 3. That while arthritis deformans has been carefully studied radiographically, lamellar separation of bone from the surface of the condyles, such as we here observe, has thus far not been described as a part of otherwise characteristic instances of this disease. While the above considerations pertain to the clinical and radiographic aspects of this case, it must be here observed that since the work of Nichols and Richardson, and especially since the appearance of Wollenborg's paper on the etiology of arthritis deformans, our clinical and radiographic concepts of arthritis deformans require to be greatly modified and brought anew into correspondence with anatomical processes which have been clearly established. We must therefore seek reply to the following ques- tions : (a) Are we in this case dealing with two distinct joint diseases, or simply with different manifestations of a single joint affection? (b) Are all of the changes in this patient's joints to be recon- ciled with the modern conception of arthritis deformans? (c) Are we dealing with the osteochondritis dissecans of Koenig, and is this process incompatible with a rational notion of arthritis deformans? It appears to us that for the answer to these important ques- tions recourse must be had to the microscopic investigation of the specimens removed from our patient. We had at our disposal for microscopic examination four pieces of tissue; three of these, a pedunculated body and two FREIBERG AND WOOLLEY 75 synovial tags, were from the right knee joint, and one, a bit of tissue resembling cartilage and synovial membrane, from the left knee joint. The pedunculated body was a rounded mass, measuring 15 x 12 X 8 mm., elastic, of pearly appearance, and apparently composed of cartilage or dense connective tissue, or both, and possibly some bone. At one end was a short fibrous tag of not more than 1.5 mm. diameter, that represented the pedicle. This body was di- vided longitudinally, and since there was a feeling of grating during division, both halves were, after fixation in formalin, placed in the phloroglucin-nitric acid mixture to insure decalcifi- cation. The tissue from the left knee was also decalcified. The other tissues were fixed in formalin. All the specimens were finally embedded in celloidin, and after cutting were stained with hematoxylin and eosin. Sections of the large body showed that it was composed of a central area containing lime salts in small amount and a small amount of yellowish material that resembles the remains of blood pigment. The tissue about the central area was hemoge- nous and hyaline, and contained groups of cartilage cells. In the neighborhood of the central area such groups were sparsely distributed, but near the periphery, which was composed of hya- line fibrous tissue, they were more numerous. The fibrous tissue of the periphery was continuous with the pedicle. Each of the two bits of synovial tissue showed the same struc- ture; that is to say they were composed of rather villous clumps of connective tissue and were richly supplied with blood ves- sels. Our' interest at once centered upon these vessels, for almost without exception ~they showed well-marked signs of perithelial and endothelial hyperplasia. In some cases they were surrounded by abundant collections of small round cells. In others they were either partially or completely obliterated by endothelial over- growth. In the villi in which the thelial proliferation was most marked the perivascular connective tissue was more hyaline than in those in which the vessels were of more normal appearance. The tissue from the left knee appeared almost avascular, and was composed chiefly of a fibro-cartilaginpus tissue, the fibrous elements predominating. In this tissue two villi were evident in 76 DAN BRIDGE MEMORIAL sections, and these were composed of fibrous tissue, with a few attenuated nuclei, arranged for the most part near the periphery, and also with well-formed cartilage corpuscles. In such villi there were also a few cells of indeterminate character, resembling fibroblastic elements, and which from their situation and arrange- ment might possibly represent the vestiges of vanished blood- vessels. The evidence gathered in the examination of these tissues which were removed at operation, is in support of the conception that the production of the large pedunculated body, which was to all intents a free body, was the result of changes in the syno- vial membranes, which were the result of blood vascular prolif- eration and obliteration. This process corresponds with that suggested by Wollenberg as the foundation for the production of arthritis deformans. Upon this basis we may logically, we think, account for some, at least, of the free bodies removed from the joints of our patient. The question remains, however, as to whether the deep shadows in the radiograms call for any other explanation; whether, for instance, the flatness of the articular surfaces has played an important role in the production of the general condition in the joints, as Preiser suggests; whether the condition is one of osteochondritis dissecans, as Koenig con- ceived it. It seems to us that Preiser's theory of static imperfections cannot explain all the trouble, because it cannot explain the pres- ence of free bodies at points where static forces do not act. Fur- ther, because the whole process as we have studied it seems to be correlated in all its aspects and progressive, we think it more reasonable to apply one principle, if it is possible, both in the pro- duction of articular deformities and in osteochondritis dissecans. We found in our case a body attached by a pedicle and com- posed of cartilage, and with some evidence of calcification, but with no actual bone, and moreover with the area of calcification at the center of the body. We found no depression in the bone, either at operation or in the radiograms, that would account for so large a loss of substance as required by the size of the pedun- culated body. But we did find in radiograms two areas in the internal condyle of the right femur that seem to point to the in- FREIBERG AND WOOLLEY 17 cipient freeing of two fragments of cartilage. These areas do not correspond to the position they should occupy to satisfy the demands of Ludloff. It seems to us that the whole condition may be explained upon the basis of the vascular theory of Wol- lenberg, and that the changes in the joints which we have de- scribed are in perfect accord with the modern conception of ar- thritis deformans as outlined by Nichols and Richardson, and finally that vascular changes may also account for osteochondritis dissecans. It seems unnecessary to describe the vascular process at great length, for Wollenberg's article is exhaustive. We shall then merely outline it as follows: As the result of one of a number of possible causes acting chiefly upon the joint tissues, chronic vas- cular changes are produced. Among such causes might well be static imperfections, traumata, acute or chronic of other sorts, toxins circulating in the blood, local disorders of metabolism, or chronic infections. Infarction would not produce the effects, because those which we are studying are of gradual development. It is possible, however, that infarction might produce bodies of the nature of those described by Koenig, as being covered on one side by joint cartilage and on the other by bone. At any rate, whatever the cause, whether chronic congestion or chronic mild irritation, the result would be changes in the vessel walls, endar- teritis or periarteritis or both, and these eventually would lead to local interference with nutrition. Gradually interference with the nutrition of bone tends to produce metaplasia with formation of tissue that is capable of depending less directly upon a blood supply. Cartilage is such a tissue. When finally obliteration of the vessels is complete, necrosis will occur, and the line of necro- sis will appear at the place where the cartilage is no longer able to obtain nourishment, either by absorption from the joint cavity or from collateral blood-vessels. The tendency would therefore be not to form free bodies, but only partially free ones, which being held in place by the living joint cartilage, might again unite as collateral vessels developed, or which might become free as the result of trauma. Such free bodies would be rounded, oval or. flat, from the fact of their gradual formation, and because 78 D A N D R I D G E M E ^I O R I A L of the tendency to compensation on the part of collateral vessels, and not wedge-shaped as in infarction. In the case of the process in the synovial membrane the same conception holds. With chronic irritation of toxic or mechanical origin there is congestion and even proliferation of blood-vessels, with hyperplasia of the synovia and formation of villi. As the irritation continues to act, obliterative vascular changes gradually reduce the blood supply; the connective tissue becomes hyaline and later chondrified and even calcified, and later atrophy of the pedicles results in free bodies. Upon the basis of such changes we may conceive that the conformation of the joint surfaces becomes altered to such an extent that static variations, friction and chronic hyperemia may form a circulus vitiosus, and that as a result, at one time or an- other, varying with blood supply, we have the production of ec- chondroses and other progressive or regressive changes that eventually bring about the more marked changes which we clas- sify under the head of arthritis deformans. In our judgment, Wollenberg's paper constitutes one of the most important contributions which has been made to the study of the chronic deforming disease of the joints. By his theory of vascular change there can be explained those mixed forms of joint affection in which we find evidences of both the prolifera- tive and degenerative types of joint disease. If, instead of in- volving the cartilage and synovial membrane, the vascular change takes place in bone near the articular surface, and where the vas- cular supply approaches the "terminal" variety, it may result in that local sequestration of bone with its overlying cartilage, which has by Koenig been called osteochondritis dissecans. To us the great interest in our case lies in the fact that the three varieties of joint changes may be found going on in the same joint at one time, apparently dependent in their reciprocal relations upon the vascular changes, as they vary either in their location in bone or synovial membrane, or as they vary in the degree to which they have progressed. In view of this study, we must concur with Nichols and Richardson in holding that the types of chronic deforming joint affections cannot be looked uf>on as separate and distinct diseases. We must look to the FREIBERG AND WOOLLEY 79 future to disclose the etiological factors which determine the predominance of this or that type in a given case. It would appear that the first stage in such etiological study has been reached with a recognition of the role which is played by the vascular changes. DISCUSSION. Dr. C. F. Painter, of Boston, opening the discussion on the paper of Drs. Freiberg and Woolley, said that what had inter- ested him particularly in this paper was the demonstration of the lesions in the radiograms. If he had understood Dr. Frei- berg correctly, he had attempted to make these comparable to the appearance in the radiogram of the lesions that occur in the chronic form of arthritis deformans, or osteoarthritis, or hyper- trophic arthritis (according to the term selected by the one con- sidering the subject). It did not seem to Dr. Painter that these radiograms, as they were representative of the pathology of the condition, were suggestive of the appearances in the ordinary cases of chronic hypertrophic osteoarthritis. The explanation, as indicated by the specimen removed at operation, might have been that these were the result of vascular changes present at the same time; but that these changes were comparable to the hypertrophic form, which might or might not have been caused by the vascular changes, did not seem to Dr. Painter to have been demonstrated. Dr. Woolley, closing the discussion, said that he had not very much more to say on this subject, having said about all he could think of while writing the paper with Dr. Freiberg. He did not think that they had proved anything by the small amount of work that they had done, but he did think that they had some basis for supporting the work of Wollenberg. The examination of a few tags of synovial membrane, even though they did show the ciianges described, was not enough upon which to build an hy- pothesis. It was interesting that they could get these various changes in this one case — changes that appeared like those de- scribed by other men in various forms of atrophic and hypertro- phic joint disease. Dr. Freiberg, closing, said that he must agree entirely with Dr. Painter in stating that the appearances of the radiogram in this case were unlike the appearances in cases cf hypertrophic arthritis. He had not meant to convey the impression that they were like the appearances usually seen in radiograms of hyper- trophic arthritis. The interesting point was that they had a case in which free bodies had formed and were apparently still form- ing, as in the right knee, and in which a second kind of free $0 DANDRIDGE MEMORIAL bodies had apparently formed on other occasions, one of which was apparently about to be set free (the cherry-like body that was removed from the right knee). When they came to examine the changed synovial membrane of these joints, they found chronic changes in accordance with the changes described by Wollenberg in cases that were typical of hypertrophic arthritis, as seen clinically and in the radiogram ; and it seemed to them that these two things must be brought into correlation, and that some explanation of this character was to be found for these cases in the osteochondritis dissecans of Koenig. He thought it was really an example of a variant of the same basic process which gives various clinical pictures of chronic joint disease. REFERENCES. Koenig: Deutsche Zeitschrift f. Chir., 1888, Bd. xxvii. Earth: Verh. d. Deut. Gesell. f. Chir., 1896. Ludloff: Arch. f. klin. Chir., Bd. Ixxxvii, 1908; also Ceniralbl. f. Chir., 1908. Preiser : Verhandl. d. Gesell. Dent. Naiurforsch, 1898, xi, p. 199. Nichols and Richardson: Journal of Med. Research. Wollenberg: Deut. Zeihchr. f. Orthop. Chir., 1909, Bd. xxiv, p. 359. A DESCRIPTION OF FOUR FILARIA LOA FROM THE SAME PATIENT.* BY O. V. HUFFMANN, M.D., AND WM. B. WHERRY, M.D. A COMPARISON of the descriptions of the morphological character- istics o/ Filaria loa by previous authors shows differences which are explained by the study of our uninjured specimens. We have prepared a table (q.v.) which shows the results of the work of various observers, together with our own. We believe that most of the drawings so far published are somewhat misleading; we have therefore drawn the essential parts as seen through the microscope with an entire diameter and a portion of a longi- tudinal section in focus. The drawings are not composite or schematic, but have been made on a large scale, with accuracy in the measurements, so as to represent the different parts in proper proportion. This species of nematode was first described in 1777 as be- ing diiTerent from the guinea-worm by Guyot, a French naval surgeon, after he had made several voyages to the coast of An- gola. He noted that these worms were very white, harder and shorter than the guinea-worm. A number of cases of the removal of worms from the eyes of negroes in St. Domingo, Cayenne and South America were reported, but it was not until 1838 that the next identification of this species was made, when Guyon described -i Filaria which had been removed from the eye of a negress on the island of Martinique and sent to him. He also, in 1864, described part of a worm removed from the eye of a negro in Gaboon. In 1877 Morton, of Philadelphia, published an account of a loa removed from the eye of a native of Gaboon, with a brief description of the worm by Leidy. The specimen had dried in transit. In this account we also find the first record of infections in Caucasians. Bachelor (1879), of Gaboon, extracted a specimen from the eye of a native and sent it perfectly preserved to the United States. * From Parasitology, vol. iv, No. 1, March, 1911. 81 82 D A N D R 1 D G E MEMORIAL Leukart^ (1886) identified the species as distinct from the guinea- worm; he had received a female 41 mm. long. In 1895 Manson" described a male Filcria loa removed from the eyelid of an Englishman who had been in West Africa; he also described a male and female removed from the eye of an English lady who had been in Old Calabar. In the same year Ludwig described a female specimen removed from the eye of a Russian who had been in Fernando Po, Gaboon, Kamerun and the Gold Coast. The specimen had been injured in several places. Blanchard (1899) gave an extended account of the anatomy of a male and female removed from the same host, who had been in the French Congo; these worms were quite young. In 1901 Annett, Dutton and Elliott obtained a female Filaria loa at Bonney, but they did not report in regard to the host nor from what part of the body it was obtained. In 1903 two males and two females, sent from Nigeria, were briefly described by Ozzard- Looss'"' (1904) published a complete anatomical description of two specimens which had been sent to him from the Gold Coast and labeled Filaria loa without other data. The male was very slightly injured by forceps just behind the cephalic end. Ward* (1906) noted some points which he considered peculiar to the three males studied by him and referred to the admirable account of Looss for a complete description of their structure. One of his specimens had been sent to him mounted in balsam. This author gives a most complete critical bibliography en the morphol- ogy of Filiaria loa as well as on all cases reported. He also calls attention to the cases vv'hich have been recorded and wrongly as- signed to Filaria loa. In the same year Livon and Penaud* (1906) observed a fe- male, but did not describe it. They report more fully in regard to the micro-filarise observed in the blood, urine and saliva of the host as well as those which were hatched from eggs which had been artificially removed from the adult females. Later Billet^ (1906) described a male 24 mm. x 0.4 mm. He states that he agrees with Manson, Bernard, Blanchard, Ozzard. Penel and Wurtz. tie does not refer to Looss' description, and he gives but few measurements and no drawings. Where he cites Bernard as an authority, we must call attention to the fact that ■7. t 1> U > .§1 o — Host From wliat aiia- toiuical localitv Kl-.MAKKS Leuckaii 1881 Loanf,'-() Furoiiean Eye Mansnii 1895 W. Africa " " 1895 0.25 OK! Calahar " Tail extremity not curved. l.udwi.i^ 1895 0.253X 0.005 Gahoon Kamerun 1 1 i< Specimens injured in several i)laces. Intestines and genital organs ]):\r- CjoIiI C'oast tially protruding. P.lancliard 189( 1899 Frcncli " Eggs, no embryo. Cephalic cone less and not so clear as in male. .\'o head pa])ill.-e. O/zard 1 1903 1903 1903 1903 Ni. no embryo. t'cphalic cone less and not so clear a> in male. \., head i.apilhe. Tail not sharply curved as in female Spicules do not protrude. .Short piislcrior spicule. l.oiijiiT anterior spicule. l.„„s. 1 1904 \ i 33 0.4 0.05 0.084 2.5 1.2 11.176 5 prs. ll.llll'J (,.(,(,, M tall li.ll!5v (1,(1(147 (i..kl Cc.asl ? ? Sl.icules partially i.n.lrndc. 1 11(14 1 9 52 0.5 0,07 0.17 0.17 2.4 lasl^ Kniie ' \V;,rJ 1906 1 Ianson. Nor was I success- ful in reviving embryos which had been dried, as suggested by the same author. In heating a wet blood preparation, slight cur- rents may be set up. which cause the appearance of slight motion on the part of the embryo and give the appearance of butting. Measurements : Coiled embryos 0.051 x 0.036 mm. Embryos 0.006 x 0.3 mm. Average projection of sheath anteriorly 0.009 mm. Average projection of sheath posteriorly 0.009 mm. Anterior V spot 0.09 mm. from head end. Posterior spot 0.06 mm. from tail end. Livon and Penaud give the length as 0.3 to 0.35 mm. and the width as 0.005 to 0.007 mm. The maximum diameter of the embr3'Os, 0.006 mm., is maintained with very slight diminution until a point 0.24 mm., from the head end is reached, where the body commences to taper to the posterior extremity. The pos- terior extremity is rounded. It is not sharply pointed, and we HUFFMANN. 95 cannot conceive such a tail being folded upon itself within the sheath, as described in the table given by Neveu-Lemaire. At the anterior extremity, v/hich is broadly rounded, there are two highly refractile black specks ; 0.09 mm. from the head end is the ovoid mass, which presents the anterior V spot. This ovoid mass causes a slight bulging of the body on three sides, but not on the fourth, as it dees not extend deeper than the plane of the central longitudinal axis of the body. Within this clear, highly refractile mass there are two black, granular specks, separated sufficiently to give rise to the V (spot), which ii an optical ef- fect. The point of the V is directed to the periphery. 0.06 mm. from the tail end is a similar, but smaller, ovoid body and V spot. When the ovoid masses are seen from a direction mid- way between that which shows their broadest cimensions and that which shows their least dimensions, a conic-il papilla is ob- served which has its apex directed laterally. All of the embryos have these spots, and they are not properly situated in relation to the length of the embryo to represent the vulvar and anal openings, as suggested by Manson and by Ashburn and Craig. In the stained specimens the ovoid masses at the V spots did not cause a bulging as in the live specimens, but at their site there was a slight narrowing of the body. Throughout the body in most specimens we could determine the stained intestine. Be- hind the posterior V spot the intestine was not stained perfectly, but in sections gave rise to the appearance of rod-like bodies placed end to end, as described by Ashburn and Craig. These latter authors permitted an ellipsis in their article where they state, "At about the middle of the posterior of the worm are sit- uated the posterior V spot and the papilla." They attempted to describe a new species of Filaria, but did not point out any determining morphological characteristics. The microfilaria which they described as a new species, F. philippinensis, had been previously diagnosed in their case as F. diurna. The interior of the live embryos, with the exception of the refractile specks at the head and the two ovoid masses, is en- tirely homogenous. In the specimens which had been stained after death the interior was made up of irregular-rhaped masses which stained deeply; the ovoid masses were not so large. The 96 DANDRIDGE MEMORIAL posterior ovoid mass becomes stained before the anterior mass, which is more resistant to staining solutions. Embryos stained by a very dilute solution of basic fuchsin, while alive, take up the stain at the periphery of the ovoid masses and in the specks near the head end. They also, if stained by a stronger solution, take up the stain in the rudimentary intestine. The unstained live embryos are white and translucent. Those which were placed in human blood (wet preparations) appeared of the same color as the blood plasma. None of the embryos either in water or blood lived more than an hour after separation from their mother. As the measurements of Filaria diiirna do not exceed those of the embryo of Filaria loa, as measured by Livon and Penaud and by myself, it is fair to assume that no great changes take place while in the blood, and that a study of viviparous em- bryos should give results not unlike those of a study of the filaria found in the blood. Foran, who found Filaria diurna in the blood of 12.5 per cent, of 826 natives of South Nigeria, noted an outflowing of substance at the anterior V spot. This may have been due to weakness at this point, for Ashburn and Craig roted the same in some of their specimens. In my specimens there is a distinct bulging of the ovoid body at the anterior V spot, yet it cannot be represented to be so large as in the sketch of Foran. Livon and Penaud noted that some had blunt tails. Many years ago O'Nielly and O'Neil observed microfilarise which had two specks at the head, alimentary canals, "bluntly pointed" tails, and which died shortly after being placed upon the glass slides. Some of the embryos which I had left sealed in water were examined two weeks later. Degeneration had set in; besides the two V spots, which did not show up so clearly, there were other spots which caused some confusion, as they were not so distinct, nor were they in focus and highly refractile at the same time as the known V spots. The lines and anatomy were not so clearly defined as in the fresh living embryos, and it is easy to see why the filarias found in the blood have been variously described. When all of the various preparations were examined one month later, it was found that the sheaths of the specimens stained by fuchsin were no longer discernible ; that the embryos HUFFMANN. 97 in the wet preparations presented irregular masses in the ante- rior portion of the body as well as several vacuoles which might be taken to be V spots; that the ovoid masses were no longer easily distinguishable; and that the tails had lost their "plump- ness," being flabby and drawn out posteriorly, and in some prep- arations which had been disturbed they were foMed upon them- selves. The sheaths of some of the embryos in the wet prepa- rations were collapsed and extended as a linear projection fore and aft. Hence it may be seen that it is impossible to determine any definite morphological characteristics except in fresh em- bryos, which present a definite form, granular specks at the head, alimentary canal and two ovoid masses definitely situated and representing without doubt the beginning of r.ndififerentiated organs. REFERENCES. Ashburn, P. M., and Craig, C. F. (1906) : A New Blood Filaria of Man — Filaria philippinensis. Am. Jour. Med. Soc, vol. cxxxii, pp. 435- 443 (with figures). Brumpt, M. C. (1904) : Filaria Joa Guyot est la forme adulte de la microfilaire designee sous le nom de Filaria diurna Manson. Conipt. Rend. Soc. Biol., Paris, vol. Ivi, pp. 630-632. Burrows, D. (15, i, 1910) : A case of filarial infection in which both the Filaria loa (male) and numerous Filaria diurna were obtained to- gether. Jour. Trap. Med. and Hyg., London, vol. xiii, p. 25. (15, ii, 1910) : The relationship of Microfilaria diurna to Filaria loa. Jour. Trop. Med. and Hyg., London, vol. xiii, p. 49. Foran, B. F. C15, ii, 1910) : Some notes on filariasis in the Ikotepene District, South Nigeria. Jour. Trop. Med. and Flyg., London, vol. xiii. p. 50. Huffman, O. V., and Wherry, Wm. B. (1911): A description of four Filaria loa removed from the same patient. Parasitology, vol. iv, p. 7. PI. 2. Livon, J. (fils), et Penaud (1906) : Un cas de Filaria loa, avec oedernes intermittents, microfilaires dans le sang, I'urine et la salive; eosinophilie marquee, fitude de la filaire adulte et de ses oeufs — leur evolution. Nais- sance des microfilaires et etude morphologique de ces parasites embryon- aires. Conipt. Rend. Soc. de Biol, Paris, vol. Ixi, No. 35, pp. 510-512. Looss, A. (1904) : Zur Kentniss des Baues der Filaria loa. Zool. Jahrb. Syst. Vol. XX, pp. 549-574. (1905) : "Filaria loa Guyot, 1778," in Handb. d. Tropenkrank- heitcn, herausgegcben von Dr. C. Mense (Leipzig, J. A. Barth), vol. i, pp. 177-179, with bibliography. Manson, P. (3, i, 1891) : The Filaria sanguinis hominis major and minor, two new species of Hematozoa. Lancet, London, vol. i, pp. 4-8. (1893) : The geographical distribution, pathological relations and life history of Filaria sanguinis hominis diurna and of Filaria sanguinis hominis Persians, in connection with preventive medicine. London : Eyre & Spottiswoode. (1897) : On certain new species of Nematode Hematozoa occur- ring in America. Brit. Med. Jour., pp. 1S37-1838. 98 D A N D R I D G E MEMORIAL (1899) : On filarial periodicity. Brif. Med. Jour., pp. 644-655. (1901): "Filarida," in A System of Medicine, edited by T. C. Allbutt. London: McMillan & Co. (iii, 1910) : On the nature and origin of Calabar swellings. Trans. Soc. Trap. Med. and Hyg., vol. iii, pp. 244-256. Neveu-Lemaire, M. (1908) : Precis de Parasitologie Humaine, Paris (F. R. de Rudeval), pp. 482-487. Wherry, Wm. B., and McDill, John R. (1905) : Notes on a case of hematochyluria, together with some observations on the morphology of the embrj'o nematode, Filaria nocturna. Jour. Inf. Dis., vol. ii, pp. 412-420. THE SUCCESSFUL TREATMENT OF A CASE OF ILLUMINATING GAS POISON.* BY WILLIAM RAVINE, M.D. In looking through the Hterature and statistics on illuminating gas poisoning, one is struck by the meagerness of the reports and by the variety of nomenclature used in describing cases. One finds, for instance, descriptions under the titles "Asphyxia," "Coal Gas Poisoning," "Carbon Monoxid Poisoning," "Poison- ing by Noxious or Irrespirable Gases." In the several instances the cases have been the result of blowing out of gas lights, either because of ignorance or with suicidal intent; carelessness in heaping clothes on gas fixtures in such a way as to turn the cocks ; leaking of gas fixtures ; badly constructed or worn-out stoves and fixtures ; or, as in my case, the overturning of a gas heater by an individual alcoholically stimulated to the point of carelessness. During the years 1900-1910, there were ten cases of illuminat- ing gas poisoning at the City Hospital with six deaths. Illuminating gas contains : PER CENT. Carbon monoxid 12 to 28 Carbon dioxid 0.3 Hydrogen 30.35 Marsh gas 21.45 Nitrogen 6 The carbon monoxid in this mixture of gases is the cause of the symptom-complex. Carbon monoxid has 200 times greater affinity for hemoglobin than oxygen, and, therefore, the life of an individual can continue only so long as the hemoglobin is able to attach enough oxygen to itself to maintain the process of oxi- dation essential to life. * From The Journal of the American Medical Associaiion, June 3, 1911, vol. Ivi, pp. 1651-1653. 99 100 dandridgp: memorial SYMPTOMS. Carbon motioxid gas has no influence whatever when applied directly to nerve and muscle;^ when it acts through the blood, however, phenomena appear which are indicative of primary stimulation, but which cause, secondarily, paralysis of the ner- vous system. Thus there occur at first severe headache, great restlessness, excitement and increased cardiac and respiratory activity, salivation, tremor, twitching and spasm, followed by mental confusion, exhaustion, drowsiness and paralysis and loss of consciousness, labored stertorous breathing and finally com- plete loss of sensibility, and death. , Thompson,- in a series of ninety cases, reports a leukocy- tosis in eighty cases, which he thinks is due to some specific action of the gas, and which is similar in its cause to the leuko- cytosis that occurs in ptomaine poisoning. In all the cases reported in the literature there was in the early stages a subnormal temperature. The maximum temper- ature is usually attained on the first day. The highest temper- ature reported is by Steele.^ The patient was a girl of eight years, who, when first seen, was in a state of coma. The tem- perature began to rise rapidly, and within eight hours had reached 110° F., accompanied by a pulse rated at 215 per minute. In this case there was a complete recovery in six days following the use of cold sponges and inhalations of oxygen. In all the cases reported the pulse has been accelerated and the rhythm of the pulse has been regular during the coma. Physical examination of the lungs, as a rule, shows no abnor- malities except in fatal cases, and in these the findings indicate a terminal edema. The urine shows no special characteristics. In a few cases there was a transient albuminuria. The pupils varied, being at times dilated, at times contracted. The symptoms on the part of the nervous system have been tremors, muscular twitchings, convulsions, rigidity, opisthotonos, anesthesia and headache. Evidence of vasomotor paralysis is found in burning sensations in the skin, especially over the face and in the red- ness of the cutaneous surfaces. The lips and extremities appear bluish and cyanotic, owing to the peculiar cherry-red color that RAVINE 101 is a characteristic of carbon monoxid, but which does not obscure it. Coma, which is profound, is always accompanied by stertor- ous breathing. Brunneaux* has reported a case of hemiplegia following gas poisoning ; Finkelstein, ^ one of dementia ; Scotr,* acute mania with recovery after ten days; Bruns/ disseminated encephalo- myelitis. Alexander Pauski* reported the case of a patient ill for months with paralysis of legs and arms, sensory and speech disturbances, amnesia and mental weakness. Becker^ reported a case of multiple sclerosis. Bontecon^" described the post-mortem findings in three cases. His histories related that the faces were pale, that the expression was placid, the eyes closed, the pupils neither contracted nor dilated and the conjunctivae clear. The muscles on section were, as a rule, red. The lungs were cherry- red in color, and on section showed a moderate edema. There was unnatural amount of blood found in the pleura or pericar- dium. The heart was empty and the blood-vessels contained fluid blood. The left ventricle of the heart was contracted, the right ventricle and auricle as a rule were dilated. The viscera were all of a pinkish color. In the case of Broadbent/^ there was a report of softening of the lenticular nucleus and the posterior part of the internal capsule. DIAGNOSIS, The diagnosis of illuminating gas poisoning is based on the history of the case and on the presence of coma with stertorous breathing, cherry- red color of the face and hands, and the spec- troscopic analysis of the blood, which demonstrates the presence of carbon monoxid hemoglobin. Carbon monoxid hemoglobin is cherry-red in color and causes the appearance in the spectrum of two absorption bands between D and F, not unlike the oxy- hemoglobin bands. The further means of recognition is the so- dium test. A 10 per cent, solution of sodium hydroxid, when added to carbon monoxid hemoglobin and heated, gives rise to a cinnabar red color. This same test applied to oxyhemoglobin produces a brownish-black mass. TREATMENT. The earliest reported treatment for illuminating gas poisoning is that of .Struthers," who advised jugular venesection, on the 102 DANDRIDGE MEMORIAL basia of his experimental work on animals. Corssland recom- mends the hypodermic use of 15 mm. of a 10 per cent, solution of nitroglycerin injected into the epigastrium. Other writers have advised electric stimulation, oxygen inhalations, cardiac tonics and venesection, with transfusion of defibrinated blood or normal saline solution. One author in his treatment of a case did a venesection and gave an enema of twenty ounces of salt solution. Heinicke,^^ in a report of twenty-five cases of coal- gas poisoning, was the first to describe intravenous injection of salt solution. CASE REPORT. January 19, 1911, at 12:45 p.m., an unknown white man (Case No. 161,349) was admitted on the East Medical Service at the City Hospital with the following history : History. — The inmates of a house at 223 George Street were alarmed by an odor of gas, and on investigation they found that it emanated from a room on the third floor, which had been en- gaged the night before by two men. On breaking open the door they found the two men lying on the floor, a small gas heating- stove overturned, and the gas escaping from the attachment on the wall. The men were hastily brought to the hospital by the police ambulance. One man was dead, the other was in a state of coma. The latter was a white man aged about forty. Exa'Hiination. — The patient's face was symmetrical, somewhat reddened, and the skin about the lower lids blue. The lips were blue and covered with a white, frothy mucus. The pupils were dilated and did not respond to light. The breath was fetid. There was no odor of alcohol. There was stertorous breathing; no marks of violence either about head or the body. The skin over the entire body was dry and cold, and the finger tips were blue. The pulse was strong and rapid — 130 beats to the minute. The rectal temperature was 97° F. There were no convulsions. Examination of heart and lungs revealed nothing of note. Ex- tremities were relaxed. There was no Babinski sign or ankle- clonus. The patient did not respond to any form of external stimulation. Six hundred c.c. of a dark amber-colored urine were removed by catherization. The specific gravity was 1.025 and the reaction was acid. No albumin, sugar or casts were present. Treatment. — The patient was well covered with blankets and surrounded by hot-water bottles, and was given 1-30 gr. strych- nine hypodermically. The median basilic vein of the right arm RAVI N E 103 was opened, and 300 c.c. of blood allowed to flow, after which an intravenous transfusion of 1,200 c.c. of a 0.7 normal saline solu- tion was given. Inhalations of oxygen were also given. Three hours later the face was somewhat reddened and the patient was perspiring, but was still comatose. Temperature was 100°, pulse 136, respiration 32. Caffein sodium benzoate, gr. 2, given hypo- dermically every four hours. After another three hours the pa- tient responded somewhat to external stimulation, but was still comatose. Temperature was 101°, pulse 120, respiration 36. At the end of another three hours the condition was about the same; temperature 101°, pulse 128, respiration 32. On the sec- ond day after entering, the house the face and hands of the pa- tient had assumed a distinct cherry hue. The man was drowsy, responded very slowly to questions, after answering which he immediately sank into sleep. The examination of the blood showed reds 4,500,000, whites 13,000, hemoglobin 80 per cent. The treatment consisted of the administration of strychnine, 1-30 gr. and caffiein sodium benzoate 2 gr., given hypodermically every four hours. The urine at this time was light amber in color. It was acid in reaction, with a specific gravity of 1.015. There was a slight amount of albumin present, but no sugar or casts. Nourishment consisted of six ounces of milk and twelve ounces of water. Outcome. — On the third day consciousness leturned. The man had no recollection of the past two days. He complained of a slight headache and dizziness. His face had a peculiar pinkish color, but the color of the hands was normal. At 6 a.m. his tem- perature was 99.3°, pulse 88, respiration 24; at 6 p.m. his temper- ature was 99.1°, pulse 72, respiration 28. On the fourth day his general appearance was good. He complained of no discomfort and was taking liquid nourishment. All medication had been dis- continued. The urine was dark amber in color, was acid in reac- tion, had a specific gravity of 1.025, and showed no albumin, sugar or casts. At 6 a.m. temperature was 98.1°, pulse 84, res- piration 20; at 6 p.m. temperature was 98.2°, pulse 80, respira- tion 22. From this day on convalescence continued uneventful. The man was discharged well on the seventh day. At the time of discharge the blood examination showed 5,000,000 red cells, 10,000 whites and 90 per cent, hemoglobin. REFERENCES. 1 Landois : Text-Book of Human Physiology. Ed. 10, 1905, p. 58. 2 Thompson, W. G. : Tr. Assn. Am. Phys., 1902. 3 Steele: Philadelphia Med. Jour.. February 16, 1901. 4 Brunneaux : These de Paris, 1893. 5 Finkelstein: Lancet, London, 1891, ii, 3778. 104 DANDRIDGE MEMORIAL 6 Scott, A. : EncVcl. Jahrb. d. ges. Heilk., 1895, vi 7 Bruns : Neurol. Ccntralbl., 1902, No. 6, p. 242. 8 Pauski, Alex. : Neurol. CentralbL, 1902, No 6, p. 242 9 Becker: Deutsche med. Woch., 1893, xix, 571. 10 Bontecon: Med. News, Troy, N, Y., 1887. 11 Broadbent: St. Mary's Hosp. Rep., London, 1893. 12 Struthers : Edinburgh Med. Jour., 1855-6. 13 Heinicke: Deutsche Chirurgie, 1885, Part 18. UNEQUAL PUPILS AS AiN EARLY SIGN IN PHTHISIS. BY J, L. TUECilTER, M.D. A PUPILLARY difference as a phenomenon in unilateral pulmo- nary tuberculosis has been recognized for some time, still we find that in most text-books and writings upon this subject it re- ceives but little or no mention. This is probably due to the fact that this difference is not always present and its diagnostic sig- nificance has not been sufficiently worked out; nevertheless, when this sign can be elicited it carries with it a good deal of importance. In examining for the pupillary difference the room should be only moderately light, or the background of a well-lighted room may be used. Direct daylight or a bright artificial light ob- scures the difference because of an existing hypertonus of the sphincter pupillse. The pupils are examined in the ordinary way by covering the eyes with our hands, thus relaxing all hypertonus, and then in diffused light, quickly watching the reaction. If there is a difference you will note that the one pupil is dilated more than the other, and that it reacts less completely and less sluggishly. In other words, it seems to lag. In a large number of cases it is not necessary to test the reaction of the pupil, but the diff^erence can readily be noted with the eyes at rest, provided again the light be not too strong. In a large majority of the cases in which the sign occurs the pupil is wider on the side of the pulmonary involvement, and this led Geza Fodor, who first described this phenomenon, to the belief that the reaction is due to a stimulation of the sympathetic nerve fibers, causing on that side a spastic mydriasis. Neverthe- less, in many cases the opposite is true, namely, that the pupil of the unaft'ected side is wider, and it is this fact which led many observers to discard the phenomenon as having no definite value. It remained for Leo Wolfer to determine the real cause of the pupillary difference. He came to the conclusion that the widen- ing of the pupil is due to a stimulation of the sympathetic fibers 105 106 D A N D R I D G E iJ E U O R 1 A L caused by pressure exerted b}^ enlarged bronchial glands of that side. For this reason it is not necessarily observed in the pupil corresponding to where our objective findings lead us to locate the pulmonary process, in so far as the glands on this side are not invariably and of necessity sufficiently enlarged to stimulate the corresponding sympathetic fibers. After observing a large series of cases I have been able to substantiate these later findings, and am satisfied that a compar- ative dilatation of one pupil signifies an enlargement of the bron- chial lymph glands of the corresponding side. y\s such glandular involvement is usually tubercular in character, and takes place at a time when the lung itself does not as yet show destructive changes, I feel that this sign is most valuable in the early diag- nosis of pulmonary tuberculosis. Before drawing a definite con- clusion as to the significance of this phenomenon, it is of course necessar}'- to rule out affections of the eye which may cause pu- pillary differences, as well as certain conditions of the thorax, such as tumor or aneurism. Several case reports may serve to show the value of this pu- pillary difference when observed. A young man, twenty-five years of age, occupation bank clerk, consulted me because of a lang-standing stomach trouble, which would clear up at times and then return. While examining the patient I noticed the inequality of his pupils, the right being wider than the left and reacting more sluggishly. In view of the fact that there was a marked tubercular famil}'- history, I made a chest examination, but found nothing, nor did he have any other subjective symptoms which might indicate a pulmonary trouble. The stomach condition persisted for two months, and gradually cleared up after sending him away on his summer -^^a- cation with strict injunctions as to rest. He returned to me several months later, greatly worried over the fact that he had had a very slight hemorrhage, and for two subsequent days his sputum was tinged with blood. On chest examination I was able to find a very early involvement of the right apex, A young patient, twenty-eight years of age, with an early tuberculosis involving the left apex, has been under my care for several months. He is tmder tuberculin treatment, so I have the opportunity of seeing him twice a week and examining him frequently. This man shows a dilatation of the right pupil — in other words, not on the corresponding side of the lesion. Even though the examination for dulness on either side of the spine T U E C H T E R 107 gives us rather doubtful results in the adult, because of the nor- mal dulness over this area, nevertheless, in so far as this patient was not very muscular, 1 felt that I was able to elicit a more or less localized area of dulness over the right side. An X-ray ex- amination of this case confirmed these findings, and showed an involvement of the left apex, together with an enlarged glandu- lar mass about the size of a pigeon's egg at the right hilum, which accounted for the pupillary enlargement. A young girl of eighteen years presented the various subjec- tive tubercular symptoms, such as decreasing strength, shortness of breath on exertion, subnormal temperature in the morning, together wath a rapid pulse and afternoon rise of temperature. There was a dilatation and sluggishness of the left pupil. The chest examination was at first negative, except for increased muscular rigidity over the left apex. About a month later I was able to elicit crepitation over this area. I had the opportunity to have an X-ray examination made and it showed a marked infil- tration about the left hilum sufficient to cause pressure on the sympathetic of that side. This phenomenon, if we look for it, can very frequently be found in tuberculosis of the bronchial lymph glands in children. It forms a valuable point in diagnosis in that type of the disease where the onset is insidious and where the child has not yet ac- quired the characteristic paroxysmal attacks of cough. An in- teresting case of this kind came under my observation on my service in the children's ward of the Ohio Maternity Hospital. A child, two and a half years old, had been exposed before ad- mission, to a tuberculous mother. The child passed almost im- perceptibly from a condition of health to one of disease. The appetite became poor, the cheeks pale and there was an apparent loss of flesh. Irregular pyrexia pointed to some systemic affec- tion, but examination disclosed nothing. The child began to cough very slightly, and a Pirquet skin reaction was markedly positive at the end of twent)'-four hours, which at this age meant that we were dealing wath an active tuberculosis somewhere in the body. There was a marked dilatation and lagging of the left pupil, and I made a diagnosis of tuberculosis of the tracheal, bronchial and pulm.onary l}-mph glands. The child was placed out of doors and did fairly well, but later developed a severe ulcerative enteritis which proved fatal. The autopsy showed, besides the ulcerative condition of the bowel, a marked enlarge- 108 DANDRIDGE MEMORIAL ment of the lymph glands around the left hiluni and bronchus. The lungs were not involved. These cases serve to illustrate that a pupillary difference, which is not caused by a pathological condition of the eye, forms a valuable early sign in phthisis, both in the absence of other signs and symptoms, as well as in their presence. It is not nec- essarily found on the side corresponding to the pulmonary in- volvement, in so far as it is due to pressure on the sympathetic by enlarged bronchial lymph glands. ACUTE TUBERCULOUS ENDAORTITIS.* BY PAUL G. WOOLLEY. M.D. The present consensus of opinion is to the effect that tubercle bacilli cannot, except in the rarest instances, be observed in the circulating blood. Yet we know that they must be present there and often in large numbers. We have built up our ideas of the production of miliary tuberculosis upon the assumption that the organisms that cause the disease are distributed by the blood, to which they gain access in three ways ; by rupture of a tuberculous focus in one or another organ into a blood vessel ; by the invasion of the walls of blood vessels, especially veins, by the tuberculous process, with the production of a tuberculous lesion in the intima of the vessel from which the bacilli are distributed ; and by the involvement of the thoracic duct in a tuberculous process, from foci in which tubercle bacilli gain access to the venous blood. Vascular involvement is frequent, and it is probable that a search in every case of miliary tuberculosis will be rewarded by finding a focus of extension, most frequently in the smaller pulmonary veins, or thoracic duct, less frequently in the renal or pulmonary arteries, aorta, or the vessels of one or another organ of the body. Invasion per extensionejn is the rule in small vessels. It is not so common in large ones, nor indeed is vascular involvement of any sort. This invasive process is the one that usually accounts for the production of a generalized tuberculosis. It is the process by which the bacilli gain entrance to the blood stream, whence they are distributed. But there is a second process by which the secondary vascular lesions are produced. It may be assumed to occur generally as the result of thrombosis of, or endothelial phagocytosis in, the capillaries of the tissues. As a result of either, the vessel wall is involved from the side of the intima. This invasion from the lumen is frequent in small vessels, but is * From the Johns Hopkins Hospital Bulletin, vol. xxii, No. 240, March. 1911. 109 110 DANDRIDGE MEMORIAL infrequent in large ones for obvious reasons. It is least common in the aorta, A review of the literature on tuberculosis reveals the fact that aortic lesions may be of the invasive or of the metastatic type, and that both are rare. The metastatic lesions may be acute or chronic in character. In the cases of Dittrich and Kamen the aorta was involved from adherent tuberculous bronchial glands, and this was fol- lowed by acute miliary tuberculosis and rupture of the aorta (Kamen). In Buttermilch's case the aortic involvement was secondary to a vertebral tuberculosis. Srhmorl mentions two cases of acute miliary tuberculosis which he conceives as being the result of the perforation of a tuberculous lymph gland or of a pulmonary cavern into the aorta. Examples of tuberculous aortitis by extension are the cases of Dittrich. Kamen, Schmorl, Hanau and Sigg, and Buttermilch. In the case of Hanau and Sigg an aneurism ruptured into a cavern in the lung. It is entirely probable that the aorta was weakened, its walls infiltrated and an aneurism caused thereby, after which rupture occurred, for the edges of the torn wall of the aneurismal sac showed tuberculous vegetations. The chronic type of tuberculous endaortitis is illustrated by the cases of Forssner, Benda, Aschoff, Longcope, Schmorl, Gaylord, Simnitsky and Luksch. In this series there has been, with few exceptions, a more or less severe arteritis or arteriosclerosis in association with the tuberculous changes, a coincidence that has lead to the assump- tion that the specific lesions have been the result of invasion of parietal thrombi by tubercle bacilli. In them the process has apparently shown no tendency to advance along the intima, so that the lesions have increased into the lumen producing either flattened nodules or, more commonly, polypoid growths. In all the cases reported by Benda the lesions were polypoid. In two cases they were situated upon areas of sclerosis, in a third upon an atheromatous ulcer. In Luksch's case the lesions in the aorta, anonyma, and left subclavian were upon an endarteritic basis. In Forssner's case there was no arteriosclerotic change, but it is possible that in this the lesion was primary in the media resulting WOOLLEY 111 from a primarj'^ involvement of one of the vasa vasorum. The intimal tubercle measured 4x1 cm. Stroebes' case was one of a child in which there was a polypoid growth 7 mm. high and 3-4 mm. thick, with no arteriosclerosis. Aschoff's case showed extreme arteriosclerosis and a tuberculous mass the size of a bean near the origin of the ductus Botalli. The lesion described by Longcope was a polyp 3 cm. long, which was found in the descending aorta of a child sufifering from tuberculous hip dis- ease. The report of Simnitsky, to which I have not had access, save through Forssner"s paper, concerned itself with a case of chronic pulmonary and intestinal tuberculosis, and no miliary tuberculosis. The aortic lesion was in one of the sinuses of Valsalva. In all of Schmorl's five cases there was arteriosclerosis, and in all the cases the tuberculous polypi were situated upon atheromatous ulcers. Accordingly it appears that in this chronic group arterio- sclerosis is more frequently present than is natural in tuber- culosis, a disease in which the arterial tree is not as a rule severely affected, and it is therefore quite possible that the conception that the aortic lesions are the result of infection of mural thrombi is corref't in the majority of cases. Ten of fourteen of the reported cases showed the presence of arteriosclerosis. In two cases I have not been able to find a description of the general aortic condition (Gaylord and Simnitsky) and in two the patients were young individuals (Longcope and Stroebe). In this enumeration Forssner's case is excepted, since it is possibly in a class by itself. The series of acute tuberculous endaortitis include the cases of Marchand. Iluber, Schuchardt, Hanot, Hanot and Levi, Simnitsky, Blumer, Flexner and the one to be reported in this paper. In all of these miliary tubercles were present in the intima of the aorta. The cases of Marchand and Huber were merely mentioned by Weigert who described them as showing the most exquisite structure, "giant cells, caseated center, etc." Schuchardt reported minute lesions situated near the junction of the thoracic and abdominal aorta. There was verv little arteriosclerosis. I have 112 DANDRIDGE MEMORIAL been unable to find the report of the cases of Hanot and Sini- nitsky. That of Hanot and Levy was one in which a tubercle was found in the superior portion of the thoracic aorta. The tubercle discovered by Flexner was situated about 2.5 cm. below the left subclavian artery, and measured 2.5 x 1 mm. in diameter. The aorta was not sclerotic. Flexner believed that this tubercle was secondary to an infective thrombus in the pulmonary artery. In all of the cases, of either acute or chronic type, the lesions have been described as containing large numbers of tubercle bacilli, a fact that has an important bearing upon the manner of the production of the general miliary tuberculosis that has been present in all except Simnitsky's first case, for many writers believe that the general lesions are the result of the escape of bacilli from the aortic lesions. It would seem reasonable, how- ever, to limit the production of secondary general disease to the chronic cases, for in the acute ones the aortic lesions seem rather to be a part than the cause of it. The case that I wish to report falls in the category of acute tuberculous endaortitides. Case 152173. — The patient, a man of fifty-nine years, and a laborer, was admitted to the Cincinnati Hospital on November 11. 1909, complaining of "bladder trouble." In August, 1909, he had been admitted to a hospital for cystitis, which was improved by treatment with urotropin and irrigations. He had suffered with "bladder trouble" for some two years previously, that is to say, he had had pain on micturition, a symptom which was not con- stant, but which occurred in exacerbations, at the onset of each of which he passed some blood. At the time of his last admission he gave no evidence of pulmonary or cardio-vascular disease, ex- cept a slight roughening of the breath sounds during expiration. There was no splenic or hepatic enlargement. He suffered with involuntary urination accompanied by pain. The urine was dark red and contained blood clots. A week after admission he had a convulsion at 9 p.m., accom- panied by a rise of temperature to 102° F., and complained of pain radiating from the bladder to the renal region. There was pain and tenderness in left lumbar region. Subsequently the temperature showed an eveninrr rise. Blood examinations showed a leuccpenia, the counts varving from 4400 to 7800. A cysto- scopic examination showed that there was a severe cvstitis pres- ent. The capacity of the bladder was but 90 cc. A diagnosis of "cystitis, probably tuberculous, secondary to tuberculosis of kid- WOOLLEY 113 ney," was made. On December 10, complaint was made of ab- dominal pain, and on December 12 death occurred. The post mortem was made three hours after death. Briefly stated the result of the autopsy was that a generalized acute miliary tuberculosis involving the lungs, spleen, liver, peri- bronchial and mesenteric lymph glands, kidneys, adrenals, pan- creas and aorta was found. The bladder and kidneys showed both chronic and acute tuberculous changes. In the thoracic part of the aorta there were a few fatty streaks, and at the beginning of the descending arch there was one calcified plaque. The abdominal aorta showed an almost completely healthy appearance except at a Doint 10-15 cm. above the bifurcation, at which point were two small raised areas on the intima that had the appearance of recent vegetations and which measured about a millimeter in diameter. There was no tuber- culous focus in the vicinity of the aorta in the neighborhood of these nodules. Microscopic examination of the vegetation-like nodules in the aorta shovved that they were really intimal tubercles, composed of epithelioid and small round cells, a partial endothelial covering, and a central area of caseation. In them were large numbers of acid-fast rods of typical and atypical form, but no giant cells. Beneath these tubercles the media and adventitia were apparently normal, except immediately in the base of the tubercles where there was evidence of a minimal degree of degeneration in the adjacent part of the media. In the lesions I have studied the bacilli were more numerous in the peripheral parts, and several were observed in the immediate vicinity of the lumen of the vessel. It is possible that some had entered the blood stream, but not in sufficient numbers to cause the appearance of the myriad lesions in other organs. A further observation of some interest relates to the form of the bacilli in the intimal tubercles. In the cases in the literature, I have not been able to find reference to any other than presumably typical rods. In my case, however, many of the rods were far from typical. Quite a large proportion were of irregular form, and while no actually branchin?" ones could be found, some of them showed bizarre figures that suggested branching. I believe that in this case the generalized miliary tuberculosis, of which the aortic lesions were a part, was the result of dis- tribution of the organism from the older foci in the kidney, and that it did not result from distribution of tubercle bacilli from the aortic tubercles. The case therefore belongs logically with the group of acute heniatogenous aortitides. It is difficult to account for the lodgment of the organism in these acute cases unless one presupposes at least an incipient de- 114 DANDRIDGE MEMORIAL generation of the cells of the intinia, and the formation of ever so little fibrin in which the bacilli may become entangled. It is very possible that in all cases of general infection and toxemia, more damage is done to the endoi-helial lining of the blood-vessels than we can readily appreciate, a possibility which Baldassari has shown to exist by his observations on the endocardium in cases of infection and intoxication. Certainly it seems simpler to look at the process in this way than to suspect that normal endothelial cells in the aorta are fortunate enough to be able to seize single organisms from the rapidly flowing stream of blood that passes them. CONCLUSIONS. 1. The case here reported is the eleventh of acute tuberculous endaortitis. 2. The aortic tubercles were the result not of extension, but of metastasis from chronic lesions in the kidney. 3. The general miliar)^ tuberculosis that co-existed with the chronic tuberculosis, was not the result of dissemination of organisms from the aortic lesions. 4. The bacilli in the aortic lesions showed bizarre forms with a tendency to branching. RliFKRENCES. Longcope : Johns Hopkins Hosp. Bull., 1901. Benda : Lubarsch u. Ostertag's Ergebnisse, 1899. : Berl. klin. Woch., 1899. Blumer: Am. Jour. Med. Sci., 1899; Albany Med. Ann., 1899. Schmorl : Munch, mcd. Woch., 1902. Luksch: Centralbl. f. allg. Path., 1904 (Ref.). Forssner: Ibid., 1905 (Lit). Simnitsky: (Cited by Forssner.) Gaylord : Allbutt's System of Medicine, 1909 (cited by Forssner and Longcooe). Schuchardt: Virchow's Archiv, 1882. Marchand : Cited by Weigert. Virchow's Archiv, Ixxxviii. Huber : Cited by W'eigert. Virchow's Archiv, Ixxxviii. Hanot : Senu. med., 1895. Hanot et Levy: Arch, de mcd. exh., 1896. Flexner : Johns Hopkins Hosp. Bull.. 1891. Stroebe: Centralbl. f. allg. Path., 1897. Aschoff: Vcrhandl. d. Deutsche path. Gesellsch, 1899. Buttermilch : Lubarch und Ostertag's Ergebnisse, vi. Kamen : Ziegler's Beitrage, xvii. Dittrich : Cited bv Blumer. Hanau u. Sigg: Lubarsch u. Ostertag's Ergebnisse, v. Baldassari: Centralbl. f. allg. Path., 1909. THE FUNCTION OF THE CHOROID PLEXUSES OF THE CEREBRAL VENTRICLES AND ITS RELA- TION TO THAT OF THE PITUITARY GLAND.* BY SIMON PENDLETON KRAMER, M.D. The secretory organs for the cerebro-spinal fluid are the choroid plexuses of the third, fourth and lateral ventricles. These are highly vascular projections of the pia mater into the ventricles, covered with villous-like projections about 1 to 2 mm. in diameter. Under the microscope these villi are seen to be made up of a number of secondary'- villi about 0.25 mm. in diameter, which again show grape-like projections. Through the center of the villi run comparatively thick-walled blood vessels, giving the entire organ a highly vascular appearance. The connective tissue of the villi is that of the pia mater. Covering the villi of the plexuses is a layer of large spheroidal cells, in each of which may be seen, in addition to the nucleus, yellowish granules. These cells are probably the secretory cells of the organ. The appear- ance of the plexuses strongly suggests an inverted gland which, instead of pouring its secretion into a series of ducts, empties directly into the ventricular system of the brain. If one strip the choroid plexuses from both the lateral ven- tricles of a dog recently killed by bleeding, and rubs them up in 2 c.c. of normal saline solution and injects the filtrate into the jugular vein of another dog, it will be found that this extract causes a marked fall in the blood pressure. This effect was found to be constant in ten experiments. Figure 1 is from a tracing of such an experiment. The blood pressure was obtained by connecting the carotid or femoral artery of the animal with a mercury manometer. The respira- tions were recorded by means of a Paul Bert pneumograph connected with a Marey tambour, so arranged that the up-stroke represents inspiration, the down-stroke expiration. The time of * Reprinted from The Journal of the American Medical Association, January 28, 1911, vol. Ivi, pp. 265-268. 115 116 DANDRIDGE MEMORIAL injection was recorded by an electric signal. The injection was made into the jugular vein. In all experiments the animals were under light ether anesthesia administered through a tracheal tube. This animal received 1 c.c, or half the total extract made from the choroid plexuses of the lateral ventricles of another dog killed by bleeding. The drop in blood pressure, which in this experiment was preceded by a slight momentary rise (not con- stant), began fifteen seconds after the beginning of the injection, reached its maximum (that is, 50 mm.) twenty-eight seconds after the beginning of the injection, and returned to within 5 mm. of the original pressure in two minutes and twenty-five seconds. The rate of the heart-beat was apparently unchanged. The res- piration was increased in rhythm from 40 to 60 per minute. Extracts made from the choroid plexuses of the human brain show the same effects in even smaller doses. Figure 2 is a tracing obtained by injecting into the jugular vein of a dog 1 c.c. of an extract made by rubbing up the plexus from one lateral ventricle in 10 c.c. of normal saline solution. The brain was removed from a man, thirty-five years of age, five and one-half hours after death from pneumonia. Extracts made from the choroid plexus of the fourth ventricle produce the same reaction. The reaction exhibited in Figure 3 is independent of the action of the vagus nerves, since the same effect is obtained when both vagus nerves have been divided. The thought suggested itself that possibly in certain cerebral affections, particularly in such as were associated with hyper- secretion of the cerebro-spinal fluid, the fluid might contain an excess of this depressant evidently secreted by the choroid plex- uses. Accordingly experiments were made with cerebro-spinal fluid obtained by lumbar puncture in three such cases. Figure 4 is a tracing obtained from a dog into whose jugular vein were injected 12 c.c. of cerebro-spinal fluid obtained by lumbar puncture from a patient with edema of the brain follow- ing a blow on the head producing subtentorial hemorrhage. It will be seen that the injection caused a marked (55 mm.) and prolonged fall in blood pressure, followed by an exceedingly slow and incomplete recovery. The cerebro-spinal fluid in this ^' t ^ ^ ^jr- I 8 bo ^ Q o o o -p 0\ u .-» • £ '.^ --^ C; c f 2g u u. '.M ^- c o 'en i_) « -a f i_, !D -a f JC « aJ OJ f > C 1-. t (« o o C f /i! ^ ; 00 bfi Q' .m H ? > CI -S t^ ■j^ o c V '■ zcjz ^ T^ '^■ ri ^ Z ^ n ^ E ^ o ] o Tt '" 2 ■r.~ K ^~ d . o\ c O c; — • o M o [i ON n! H|| KRAMER 117 case evidently contained a great excess of the "choroid de- pressant." Figure 5 is a tracing obtained from a dog into whose jugular vein were injected 5 c.c. of cerebro-spinal fluid drawn from a marked case of delirium tremens. This fluid was much more depressant than that from the previous case. The injection of 10 c.c. of the same fluid fifteen minutes later into the same dog produced a most violent and prolonged de- pression, from which the animal incompletely recovered only after an interval of eight minutes. This is shown in Figure 6. Figure 7 is a tracing obtained by injecting 30 c.c. of cerebro- spinal fluid drawn from a subject who had recovered from de- lirium tremens. There was but little depressant effect, a fall in blood pressure of not more than 5 mm., whi^'h was quickly re- covered. The individual from whom this cerebro-spinal fluid was obtained had had a mild attack of delirium tremens which had lasted only forty-eight hours, and, at the time the fluid was withdrawn, the patient's pulse was normal again and the attack of delirium tremens had disappeared. The patient died from whom the fluid used in Experiments 5 and 6 was obtained, and at autopsy a marked cerebral edema was found. The ventricles were filled with fluid which, when injected into dogs, was markedly depressant. It also occurred to me that if such a depressant were secreted by the choroid plexuses and poured out into the ventricular system it would meet there whatever was given oflF by the pitu- itary body, and it seemed wise to determine, if possible, what action these two principles might have on each other. As has been abundantly shown, the infundibular lobe of the pituitary gland contains a substance which causes a marked elevation in blood pressure lasting for some time and accompanied by a marked slowing of the heart and an increase in the force of the cardiac systole. Tracing 8 was obtained from a dog into whose jugular vein was injected 0.75 c.c. of an extract of the infundibular lobe of the sheeps' pituitary gland. The well-known efiFect is here nicely shown. When an injection was made of a mixture of the pituitary 118 DANDRIDGE MEMORIAL extract just mentioned and an extract of the human choroid plexus it was found that these substances tend to counteract each other, though incompletely. Of course, it is difficult to determine the completeness or incompleteness of such counteraction in the absence of known dosage. If we examine a tracing (Figure 9) of such an experiment we shall find it very interesting. The depressant effect of the choroid is shown, but lessened in amount and only transitory in time. This is succeeded by a rise in pressure due to the pituitary ex- tract but this also is lessened in amount (15 mm.) and greatly shortened in time of duration. At the end of two minutes and thirty seconds the blood pressure was within 5 mm. of that which obtained before the injection. The slowing of the heart is present but also reduced. It is evident then that these two principles which, we presume, are poured into the cerebro-spinal fluid have a tendency to counteract each other insofar as their effect on the circulatory apparatus is concerned. It will be a matter for future investigation to determine, if possible, under what circum.stances the one or the other gains the supremacy. A further report on the nature of the choroid "depressant" will also be made in the future. THE EFFECT OF INJECTIONS OF INDOL AND TYROSIN IN EXPERIMENTAL ANIMALS. A Preliminary Report.* BY PAUL G. WOOLLEY, M.D.^ AND L. H. NEWBURGII, M.D. During the past year we commenced a series of experiments on rabbits and white rats, the object of which was to discover what relation chronic intoxications wath some of the lower derivatives of protein decomposition bore to changes in the adrenals and kid- neys. We had a suspicion that indol might have, in the process of secretion, or in the process of transformation into indican, or both, an effect in producing changes in the organs, which would indicate hyperactivity of certain organs (the liver, and perhaps the adrenals) or irritative changes in others (the kidneys). There seemed to be some basis for this suspicion in the fact that indi- canuria, especially when it is of well-marked degree, is accom- panied by albuminuria and cylindruria. It seemed useful to dis- cover, therefore, whether injections of indol would produce any noticeable changes in the kidneys; and, since the liver has been supposed to be the site of transformation into indican, it seemed possible that some changes in that organ might be expected. The tyrosin series had a different basis. We were interested in the physiology of the adrenal glands, and had been led to suspect that the pigmentation of Addison's disease might be a result of variation in either the content of the chromaffin tissues in tyro- sinase, or in the overabundance of tyrosin or some related sub- stance in the body. This was indicated by the suggestion of von Fiirth that melanin and related bodies are the result of the action of tyrosinase or related oxydases on the aromatic constit- uents of the protein molecule, a suggestion which, as Adami says, has been supported by Halle, who demonstrated that tyrosin is converted into epinephrin by a ferment in the adrenal. Adami * From The Journal of the American Medical Association, June 17, 1911, vol. Ivi, pp. 1796 and 1797. 119 120 DAN BRIDGE MEMORIAL suggests that pigmentation in Addison's disease is produced when this ferment is deficient — when, in other words, the tyrosin is not converted into epinephrin by the adrenal, but into melanin in the skin. All of which induced us to attempt to discover whether tyrosin would stimulate the adrenals to increased activity, or whether large excesses of tyrosin would produce melanosis in ex- perimental animals. If the former were the case, we might ex- pect to find as a result of increased epinephrin production either arterial changes or renal changes or both. Finally, because of the similarity in origin of indol and tyro- sin, we ran parallel series, each with its control. We have no definite knowledge of the manner of action or of the effects of tyrosin in the organism. We know but little more concerning indol. We are led to think that massive doses of the latter may be consumed with no, or but little, ill effects in normal man (Nesbitt). Such effects are headache, insomnia, confusion and irritability (Hertet*), and, with decreased activity in the cells in disposing of such substances, intoxications are possible (Rich- ards and Rowland). It is, however, possible that comparatively small doses given over long periods of time may, even without producing symptoms, cause changes in the organs which may lead to very serious results. Our series of experiments deals with the possibilities of such results. In performing these experiments we used rabbits and white rats. Originally we used intravenous injections. We used satu- rated aqueous solutions of Kahlbaum's indol and tyrosin. For the sake of brevity we shall at this time merely summar- ize our results by saying that after these injections we have found the medullas of the adrenals hyperplastic and apparently hyper- trophic, and that the evidences of chromafiin activity increased in proportion to the number of injections. The chrome reaction is similarly increased. We also found very slight interstitial changes in the kidneys. We had at the commencement of our experiments a suspected relation between tyrosin and adrenal changes; a suspicion of a possible relation between indol and renal changes, and the possi- bility of a relation between adrenal and renal changes. W O O L L E Y AND N E W B U R G H 121 From our incomplete results, the small importance of which we realize, we are not justified in drawing any conclusion, but we might suggest for the sake of perspective that, provided it be true that a true hyperactivity of the chromaffin is produced by one or other, or both of the substances we have used, or by other sub- stances of the same chemical order, that is to say, belonging to the aromatic series, it might be suspected that such an hyperac- tivity, extending over a considerable period of time, may be a cause, perhaps the cause, of the symptom-complex known as dia- betes. This would result from a change in the chromaffin-pan- creas equilibrium. Eppinger, to whom the idea was possibly suggested by Boinet, has remarked that tuberculin may be a substance which of itself produced inactivity of the chromaffin tissues of the body, and that by means of tuberculin the pancreas-adrenal equilibrium can be upset on the adrenal side, that is to say, in the Addisonian direc- tion. In other words, under the influence of tuberculin the glyco- lytic function of the organism is increased. Our experiments in this direction have led us already to a tem- porary belief, at least, in Eppinger's conception. We have found that seven injections, each of 0.5 mg. of tuberculin, led to an in- crease of sugar consumption in rabbits. A normal rabbit after 50 gm. of glucose (by mouth) showed 0.43 gm. of glucose in the urine (1.72 per cent.). The same rabbit after seven injections of tuberculin showed 0.07 gm. (0.35 per cent.). These results with tuberculin, especially in view of the fact that the medulla of the glands shows atrophy after tuberculin treatment, are interesting if considered with the fact that in the diagnosis of Addison's dis- ease tuberculin should be used with the greatest circumspection. Our final suggestion is that it seems possible that tuberculin in- jection may be of value in the treatment of diabetes, because of its influence on the chromaffin, and, through that influence, be- cause of its tendency to bring back — to correct — the adrenal-pan- creas equilibrium. We are continuing our work by carrying out a careful series of physiologic experiments. AMYLOID DEGENERATION LOCALIZED IN THE ADRENAL. 15 Y PAUL G. WOOLLEY, M.D. It is, of course, a generally well known fact that the adrenal is frequently affected in conditions in which the formation of amy- loid is widespread. There is, for instance, no lack of cases in which, with amyloid changes in the kidney, spleen and liver, the adrenal is also the seat of amyloid deposits. But there are few cases in which the adrenal alone is affected, and as far as I know there is no description in the literature of the structure of the amyloid areas of the adrenal, with reference to the finer effects that are produced upon the functional cells of that organ. It is because of the focalization of amyloid in the adrenal, and because of the relation of the changes in the parenchymatous cells of the adrenal cortex in the lesions, that I wish to report the following case : Case No. 158697. — The patient was a man of forty-one years. His family history was negative. He denied venereals, but had been a heavy drinker. He came to the Cincinnati Hospital com- plaining of swelling of the legs and abdomen and shortness of breath. He said that he had had "heart trouble" for years, and that this became worse some two months before admission. At that time he suffered with shortness of breath and dizziness, and his ankles and feet began to swell. He had pain in the cardiac region. At the time of admission his lips, ears and nose were cyan- otic. His temperature was 97° P., his pulse 88 and his respira- tion 32. With the exception of a slight bulging of the upper left side of the sternum, the conformation of the thorax was normal. Per- cussion showed a somewhat diminished resonance over the upper lobe and an area of flatness over the upper left sternal region. This area was in communication with the area of cardiac dullness, which was increased downward and to the left. Posteriorly there was also an area of dulness 6-7 cm. in diameter in the region of the sixth, seventh and eighth dorsal vertebras. Over this area there was distinct bronchial breathing. A blowing systolic bruit was heard at the apex of the heart 123 124 DANDRIDGE MEMORIAL and over the tricuspid area. A diastolic murmur was also present at the apex. Over the pulmonic area there was a distinct whir- ring sound. The systolic bruit was transmitted to the axilla and back. The abdomen was enlarged and contained a considerable amount of fluid. Three days after admission the patient died suddenly. Death was preceded by an increase of dyspnea. Clinical Diagnosis. — Myocardial insufficiency ; valvular heart lesion; aneurism of the arch of the aorta; nephritis; general ana- sarca. Post-mortem v/as made two hours after death. The body was that of a fairly well developed, fairly well nour- ished white man, apparently thirty-five years of age. Rigor mor- tis was not present. There was no post-m.ortem lividity. Scat- tered over the legs and over the outer portions of the arms were numerous small white scars, averaging about 3 mm. in diameter. They were slightly raised above the surface of the skin and their centers were slightly depressed. They were not pigmented. At the base of the glans penis, on the left side, was a small bluish area measuring about 1 cm. in diameter. There was a general edema of the subcutaneous tissues. On opening the chest cavity, the lungs were partially con- tracted and did not meet in the median line. There were numer- ous old fibroid pleural adhesions on all sides. The lungs were of a dirty gray color, and evidently contained an increased amount of fibrous tissue. At the base of the right lung was an area, about 3 cm. in diameter, which was harder and firmer than the sur- rounding tissue. The center of this mass was soft and filled with yellowish pus. In the left lung, about a hand's breadth (9 cm.) from the apex, was a small area measuring 2 cm. in diameter. On section this area was of a yellowish-white color and somewhat cheesy and gritty in consistency. The lobes of the lungs were bound together by old adhesions. The right lung weighed 425 gms., the left 250 gms. The pericardium contained 75 cc. of a clear straw-colored fluid. The heart was generally enlarged, and the right side was markedly dilated. The muscle tissue was pale. The anterior leaflet of the aortic valve was adherent to the middle leaflet. Oth- erwise the valves appeared to be normal. In the aorta, just be- yond the aortic valve, were a few small white or milky patches. The aorta was much smaller in diameter than normal, but other- wise showed no abnormalities. The heart weighed 425 gms. The peritoneal cavity contained a large amount of fluid simi- lai to that in the pericardium. The abdominal organs occupied their normal positions. The liver was small and of a reddish- brov/n color. The surface was very rough, and the capsule was WOOLLEY 125 somewhat thickened and in places of a hyaline appearance. The gall-bladder contained a greenish-brown bile. Its walls were thickened, fibrotic, and had a yellowish-red mottled 'appearance. The liver weighed 1,450 gms. The spleen weighed 130 gms. It was of a dark red color, and cut with slightly increased resistance. Over the lower portion of the spleen the capsule averaged 5 mm. in thickness, and was white, firm and fibrous. At the lower pole of the spleen, under this thin sclerotic capsule and extending into the substance of the spleen, was a nodule similar in size and appearance to the one in the apex of the left lung. The kidneys each weighed 130 gms. On section they were somewhat congested, cloudy and distinctly edematous. The cor- tex was of normal thickness. The line of demarkation between cortex and medulla was distinct. The adrenals measured 2xlx^ inch. The medullas were congested and apparently hyperplastic. The cortex showed no distinct evidence of abnormality. At the time of necropsy there were no appearances that sug- gested amyloid. Later, when sections of the organs were studied, there was no indication of amyloid in any of the organs except the adrenal. In a few sections of the adrenal, a small clear cortical area, measuring less than a millimeter in diameter, was visible to the unaided eye, lying just outside the line of demarcation between cortex and medulla. Microscopically, these are'ks were composed of a homogen- eous ground substance in which a considerable number of cells resembling those of the adrenal cortex were imbedded. There were a number of capillary blood-vessels separated from the cells by the homogeneous matrix. This hyaline homogeneous material reacted slowly but defi- nitely to the amyloid reagents, best, perhaps, with iodine and sul- phuric acid. The imbedded cells were all more or less filled with large and small yellowish refractile granules similar to those nor- mally present in the adrenal cortex. In other parts of the cortex there were smaller amyloid areas more or less irregularly dis- tributed and confined to the immediate neighborhood of the smaller blood-vessels, and only occasionally involving the cell columns. In but a single place in the medulla was there any evi- dence of amyloid, and that was in the walls of two blood-vessels. The medulla of the gland .showed a remarkable degree of con- 126 DAN BRIDGE MEMORIAL gestion and hyperplasia. In sections of tissue fixed in bichromate- formalin the medulla measured 3 to 4 mm. in thickness, the cor- tex 1 to 1.5 mm. Everywhere throughout the medulla the nests and columns, surrounded by dilated capillaries, were made up of cells with dark-brownish, finely granular, pigmented, abundant protoplasm and vesicular nuclei. The size of the cells varied im- mensely. Some were small with large nuclei and relatively small amounts of protoplasm ; some were very large with abundant protoplasm. All stages between these extremes were found. Still other cells had enormous vesicular nuclei, some oval, of'casionally cres^^entic, some round. Multinuclear cells were infrequent. Mi- totic figures were present. The cortical cells showed no marked variation from normal. The medullary ganglion cells were well preserved. We have, of course, no basis from which to speculate in the meaning found in this adrenal. We might suggest, however, that in this case the appearance of amyloid in the adrenal indicated the first changes in the process of the production of a general amyloidosis. ACQUIRED DIVERTICULA OF THE SIGMOID, WITH A REPORT OF SIX CASES.* BY ARTHUR D. DUNN, M.D., AND PAUL G. WOOLLEY, M.D. At the twenty-seventh Congress of Surgery, Graser demonstrated a stenosis of the sigmoid due to chronic hyperplastic inflamma- tion, on which an operation for cancer had been performed. He believed the portal of entrance for the infection to be a number of acquired diverticula, some of which were seen entering the in- flammatory mass. From Graser's paper dates the clinical interest in the subject, for before that time diverticula had been consid- ered merely pathological curiosities. They had been described by Morgagni (1796), Fleischmann (1815), Albers (1844), Hab- ershon (1857), Klebs (1869), Loomis (1872), Fischer (1900) and others. Acquired diverticula are of two varieties, the true and the false. True diverticula are merely wide-mouthed pouches whose walls contain all of the layers of the normal bowel. They are the result of an abnormal tendency to haustrum formation, and seem to be of anatomical significance only. False diverticula, on the contrary, are hernia form protrusions of the mucous mem- brane through the musrularis, and are of increasing clinical and pathological moment. Acquired diverticula may occur throughout the entire intes- tinal tract. They have frequently been seen in the duodenum in the vicinity of Vater's papilla. They are common in the colon, and they cease abruptly at the first portion of the rectum. Oc- casionally they have been observed in the appendix, where they may be the seat of a condition which cannot be differentiated from appendicitis. They vary in number from several hundred (400, Hansemann) to an isolated protrusion. They are generally multiple. Since diverticula of the sigmoid are much more likely to give * From the Americun Journal of the Medical Sciences, July, 1911. 127 128 DANDRIDGE MEMORIAL rise to clinical manifestations, your attention will be directed toward them only. Etiology. — Their origin is still a mooted question. A predis- position to diverticulum formation undoubtedly exists, and accord- ing to Graser and Sudsuki is common. On miicroscopic examina- tion of the sigmoid in old subjects, the former found small di- verticula in ten out of twenty-eight cases, and the latter in fifteen out of forty cases. The following theories as to cause have been suggested : 1. That the fenestra through which the vessels penetrate the muscularis form loci minoris resistentice. The vessels are sur- rounded by loose connective tissue, which contains a variable amount of fat. As the individual ages, the fat increases, the connective tissue becomes weaker, and the fenestra are increased in size by atrophy of the muscularis. Intermittent stasis also stretches and increases the diameter of the fenestra. During pe- riods of cessation of stasis, the caliber of the vessels diminish, and loose space in the "vessel holes" results. These factors increase the predisposition. Accumulation of feces and gas incident to constipation, bowel atony, and abnormal decomposition act to a degree as determining factors. The vascular theory is accepted by Fischer, Koch, Hansemann, Berner and others, and is cor- roborated by four of the cases which we studied microscopically. 2. Bland-Sutton believes that the appendices epiploicae form points of lessened resistance because, as he has shown, their fat is in immediate continuity with the subserous fat of the intestinal wall. It is difficult to see, however, why continuity of fat should predispose to diverticula. The process is that of a penetration of the muscularis, and it seems highly improbable that the weak serosa and its subserous layer of fat could play any part in it. It is more probable that the fact that blood-vessels penetrate the muscularis at this point is the chief reason for the common inci- dence of diverticula here. In some cases an adherent appendix may cause the production of traction diverticula. 3. Franke believes that developmental anomalies are at the basis of diverticulum formation. What these developmental im- perfections are he leaves unspecified. 4. Beer and Telling consider weakening of the muscular coat DUNN AND WOOLLEY 129 in adult life as the chief cause of diverticula. They do not state why the muscular wall should weaken in certain spots and not in others. They assume that the vessels may "direct the path" for the diverticula. Beer states: "The fact that diverticula occur in old people, in people whose intestines have been more or less worked out, as evidenced by constipation, points to a muscular deficiency, and in this muscular weakness the cause of false diver- ticula must be sought." 5. Age seems to be to some extent a determining factor. In eighty cases the average age was sixty years (Telling). Forty- seven of the eighty cases gave rise to clinical symptoms at the average of fifty-five years. The ages of our six cases were as follows : Without symplioms, sevenity-five, seventy-eight, and unknown; with symptoms, eighty-three (symptoms due to cicatri- cial stenosis secondary to diverticulitis), forty-five and fifty. 6. Sex also plays a part. Of eighty-one cases fifty-three were male, twenty-eight female (Telling). Our six cases were all men. 7 . Obesity has been emphasized as a causative factor by Klebs, Mayo and others, but it seems to be only an indication of invo- lution processes and thus only a concomitant of weakness in the muscularis or in the "vessel holes." Only two of our cases showed any unusual increase in fat, 8. Cachexia and absence of fat were marked in one of our cases. It might be inferred that in individuals who had been obese the loss of fat would tend to weaken the intestinal wall by leaving unoccupied or loose spaces, 9. The physiological role of the sigmoid must be of some mo- ment in promoting diverticulum formation. The feces are re- tained longest in this segment (average ten to twenty-four hours), and its walls are incessantly subjected to changes in pressure due to variations in the quantity and quality of its contents, and so a predisposition and tendency to atony is inherent in the nor- mal function of the sigmoid. 10. When the physiological retention of feces becomes exces- sive and constipation arises, the strain upon the gut walls is abnor- mal, and any tendency to atony is aggravated. Localized weaken- ings are subjected to a determinative factor. The causal relation- 130 DANDRIDGE M E xM O R I A L sliip of constipation to diverticulum fonriation so often observed might seem to support this view. Fischer's doubts as to the im- ]>ortance of constipation, however, are well founded. Its role has certainly been exaggerated, and cases are numerous in which con- stipation has not been recorded. Only a very small proportion of the constipated have diverticula. Abnormal decomposition of re- tained contents with gas production is probably of more moment. Constipation, if it plays a part, must apparently be of the atonic type The writer knows of no investigation as to this point. Any factor, however, that will increase intrasigmoidal pressure must influence the development of diverticula at points of lessened resistance. We may briefly summarize the etiological factors, all of which may be present to a variable extent in every case, as follows: (1) Congenital or acquired anatomical predispositions to localized VN^eakness in the wall of the gut. (2) The addition of certain positive mechanical factors to the above potential factors, viz., (a) strain on the bowel w^all due to the accumulation of gas and feces; (b) changes in the caliber and structural strength of the "vessel holes" consequent on stasis and senile circulatory dis- turbances, or on rapid loss of visceral fat; (c) atony, v/hich may be due to age, distention or obesity. Pathology. — There is little definite information on the post- mortem incidence of acquired diverticula of the sigmoid, for, as a rule, little attention is given to this segment of the gut in the routine autopsy, unless clinical manifestations or conspicuous pathological alteration draws the attention thither. In seventy- eight cases in which the sigmoid was carefully examined by us at the autopsy, acquired diverticula were found five times. Two of the above cases were clinical. In one, the diagnosis was sus- pected almost to a certainty, in the second it was a "find." The remaining cases were discovered because they were looked for. False diverticula are usually situated near the mesenteric at- tachment. According to Bland-Sutton, Franke, and Telling, they are most commonly formed at the appendices epiploicje. In three of our autopsies they were located at these points. In one case their location was at the mesenteric attachment. In one case the diverticula were located in the vicinity of the appendices, but DUNN AND WOOL LEY 131 their relationship to them could not be determined on account of the hyperplasia of the gut wall and an inflammatory infiltra- tion of the immense amount of fat surrounding the sigmoid. One peculiarity in this case not hitherto noted is the location of the diverticula on the summits of the rugae, where they were dis- covered as minute depressions only after careful search. One of these innocent-looking depressions led into a fistulous tract. Lo- cation opposite the mesenteric attachment has been described by Hansemann. The sice of acquired diverticula varies from minute hernia- form protrusions of the mucosa, discoverable only with the micro- scope, to processes the size of peas or grapes. (Size of an apple — Edel; of an egg — Virchow). They are conical, saccular, spheri- cal, or teat-like processes. The ostia vary markedly in size. Sometimes the diameter of the opening equals that of the average diameter of the diverti- culum. Often the openings are narrow, and although one easily discovers the pouch on the outer surface of the bowel, the mu- cosa must be scanned carefully to find the mouth. Alany of them are distinctly flask-shaped, and their necks seem to be constricted by the penetrated musculature. This shape is especially charac- teristic of diverticula into the appendices epiploicse, and creates an excellent mechanism to prevent drainage. Catarrhal inflam- mation may easily cause edema and swelling of the mucosa, and thus completely occlude the neck. Thus, there is formed a thin- walled sac filled with infectious material lying outside of the gut. The peritoneal cavity is protected only by a thin membrane consisting of mucosa, serosa, and possibly a few attenuated muscle fibers. The mucosa itself is often eroded or atrophic. It may be completely denuded. Localized foci of infection are common. The coats of the diverticulum vary. ^Mucosa, sub-mucosa and serosa are constant. The amount of muscularis varies in different diverticula, and in different parts of the same diverticulum. The walls are thinnest at the tips of the processes. Here there may be nothing but a thinned outer layer of mu- cosa and serosa. In our sections the penetration of the mus- cularis is clear, even though the diverticulum carries some mus- cle fiber with it. The contrast in the thickness of the muscular 132 DANDRIDGE MEMORIAL coating of the diverticulum, and of the layers through which it passes, is most marked. This accumulated musculature at the neck is suggestive of a sphincter. Beer and others have sug- gested that the origin of this picture is a localized weakening of the muscularis, but this still leaves an explanation to be ex- plained. The potentiality for mischief which lies in these struc- tures is evident from an inspection of the section shown with the description of our cases. The morbidity from false diverticula depends on the follow- ing factors : 1. Thinning of the coats. 2. Ulcerative and perforative action of retained concretions and feces. 3. Presence of pathogenic micro-organisms. 4. Defective drainage due to (a) lack of an effective muscular coat; (b) closure of the neck by edema of the mucosa second- ary to colitis or stasis. A mild catarrhal colitis may occlude the openings, and thus result in the formation of a pocket of infec- tious material, from which the peritoneal cavity is poorly pro- tected by a coat of variable thinness; (c) strangulation of the opening by kinking, torsion or muscular (sphincter) action. The following morbid processes, due to acquired diverticula of the sigmoid have been noted : 1. Local Peritonitis. — Cases have been reported in consider- able number. Abscesses in the left iliac fossa have frequently been drained and attributed to various causes, such as left-sided appendicitis, infected appendices epiploicae, colonic ulceration, etc. This is probably the most frequently observed clinical manifes- tation of diverticulitis. (Telling collected twenty-four cases.) One of our cases was of this type. 2. Acute General {Diffuse) Peritonitis. — (a) With perfora- tion, fourteen cases (Telling) ; {b) without perforation. Loomis (1872) reports a single case of general peritonitis in which di- verticula were present in large numbers. He assumed that the infection traversed the thin wall of a diverticulum without rup- ture. 3. Chronic Hyperplastic Sigmoiditis. — Within the last few years a number of cases have been reported, characterized by a DUNN AND WOOLLEY 133 productive inflammation of the sigmoid, which manifests itself by disturbed function of the lower bowel ; pain, intermittent and colicky in character; tenderness and constipation, often spastic in type and frequently alternating with diarrhea. Mucus and occa- sionally a trace of blood are present in the stools. Examination showed tenderness in the left iliac fossa with a movable sausage- shaped tumor. Recent observations prove a large percentage of these cases to be the result of diverticulitis and peridiverticulitis. Patel says : "Peute-etre un jour sera-t-on droit de dire que dans presque tons ces cas decrites sous le nom de sigmoiditis, il s'agit de veritables diverticulites, absolument comme I'appendicite a ete substitute peu a pen a la typhlite." There is little question but that many of the successful resections of the sigmoid for carci- noma have been cases of infiltrating sigmoiditis. A review of museum specimens (Mayo, Wilson, Telling, etc), is already put- ting certain excised cancers of the sigmoid into this class. Such reports will increase in frequency as the condition becomes bet- ter known. 4. Cancer. — Four cases are reported by Hochenegg, Stierlin, Telling and Wilson, in which cancer has developed on the basis of a sigmoiditis and perisigmoiditis secondarj^ to chronic diver- ticulitis. The low grade of prolonged inflammatory irritation which so often precedes carcinoma elsewhere is here produced by a chronic diverticulitis. 5. Stenoses. — These are the result of inflammation in the in- testinal wall. Usually they are caused by a productive inflamma- tion, i.e., sigmoiditis and perisigmoiditis, which narrows the lu- men of the gut. The mucosa is thrown into folds, but, as a rule, is not ulcerated. Cicatricial contraction following a diverticulitis may produce stenosis, as is clearly shown by one of our speci- mens. Telling reports the only other case in tHe literature. 6. Adhesions. — Adhesions produce symptoms by : (a) Traction and constriction. The obstruction is commonly due to the fact that the small bowel becomes adherent to the inflammatory area; (b) adhesions of the gut to the bladder, with vesicosigmoidal fistula. Telling found adhesions reported sixteen times and fistula eleven times. 7. Chronic Mesenteritis. — Riedel, Brehms, Ries, Simpson and 134 DANDRIDGE MEMORIAL Gardinier have called attention to the probable importance of sig- moid mesentery, a state which predisposes to volvulus. One of our cases was of this type. 8. Metastatic Suppuration. — Whyte (1906) has reported the only case of this type. A limited necropsy disclosed multiple abscesses of the liver. The original focus was supposed to be an inflamed diverticulum of the sigmoid containing a fecal con- cretion. 9. Perforation Into a Hernial Sac. — Stierlin has reported a case of suppuration into a hernial sac from a perforated diver- ticulum in an incarcerated sigmoid. Case I. — B. K., male, aged forty-live years. The family his- tory is negative, and the personal history also until one and one- half years before the present illness, when the patient had an attack of pain and distress in the hypogastrium with temperature. There was some diarrhea and tenesmus. Constipation was not present at any time. lie went to bed for several days on a re- stricted diet and recovered rapidly. Except a few fleeting pains and an occasional sense of ftill- ness in the lower quadrants, which disappeared wuth catharsis, nothing of moment occurred for one and one-half years, when, after a few days of indefinite distress in the hypogastrium, he suffered severe pains in the lower abdomen, which were accom- panied by dizziness, faintness, chill, temperature of 103°, and later sweating. The bowels had been free, but with some griping and soreness. The patient went to bed on a restricted diet, and for several days had an irregular temperature, ranging from 99° to 103.5°, accompanied by distress in the lower abdomen. Exami- nation brought out the following facts : The patient was a well-developed, middle-aged man. His com- plexion was muddy, his tongue coated, and his breath foul. Ex- aminations of the heart, nervous system, and lungs were negative except for the rapidity of heart and for signs of retraction at the left apex. The abdomen was uniformly distended and tym- panitic. There was diffuse tenderness below the umbilicus, which was best defined in the left iliac fossa, and in the median line, where he always referred his pain. No tumor mass could be dem- onstrated. A slight visceromotor reflex was present in both lower D U N N A N D W O O L L E V 135 quadrants, but was most marked on the left. There was no area of cutaneous hyperesthesia. Neither testicle was tender. Rectal examination was negative. The leukocyte count was 15,- 000. The urine contained much indican, but was otherwise nega- tive. The stools were very offensive, contained a little mucus, but neither blood nor pus. Large, thick Gram-positive bacilli were present in large numbers. The pulse was rapid ( 100 to 130). With colonic irrigation and on a diet of buttermilk and car- bohydrates the patient slowly improved. For a month there were occasional attacks of pain, with a little temperature, which were relieved by flushings. Convalescence was slow. Several leukocyte counts during this period gave an average of 8,000 to 10,000. Indican was more or less constantly present until con- valescence w-as well established. A diagnosis of intestinal toxemia with possible sigmoiditis was made at that time. The patient left home and did fairly well for one month, when he was taken with sudden, severe pain in the hypogastrium, hur- ried to the hospital, and was operated upon with the diagnosis of appendicitis. In a personal communication the surgeon stated that *'the appendix was thickened and slightly injected, but I must confess it hardly seemed sufficiently involved to account for the large amount of turbid fluid which we found in the lower abdo- men. There were no adhesions about the cecum, which was apparently normal. I did not examine the sigmoid colon." One month later the patient returned for treatment. His distress had returned after the operation, although not to the same degree. A strict dietetic and hygienic regime, with colonic flushing gradually brought the patient into the best health he had enjoyed for several years. Strict injunctions against excessive indulgence in proteids, especially high meats and cheese, were given, as experience had proved that a minimum of proteid was accompanied with less distress. With much proteid ingestion, in- dican always appeared in the urine and undigested meat fibers in the stools. When the diet was strictly followed, the stools lost their offensiveness, the gas diminished, and the number of Gram- positive bacilli decreased. Repeated rectal examinations were negative. 136 DANDRIDGE MEMORIAL After three months of comparative freedom from trouble, the patient committed two dietetic indiscretions within twenty- four hours. Pain and distress in the hypogastrium followed with temperature ranging from 99° to 104°, and a pulse of 100 to 120. His condition improved slowly for five days under treat- ment, when a sudden, sharp pain followed an injection of water. The pain was so severe that morphine was given before the pa- tient was seen. On examination there was considerable tender- ness in the lower abdomen, some rigidity, but no cutaneous hy- peresthesia. Rectal examination was negative. There was a lit- tle nausea, but no vomiting. A tumor mass could not be demon- strated at this time ; there was some pain at the end of urination. On several occasions during the next few days the stools showed a little pus, mucus and blood. Ten days later a mass had clearly defined itself in both iliac fossa, and could be detected per rectum as an irregular, elastic, bulging body. The patient's general ap- pearance was decidedly septic, and he was removed to the hos- pital for operation. Leucocytes, 40,000. From the clinical course it was assumed that the condition was a localized purulent peritonitis rising from the sigmoid. A chronic ulcerative process was excluded on account of the absence of blood and pus in the stools until the last few days. Perfora- tion of a carcinoma was unlikely from the length of the clinical course (two years), the absence of signs of stenosis, the almost entire absence of blood, the absence of a tumor until a few days previous, the character of the tumor and its rapid development. By exclusion, diverticulitis of the sigmoid with perforation of an infected diverticulum resulting in a pelvic abscess was considered probable. Operation. — An incision was made in the median line, and in- asmuch as the most prominent part of the tumor mass seemed to the surgeon to be on the right side, a wide incision was made well to the right of the rectus muscle, and free drainage instituted. The case passed from observation, and death took place about six weeks after the operation. The autopsy report was as follows: Operation about ten hours after death. Skin very pale. Slight rigor mortis. Peripheral lymph glands not enlarged. Two oper- ative wounds on abdomen — one in mid-line about 10 cm. long. DUNN AND woo LLEY 137 one over appendix about 7.5 cm. long. The latter drained. Sub- cutaneous fat well developed. Upon opening the peritoneal cavity it was seen that the omen- tum was adherent over the whole anterior surface of the perito- neum, and less extensively to the intestinal coils. It was rolled into a mass in the left hypochondrium. The intestinal coils were more or less generally adherent by old fibrous adhesions, and were also adherent to the parietal peritoneum in the right flank. The coils of the ileum were closely adherent to one another, and the lower ones were also adherent to the sigmoid by old and recent adhesions. The cecum was bound down by adhesions, most of them recent, the results of an operation done some days before to drain the cecal and pelvic regions. There was no pus in the pelvis or about the cecum. The appendix had been removed. The intestines were -^are fully dissected out, and no other pro- cess than an adhesive fibrosis was encountered until the lower loops of the small intestines were dissected away from the sig- moid, just at the brim of the pelvis. At this point an abscess cavity situated under the sigmoid and walled ofT by the small in- testine was opened. As the large intestine was removed, pus was again encountered to the left and beneath the descending colon and sigmoid. This suppurative process could be traced to the abscess cavity men- tioned above and to a larger one to the left of it, in the postin- testinal tissues, and just at the brim of the pelvis. The process had apparently also extended down (judging from the adhesions), but this extension had been limited by adhesions in the pelvis. Extending up along and behind the descending colon, the line of extension of suppuration could be followed to the spleen, which was half enclosed in an abscess cavity. An incision through the diaphragm from below and explora- tion of the left pleural cavity occasioned a gush of foul-smelling, greenish-yellow, thin ous, to the amount of about 500 c.c. The thorax was then opened and examined. The left lung was partially compressed by an empyema that extended from the dia- phragm to near the apex. The pleura was covered by a green- ish-yellow fibrinopurulent exudate. The left apex was th.e seat of a large healed scar, and scattered about on the pleura and in the pulmonary tissue were fibroid and calcareous obsolescent tuber- cles. The right lung was also the seat of a healed tuberculous pro- cess, the pleura being thickly studded with obsolescent tubercles, especially at the junction, posteriorly, of the interlobar clefts. The heart was pale, but otherwise normal. The liver was sm.all, pale, and exceedingly soft. 138 DANDRIDGE MEMORIAL The kidneys were very large and pale. The capsules stripped, leaving an un'torn surface. Section of the organ showed the cor- tex enlarged, pale and granular in appearance, with little line of demarcation between it and the medulla. The adrenals were normal. The pancreas was normal. The spleen was of normal size, but soft, and the seat of an acute suppurative perisplenitis. When the intestines were opened it was seen that the small intestine was atrophic, the walls thinned, the rugse not prominent, and the mucosa thinned. P'rom the cecum, down the sub-mucosa and the muscularis became gradually thickened until, in the vicin- ity of the brim of the pelvis, the wall was from two to five milli- meters thick and perisigmoidal and rectal tissues were generally firm and infiltrated. The sigmoid and rectum showed accentuated diverticular pouches, all of which had thinned distal ends and mouths, about which the sub-mucosa and the muscularis were very thick and edematous. Extending from the distal end of one of these pouches was a sinus, surrounded by thickened fibroid walls, that communicated with the larger postcolonic abscess cavity. From this pouch or diverticulum the suppurative process had appar- ently originated. The tops of the folds of the descending colon and sigmoid showed number of small areas having somewhat the appearance of shallow ulcers. These areas measured not more than one by two millimeters. They had slightly thickened, raised and rounded margins and gray bases. Anatomical Diagnosis. — Anemia; catarrhal sigmoiditis and proctitis ; diverticulum formation ; chronic perforative diverticu- litis; suppurative perisigmoiditis, pericolitis and perisplenitis; em- pyema ; parenchymatous degeneration of the kidneys ; fatty re- generation of the liver; obsolescent, calcareous pulmonary tuber- culosi,s ; left apical scar; general organized peritoneal adhesions; operative wounds. The striking clinical features of this case are the absence of constipation, the indefiniteness of the bowel disturbance, the re- peated presence of large quantities of indican in the urine, the favorable influence of a proteid diet, the persistent rapidity of the pulse in all his attacks, the distress at the end of urination, the fact that perforation evidently followed distension of the sigmoid with water, the fact that a surgeon of high diagnostic ability operated for what seemed to be an acute attack of appendicitis, the interesting disitribution of the tumor mass, which extended from the left iliac fossa dov/n into the cul-de-sac and up into the right DUNN A N D WOOL L E Y 139 iliac fossa, where it reached its greatest prominence, and that this led a surgeon of large experience, after making a median explo- ratory incision, to drain the apex of the abscess in the right ihac fossa, with the belief that the seat of the trouble was there. Case II. — The following case was seen with Dr. Schleier, of Omaha. J. S., male, aged eighty-three years. The patient en- tered St. Joseph's Hospital, December 9, 1908, in a semicomatose condition. No history could be obtained except that three days before admission he had had some trouble in passing urine, and had therefore been catheterizcd. Subsequent urin'ation had been free and the urine bloody. General examination proved negative, except for pulmonary emphysema and a well-developed arteriosclerosis. The abdomen was distended. Peristaltic waves could be seen starting in the region of the cecum, disappearing in the right hypochondrium, and again appearing at the median line, thence proceeding to the left and downward to the hypogastrium. There was no abdom- inal rigidity. There was tenderness posteriorly over both kid- neys, with an area of renal hyperesthesia on both sides above the crest of the ilium. There was no abdominal tenderness. The bedsheets were stained with bloody urine; a specimen could not be obtained by catheterization. The breath was not urinous. Recta! Examination. — The rectum was ballooned, the pros- tate moderately enlarged, but not tender. No tumor mass was palpable. Clinical Diagnosis. — Chronic intestinal obstruction, probably due to stricture, cause unknown. Without a urine examination a chronic intestinal toxemia was suggested as a possible cause of the hematuria. Colotomv was advised, and performed by Dr. Schleier. Death occurred about eighteen hours after operation. Autopsy was performed eight hours after death. The patient was a somewhat emaciated elderly man. There was moderate edema and posterior congestion of both lungs, and marked senile emphysema. The heart was normal in size : there was tremendous calcification of the mitral valves and complete calcification of certain areas in the coronary arteries ; thei"e was also calcification of the aortic valves and marked atheroma of the aorta through- out its entire length. The celiac axis was almost completel)^ ob- literated. The large intestine was dilated throughout its entire length ; the hepatic flexure was adherent beneath and covered by the liver, a condition which explains why peristalsis could not be seen in this region. A colotomy wound was observed at lower part of descending colon. There was a stricture at the junction of the middle and lower third of the sigmoid. Numerous false di- verticula were present in the area of the structure, which was 140 DANDRIDGE MEMORIAL about one and one-half inches long. There was a slight perisig- moiditis at the site of the stricture. Diverticula were numerous for a distance of a foot or two above the stricture. They varied in depth ; their mouths were generally wide, and they entered the appendices epiploicze. Ihere was atrophy of the wads of the colon and of the small intestine. The kidneys were normal in size, the capsules stripped easily, and the surface slightly gran- ular. The cortex was atrophic, but there were no gross signs of inflammation. The pelvis and both kidneys were markedly injected and covered with a dirty, sanguinopurulent exudate. The ureters were distended and similarly inflamed. They were so red and injected as to look like veins from the outside. The bladder was thickened and markedly injected. The bladder con- tained a small amount of bloody urine, which showed pus cells and desquamated epithelium in large amounts. There were micro- scopic clumps of a dozen or more epithelial cells together, show- ing that desquamation en bloc of areas of bladder, ureteral and pelvic epithelium had occurred. The prostate was hypertrophied ; there was marked peripheral arteriosclerosis, with extensive de- posits of lime salts in the vessel walls. The pathological diag- nosis was emphysema and passive congestion of the lungs; coronary arteriosclerosis and calcareous deposits in mitral and aortic valves ; general arteriosclerosis ; passive congestion of liver and spleen ; senile atrophy of spleen ; chronic intestinal ob- struction due to benign cicatricial stenosis of sigmoid; false diverticula of the descending colon and sigmoid, especially at area of stricture; dilation and atrophy of the colon; hypertrophy of the prostate ; ascending cysto-utero-pyelitis. The intimate relation of the numerous false diverticula to the stenosed areas in this case makes probable their pathogenic sig- nificance in benign cicatricial stenosis of the sigmoid. Case III. — S. B., farmer, aged fifty years, entered St. Joseph's Hospital, January 4, 1909. The patient was in a stuporous con- dition, and the following history was obtained with difficulty: The duration of illness was indefinite and onset had been grad- ual. The patient complained of intermittent abdominal pain, which was described as "sore, colicky," of belching, headache, weakness and of constipation. His bowels had not moved at all for three days, and not well for several weeks previously. No pulmonary, cardiac or renal symptoms could be elicited. The past history was negative except for indefinite trouble with the lower bowel and constipation. Later, a history was obtained of a dis- turbance, nine months previous, in the lower abdomen, which lasted several weeks, and was characterized by colicky pains and distress in the median line and to the left, alternating diarrhea and constipation with mucus in the stools, fever and soreness in the DUNN AND WOOLLEY 141 left lower quadrant. The condition of the patient wlien first seen was as follows: lie was an emaciated, medium-sized man, stupid in appearance, and apparently of some sixty years of age. He lay quietly in bed, yawned continuously, his eyes were half closed, and he paid but little attention to what was going on around him. It was necessary to speak loudly and prod him to obtain answers to questions. Both lids were equally ptotic, but he could raise them with the assistance of the frontal muscles to the level of the iris. The pupils were equally contracted, and reacted slightly to light and distance. The breath was foul and the teeth poor. Vision seemed good. There was no asymmetry in muscle power. The patient could recognize a watch tick for a distance of only about an inch from each ear. Examination of the neck, lungs and heart were negative. The abdomen was soft and not especially tympanitic. The liver and spleen were nega- tive. Peristaltic waves occasionally could be seen traversing the hypogastric region from right to left. They were about two to three inches in breadth, and were accompanied by signs of distress and rubbing of the abdomen. Rectal examination, save for "ballooning," was negative. No tumor mass was palpable. The urine was highly concentrated. It contained indican and uro- bilinogen (Ehrlich's aldehyde reaction) in large amounts, a trace of albumin with occasional hvalin and granular casts. The su- perficial reflexes were markedly diminished, and the deep re- flexes were faint or absent, but svmmetrically so. The tempera- ture was 101°, and the pulse 70. An injection of warm olive oil was ordered, with a mercurial and saline, which brought away a large amount of fecal material. The mental condition bright- ened for several days. Then relapses occurred at varving inter- vals vvith conditions similar to those described. The trouble al- ways could be relieved by a rectal injection of one to two quarts of water. A diagnosis of chronic intestinal obstruction, of un- known cause, in the region of the sigmoid, was made at this time. On January 25, 1909, the patient developed a double lobar pneu- monia, which lasted ten days. During this time injections of water v.ere given each day. On February 28, 1909, another attack of pneumonia occurred which produced stupor and was accompanied by signs of intestinal obstruction, e.g., peristalsis and obstipation, which were relieved only by repeated injections of both oil and water. A large sacral decubitus four inches in diameter developed at this time. Several attacks of obstruction followed, which were easily remedied by injections. During intervals of from one week to ten days the patient had normal although constipated stools. It was clear that an intermittent intestinal obstruction existed. This must have been caused by a mechanical factor prevailing 142 DAN BRIDGE MEMORIAL only at intervals. The occasional copious and well-formed move- ments spoke against stricture. The constant absence of blood in the stools, and of a tumor mass, spoke against malignant disease. There was no evidence of hernia. Of causes that could produce .such a frequent recurrence of obstruction, followed by free in- tervals, only two could well be assumed. The first was adhesions. But a band could hardly produce this picture by mere constriction. Traction of an adhesion on a loop of intestine might cause kinking when influenced by changes in intra-intestinal pressure, and by variations in the position and caliber of the gut, both of which factors are, to a certain extent, dependent on the intestinal con- tents. The second possible cause was intermittent volvulus upon the basis of cicatrization and retraction of the mesosigmoid form- ing an axis on which rotation of the sigmoid might occur. Such a condition might have accounted for an intermittent intestinal obstruction, which Vi^as not relieved by catharsis, but by rectal injections. A history of intermittent intestinal trouble with fever, pain, and diarrhea, with the presence of blood the year before, suggested the possibility of such a condition. Operation was advised on the basis of a diagnosis of inter- mittent chronic intestinal obstruction, due to volvulus or to adhesions. An old inflammatory process resulting from a diver- ticulitis was suggested as a possible causa morhi. The operation was performed by Dr. C. C. Allison. An in- cision was made to the left of the median line. The upper and lower segments of the sigmoid were found separated b)' about one inch of scarred mesosigmoid. There were slight adhesions running from the origin of the sigmoid to the parietal peritoneum. Several diverticula were seen close to the mesenteric attachment in the vicinity of the retracted mesosigmoid. It could not be demonstrated without opening the gut, that the cicatrization was secondary to a diverticulitis, and so, although the existence of the diverticula may have been a coincidence, yet inference to the contrary is permissible. The upper limb of the sigmoid was freed from adhesions and stitched to the parietal peritoneum higher up. A complete recovery took place. Case IV. — N. A. C, male, aged seventy-five years. The case was a coroner's autopsy. The anatomical diagnosis was: Myo- malacia cordis ; sclerosis and obliteration of the right coronary artery; general arteriosclerosis; passive congestion of liver, spleen and kidneys; chronic interstitial nephritis; pulmonary emphy- sema. Several false diverticula of the sigmoid were found enter- ing the appendices epiploicse. Case V. — E.R., male, the anatomical diagnosis was : Healed tuberculosis of both apices; chronic bilateral pleural adhesions; DUNN AND WOOLLEY 143 dilatation and hypertrophy of the heart ; myomalacia cordis with cardiac aneurysm ; passive congestion of lungs, liver, kidney, and spleen ; cholelithiasis ; arteriosclerotic kidney ; diverticula of the sigmoid and descending colon. The diverticula were located in the vicinity of the mesenteric attachment. Their walls were ex- tremely thin, and they contained inspissated feces. Case V'I. — The case was a coroner's autopsy. The subject was an elderly obese male, of unknown age. The anatomical diagnosis was : Edema of lower extremities ; passive congestion and edema of the lungs ; hypertrophy and dilatation of the heart, especially of the left ventricle; degeneration of the myocardium; passive congestion of the liver, spleen, and kidneys; chronic interstitial nephritis; false diverticula of the sigmoid. The sigmoid was surrounded with a large amount of fat, and the appendices epiploicae consisted of large fatty masses. Six false diverticula could be seen penetrating these fatty masses. Diagnosis. — It can be easily seen, from the brief resume of the pathology of diverticulum disease, that the symptoms may be manifold and difficult of interpretation. The diagnosis is seldom easy, rarely certain, and often impossible. Franke was able to collect from the literature only two cases in which the diagnosis had been made. To these he added a case of his own. Graham recently suggested the diagnosis in one of Mayo's cases. To appreciate the possibilities is a long step in the direction of a diag- nosis, which must be made largely by exclusion. The most easily recognizable condition is that of the so-called "left-sided appendi- citis." There is pain, gastric disturbances, tenderness, and rigidity in the left lower quadrant, with temperature and leukocytosis; abscess formation often appears later. Another class of cases that is moderately easy of recognition is that of chronic hyper- plastic sigmoiditis. This has been treated as a disease entity by Ewald, Boaz, Rosenheim, and others, but it is possible that diver- ticulitis may be found a basis for it. In this complex there is always intermittent pain, disturbed function associated with ir- regularity of bowel action, gas, and often spastic stools in which there is frequently an increase in mucus and occasionally a trace of blood. Physical examination discloses a tender sausage-shaped tumor which may be either adherent or freely movable, and which varies in size from time to time. Infiltration may be felt occa- sionally per rectum.. Sigmoidoscopy shows a swollen, reddened. 144 DAN BRIDGE MEMORIAL rugous mucosa, and often narrowing of the lumen of the gut. Obstructive symptoms may be present, but are not so common as in cancer, from which condition it must be differentiated. In carcinoma the clinical course is more progressive and definite. Its duration is limited ; ulceration with blood in the feces is the rule, and when blood once appears it is usually quite constant. The tumor is harder, more likely to be movable, definitely circum- scribed, constantly increases in size, and is not elongated. Bladder symptoms are apt to be frequent in diverticulitis, as the bladder ir; often involved in the inflammatory process. Cripps states that vesicosigmoidal fistula is more commonly inflammatory than ma- lignant (forty-five out of sixty-three cases). If such be the case, many of them may be the result of a diverticulitis. Disturbed bowel function is constant. Manv cases record constipation as a more or less pronounced prodromal symptom. Pelvic abscess, tubo-ovarian abscess, mucous colitis, amebic colitis, chronic proc- titis, tuberculosis and syphilis of the sigmoid, psoas disease, retro- peritoneal abscess in the left flank from other causes, etc., must, in addition to the conditions already mentioned, be differentiated. Treatment. — The treatment must be surgical in many cases. The prognosis is often a question of technical efficiency. It is certain that, as in appendicitis, many of the cases will recover without operative interference. Just what are the indications for resection in hyperplastic sigmoiditis is a question for future de- termination. Abscesses and vesicosigmoidal fistulse should always have the advantage of surgical treatment. As knowledge of the morbid anatomy of false diverticula increases, as cases are recog- nized, reported, and treated, as methods of surgical procedure become crystallized, facts will be obtained for reliable diagnosis and prognosis. rp:ferences. Fischer : Journal Exper. Med., 1900, v, 33. Beer: Amer. Jotir. Med. Sci., 1904, cxxviii, 135. Telling: Brit. Med. Joicr., October 31, 1908,2496. Franke : Deutsche nted. Woch., 1909. xxxv, 98. Eisendrath : Arch. Diag., October, 1909. Giffin and Wilson : Amer. Jour. Med. Sci., 1909, cxxxviii, 661. A SIMPLE METHOD OF CULTIVATING THE MORAX- AXENFELD DIPLOBACILLUS. BY WILLIAM H. PETERS, M.D. The following note calls attention to the fact that the Morax- Axenfeld bacillus grows as readily and in as characteristic manner on Dorset's egg medium as upon Loeffler's blood serum. The comparative ease with which the former medium can be prepared should render this fact of value. To cite an illustrating case : James M. W., aged thirty-four years, a blacksmith, was ad- mitted into the service of Dr. D. T. Vail on October 24, 1910. He was suffering from a double catarrhal conjunctivitis which he thought had been acquired by using the towel of his roommate who had sore eyes. Smear preparations from the purulent secretion from each eye showed the presence of isolated diplobacilli lying between the polymorphonuclear leucocytes and apparently in pure culture. The diplobacilli measured 2.7 x 3 fi and the rods had rounded ends. They stained well with Loeffler's methylene blue but lost the stain in Gram's method. Slants of Dorset's egg medium and Loeffler's blood serum were inoculated with pus from each eye. After twenty- four hours' incubation numerous characteristically pitted colonies ap- peared, resembling those described by Morax (An. de VInst. Past., 1896, 10, p. 337) and Pusey (Journal A. M. A., 1906, 47, p. 255). The pits in Dorset's egg medium were not quite as deep and the diameter less than those in Loeffler's l>lood serum and they did not become confluent upon the former medium as rapidly as upon the latter. Transplants failed to grow upon the ordinary laboratory media. 145 THE ELECTROCARDiUGRA-M.* BY JOHN E. GREIWE, M.D. In attempting to analyze the rather complicated results obtained by means of the electrocardiograph, it will be necessary to bear in mind that in the heart muscle we have to deal with tissue which has a number of definite functions to perform. It is obvious that we are dealing with muscular tissue whose prime function is that of expelling the blood into the greater and the lesser circulation. In order to accomplish this end to greatest advantage, we find that there is a constant and definite arrangement of this muscular tissue. Without going into detail, one can obtain a fair idea of this complicated structure by recalling for a moment the component parts in the distribution of heart muscle in the auricles and ventricles. The circular muscle fibres found at the mouth of the superior vena cava, are found to be continuous with those of the auricle. One may do well to fix in mind this area of auricular muscle fibres at the mouth of the superior vena cava, since we find here the node of Keith, in which the normal heart stimulus begins, and furthermore since Wenkebach calls our attention to the fact that he has found this area to be the seat of important pathologic changes which he believes of great consequence in the explanation of heart irregularities, especially in connection with tricuspid in- sufficiencies. The auricles have each their own separate muscle fibres, which can well be seen through the thin endocardium. Then there are a limited number of fibres common to both auricles. Of special interest in the auricle is that strongly developed muscular mass, the auricular appendage, which is believed to have much to do with the passing, under great pressure, of the last few drops of blood between the almost closed auriculo-ventricular valves. The distribution or arrangement of muscle fibres in the auri- * From The Lancet-Clinic. July 20. 1912. 147 148 DANDRIDGE MEMORIAL cles is comparatively simple. Not so, however, in the ventricles. These chambers have some fibres common to both, and again, there is a distinct system of fibres for each ventricle. We may, however, simplify matters by bearing in mind that we have here: The external and internal longitudinal or spiral muscle fibres. The circular muscle fibres. The papillary muscles. The external or spiral muscle fibres have their origin at the base of the heart, at the fibrous ring in the auriculo-ventricular septum. They pass over the heart diagonally, viz. : From the Fig. 1. — Diagram of the Muscular System of Heart. base, anterior surface (right ventricle), downward and outward to the left; from the base posteriorly (left ventricle), downward and inward to the right. They end in the whorl at the apex of the heart. The peculiar distribution of the circular muscle fibres is of special interest in the analysis of the electrocardiogram. It should be remembered that they have no tendinous attachments. If one can speak of this system of fibres as of greater importance than any other it is because of its strength and it3 function. It is to this system of circular muscle fibres, so well developed, and with the function of expelling the blood from the ventricles into the large arteries at the base, that the Germans have appropriately applied the term "Das Treibwerk des Herzens." These fibres are not found exactly at right angles to the axis of the heart, but they G R E I W E. 149 end in one another without any tendinous attachments. Attention will be called to their position in the electrocardiogram. Of more than ordinary interest is the position and relation of the papillary muscles in the construction of the ventricles. The stimulation and contraction of the papillary muscles is not only well seen in the electrocardiogram, but by means of it the dispute as to whether the base or the apex of the heart is the first to contract seems to be definitely settled. We see that the stimulus passes from the bundle of His to the papillary system before the circular muscle fibers can be affected. ( Figs. 1 and 2. ) CIRCULAR §i ^^ l^h^ TO VENTRICLE MUSCLE FIBRES SPIRAL MU SCLE \^ '"^^W^T" Wl SPlRAt. flUSCLS FIBRES m "^^^ m FIBRES Fig. 2. — Diagrammatic Scheme of the Heart Stimuli {after Nikolai). I have here given very briefly the relations of those muscu- lar structures which are engaged in passing the blood from the upper into the lower chatnbers, and with the expulsion of this same mass from the lower chambers into the great vessels at the base of the heart. It will be seen that so far we are dealing with structures whose main function is that of contraction, and while we recognize that the muscle fibers have other important functions, we know now that the path for stimulus lies in a definite system of fibers. For the purpose of our study it is necessary to call to mind that there is in the normal state a definite connection and correlation of 150 D A X D R I D G E M E M O R 1 A L these muscular structures just considered, and that there is a definite path of communication between the upper and lower chambers of the heart. The work of Ludwig, His and Kent, Aschoit and Tawara, has thrown much hght upon the muscular structure of the heart and the paths of stimulus conduction. His and Kent, in 1893, called attention to the muscular con- nection between auricle and ventricle. Albrecht, in his monograph upon the heart muscle, demon- strated the connection between the papillary system and the cir- cular muscular fibers, and more recently our attention has been called to the further distribution of the bundle of His and iis relation to the fibers of Purkinje in the walls of the ventricle. It is the fact that in the electrocardiogram we have a means of analyzing the course of the stimulus through this intricate mass of muscle tissue in normal as well as in pathologic condi- tions, which makes this new method one of great interest to the physiologist, the pathologist and the clinician. \\'e speak of the stimulation and contraction of the heart as two separate functions. They must be so considered. Xevev- theless, stimulation and contraction are so closely allied, so inti- mately related in time, that for the purpose of clinical research they may in a sense be considered as occurring simultaneously. It is generally impossible to disconnect these two functions in or- dinary cases, such as would come to the obsen-ation of the clini- cian. It should be stated, however, that some recent observations with the electrocardiograph have clearly shown the electric vari- ation waves in the dying heart of lower animals, when active con- traction had ceased, and when nothing more than fibrillary twitcli- ings of the heart muscle could be detected. In the electrocardiogram we see the efifects first, of auricular stimulation ; next, a period in which the stimulus passes through the bundle of His between auricle and ventricle ; then the passage into the papillary system ; next the passage through the circular muscle fibers. Immediately following this is seen a period in which the stimulus passes from the region of the apex of the heart, by means of the external fibers, back to the base of the heart. GREIWE. 151 In the interpretation of most features of the normal electro- cardiogram, investigators have for the most part agreed. There are still many features which must be cleared up before we can be finally satisfied. These relate to the peculiarities of the elec- tric phenomena of the normal variations, and more especially to those cardiograms obtained from pathologic conditions. In this connection it may be well to call attention to an important ob- servation of A. Samojloff, who after stating his own researches, and after analyzing the work of Waller, Einthoven, Krauss and Nikolai, says : "Die Akten iiber die Auffassung der Entstehungs- weise des V'erlaufes des Electrokardiogrammes sind lange noch nicht geschlossen." However, by calling to mind the development of the heart from the primitive tube, and remembering that by means of the curving or twisting of this primitive tube we have the sinus and the aortic bulb, two extremes of the tube, brought in close ap- position, and furthermore having constantly in mind the path of stimulus conduction, we may consider ourselves in a fair way to obtain valuable information concerning the meaning of the electrocardiogram. Let me again emphasize the fact, that although it is plain we are dealing with the release" of electric energy, it is not quite clear whether this release of energy in the form of electrical waves is due to stimulation or contraction. As already stated, the stim- ulus passing through a dying heart, an organ in which active con- tractions are no longer manifest, will still give rise to a well- marked release of electric energy. It is possible that such a heart, in which only fibrillary contractions are seen, is still attempting to contract, and is responding to the stimulus in this manner, and that, as a consequence of the effort, such chemical changes are produced which result in the electric effect. That there is a decided difference in normal and abnormal cases in the electro- cardiograms may be seen in such cases where we have hypertro- phy of certain segments of the heart. It is well known that the left ventricle, when the seat of degenerative lesions such as are seen in arrythmia vera, will show negative variation waves which differ most decidedly from those obtained from the powerfully contracting left ventricle. So, too, Krauss and Nikolai, in study- 152 D A N D R I D G E MEMORIAL ing the electrocardiograms from cases of pure mitral stenosis, show auricular waves so well marked, so prominent in the elec- trocardiograms, that one can safely venture a diagnosis of ste- nosis of the mitral orifice from the appearance of the cardiogram. (No. III.) We may, therefore, from a practical standpoint, con- sider the two functions of stimulation and contraction as so Fig. 3 — After Nikolai. closely allied that in the electrocardiogram they may be consid- ered as occurring synchronously. In the electrocardiograph we have an instrument of precision for measuring the release of electric energy from the function- ating heart. The whole subject is a study of negative variation waves. A tissue whi'^h is absolutely at rest is referred to as iso-elec- tric, and while certain tissues of the body may for a time be at rest, there is constantly present, somewhere in the body, activity of various organs, and more particularly of the constantly -.7- 1 >2 W Electrocardiogram No. III. — Mitral steno- sis with marked A wave. G R E I W E 153 contracting heart, so that electric waves are generated. In other words, action currents are constantly being generated, and by means of appropriate instruments such action currents are re- corded. Any gland in function or any muscle in contraction will produce action currents. It may be important in connection with the analysis of the action currents generated in the heart, to bear in mind the distinction which is made with reference to the dif- ferent effects obtained by stimulating and recording the effects of stimulation and contraction in a muscle which is contracting against a load which it can overcome, and the contracting of a muscle working against a load which it cannot overcome. If a muscle contracts against a load, and a shortening of the muscle occurs, we are dealing with what physiologists speak of as an iso-tonic contraction; whereas, if the muscle contracts against a load constantly increasing in tension, we are dealing with iso-metric contractions. Iso-tonic contractions show negative variation waves, and iso- metric contractions give positive variation waves. Just how far this distinction between negative and positive waves may be interpreted from the point of view of their being iso-tonic or iso-metric remains to be seen. The recording of electric waves generated by the contracting heart is not new. Physiologists have long been ?tcquainted with the work of Waller in experimenting with the exposed heart of the dog. The present work, however, is in so far of the most practical nature that we are able to make use of the former re- search, and by means of the Einthoven string galvanometer we can now record the action currents of the human heart, using the tissues about the heart and the extremities of the body as conductors. To Waller, therefore, belongs the credit of demonstrating the possibility of recording electric waves generated by the acting heart. Waller used the capillary electrometer. The work of Einthoven is based upon the results obtained by Waller, but the instrument devised by Einthoven is much more delicate and re- sponds promptly and effectively to the finest possible variations of the electric waves generated in the heart. Waller called atten- tion to the diagonal position of the heart as giving rise to the pos- 154 DANDRIDGE MEMORIAL nihility of recording the difference in potential between base and apex of the heart. The heart in its diagonal position is sending currents from base and apex to the right and left halves of the body or to the upper and lower parts of the body. The well-known figure by Waller, showing the difference in electrical potential, will be found in all the recent text-books on physiology. The third figure, worked out more definitely by Nikolai, gives the values in figures, and reference to the latter scheme will show II i Fig. 4. — Diagrammatic Scheme of the Electrocardiogram {after Nikolai). H, His bundle; T, circular muscle fibers — Treibwerk; A, auricular wave, J, initial ventricular wave ; F, final ventricular wave. that the greatest difference in potential can be obtained by con- ducting from the mouth and anus. For convenience sake, how- ever, a very decided difference in potential can be obtained by conducting from the right arm, giving a — 4, and the left leg, giving a +3. Even this is somewhat inconvenient, and for clin- ical and practical purposes, when the right arm and left arm are used, we still get a difference of — 4 and -\-2. It has been sug- gested that in important cases one take measurements both as manifested in cardiograms from the right arm and left leg as well as from both arms. (Fig. 3.) When one considers how rapidly the stimulus passes through the complicated heart structure, it will be seen that by the time the electric effects have passed by means of the surrounding GREIWE 155 structures to the surface of the body, the instrument for record- ing such delicate waves must be exceedingly fine and exact. It must have the necessary delicacy to respond promptly to all the finer impulses. It must above all else be aperiodic. To meet these delicate requirements Einthoven has constructed an instru- ment which differs from the usual galvanometer. The great dif- ference, among others, is that whereas in the ordinary galvanom- eter the magnet is the movable part, and the current passes through the spools, the contrary is the case in the Einthoven instrument. Here the current passes through the delicate thread, and the mag- net is fixed as in the D'Arsonval galvanometer. The string, a quartz fiber coated with silver, has the thickness of 0.001 to 0.003 mm. This deHcate thread, suspended by its ends in the middle of an electro-magnetic field, when stimulated, vibrates Hke the string of a string musical instrument. This thread is an exceed- ingly good conductor, and because of its extreme delicacy is found to have practically no weight. As a matter of fact, the thread is so delicate that it can scarcely be seen with the naked eye, and because of this it is illuminated by means of the arc light and magnified by means of the projection microscope. The construction of the Einthoven string galvanometer is a niosi: complicr'ted aft'air, and to those who are interested it may be well to refer to the brochure by Edelman, Jr., of Munich. The essential parts of the instrument are : 1. A delicate platinum thread or quartz fiber coated with sil- ver, suspended in the middle of an electro-magnetic field. 2. This thread is under the control of a micrometer screw, in order to control its tension. 3. It is connected with electrodes coming from some parts of the body, which will allow one to receive the current generated by the contracting heart. 4. The strength of the electro-magnetic field is always under control, so that the weakest currents generated by the heart can be recorded. Furthermore, the thread, being practically invisible to the naked eye, is illuminated by means of ihe arc light, and then, by means of a projection microscope, enlarged and thrown upon the screen, or against an aperture in a photographic instrument. 156 DAN BRIDGE MEMORIAL It is necessary to state also, that not the whole thread, but only- one small point of the vibrating string is photographed in its movements. The string being placed vertically, is seen to vibrate in that position. The slit in front of the sensitive film is placed horizontally, and therefore, as the film unrolls itself vertically, we have this one small point photographed as a shadow, with the result as seen in the annexed electrocardiograms. (Nos. I and II.). These electrocardiograms, taken from strong normal individ- uals, will be seen to have certain points in common, although there must have been some little difference in the tension of the string or in the strength of the electro-magnetic field. Another great advantage in the electrocardiograph of Ein- thoven, consists in the fact that one can measure the action cur- rent of the body generally, and then by sending in a counter- current of like strength one is enabled to deal with the eft'ects of the heart current alone. One may be permitted at this point to call attention to a few general laws in electro-physiology, since they are essential in the proper understanding of the electrocardiograms. Every striped muscle in contraction, as well as every gland tissue in action, gives rise to chemical changes as well as chemi- cal effects. The measure of the difference in electrical potential in two different parts of the structure is referred to as the action current. Furthermore, in every electrically excitable substance, the point of excitation is at the moment of excitation electro- negative, while at the same time all other points of that excitable tissue are considered electro-positive. It will be seen that a num- ber of conditions may arise here. If we had the excitation at a definite point, remaining here and not passing on, simply increas- ing in intensity and then dying out, we would have a so-called monophasic curve. Such a condition evidently does not obtain in the human heart, for we have here not only the function of excitability but also that of conductivity, so that a given point of the heart muscle is at the moment of excitation electro-nega- tive, but the excitation in passing on would render the newly ex- cited points electro-negative and leave the first point of stimu- lation positive. We are therefore dealing no longer with mono- phasic but with diaphasic curves in the electrocardiogram. > u: w GREIWE 157 In the electrocardiograph of Einthoven the right and left arms are immersed in a salt solution, and the current is then in an appropriate manner conveyed to the quartz film in the middle of the electro-magnetic field. With each contraction of the heart one notices upon the screen the vibration of the delicate thread. A study of the electrocardiogram reveals the fact that We have a definite series of waves recorded, sho\ving in the first place the regular path of heart stimulation and contraction ; next, one gets a good idea of the tone or strength of the contraction, not only of the heart as a whole, but of its component parts; one is able, furthermore, to recognize the evidence of myo-degenera- tions, of arrhythmias, of heart-block, of extra systoles and their probable origin. A glance at electrocardiograms Xos. I and II will show at once that there are three distinct waves present in the normal condition. The very small serrations are due to unavoidable twitching of muscle. They may be neglected in the analysis of the electro- cardiogram. It has been definitely established that the first ele- vation is due to activity of the auricle, whereas the second and third elevations are ascribed to ventricular action. These elevations have been referred to by Einthoven and the majority of writers upon this subject as respectively the P., R. and T. elevations, the P. elevation being of auricular origin and the R. and T. elevations arising from the ventricles. There can no longer be any question as to the correctness of these views, since Samojloflf demonstrated in the animal heart the effects, first, of stimulation from auricle and ventricle, and then, after obtain- ing his cardiogram in this manner, followed by stimulating the ventricles alone, without auricle excitation, obtaining only in the second experiment the R. and T. waves without any evidence of the auricular wave. Thus far all are agreed as to the results to be read in the electrocardiograms. The P. waves of Einthoven are thus seen to be due to auricular action. Immediately after the P. elevation one notices a very small period of rest, between the P. wave and the R. wave. According to the researches of Nikolai, we are to look upon this period of the electrocardiogram as indicating the passage of the stimulus through the bundle of His from the auri- 158 DANDRIDGE MEMORIAL cle to the ventricle. The stunulus, according to the now accepted views of physiologists, then passes to the papillary system, and at once a powerful contraction takes place, resulting in the very pronounced R wave, a wave called by Nikolai, in his newer des- ignation as the Y wave, or the initial ventricular wave. Having passed through the papillary system, the next effect should be expected from the now known path of conduction in a contraction of the circular muscle fibers, from the Treibwerk, as designated by the Germans. The circular muscle fibers are peculiarly situated, and we are told that the dift'erence in poten- tial does not express itself in the electrocardiogram. These fibers have no tendinous attachments, they end in one another, and are in a measure continuous with one another. The result is that we have in the electrocardiogram a comparative period of rest, or at least a period not expressed by a distinct elevation. We are to look upon the straight line between the R and T elevations as expressing the time of activity of the circular muscle fibers of the heart. Immediately after this period we get the final ventricular con- traction in the elevation T, which expresses the time of the pass- age of the stimulus from apex back to base of heart. Nikolai proposes to alter the terms P, R and T elevations, and designate these periods by terms which are at the same time immediately expressive of what is actually occurring. (Electro- cardiogram No. II.) It will be of interest here to give the diagrammatic representa- tion of the electrocardiogram according to Nikolai. (Fig. 4.) The further advantage of such figures may be that of fixing in mind the path of the heart stimulus and the successive events in the cardiac cycle. Through the courtesy of Prof. Krauss and Dr. Nikolai it was my privilege to spend a short time in the laboratory of the Charite in Berlin. During that time experiments were being made prin- cipally upon patients who were the subjects of valvular lesions. It is remarkable to note with what exactness certain features were constantly found to repeat themselves in cases of mitral stenosis, mitral regurgitation, aortic regurgitation, etc. More especially is this true with reference to the hypertrophy of the GREIWE 159 auricle in mitral stenosis, which may be seen in the electrocardio- gram No. III. The auricular wave is exaggerated, and it is almost as well expressed as the initial ventricular wave. It is so constant a fea- ture in uncomplicated cases of mitral stenosis, that the diagnosis was made from the cardiogram, and then finally confirmed by the later physical examination. In cases of uncomplicated mitral regurgitation there was found present a condition as shown in electrocardiogram No. IV. There is a most marked drop after the R wave, or the initial ventricular wave of Nikolai. The final wave in this case is clear and distinct, and may be taken as a sign of perfect compensation on the part of the left ventricle. Just why the drop below ihe base line should occur is not clear. There is still much dispute as to the origin and meaning of this efifect, and further time must be given to its elucidation. I give here another electrocardio- gram from a case of myo-degeneration, showing the weakness of the whole heart, and more particularly degeneration in the ventricles.i We have here not only an arrhythmia as to time, but also as to strength and tone of the ventricle. (Fig. V.) The results of work wath the cardiogram so far demonstrate that it will not only be used in physiological laboratories, but a sufficient number of important clinical observations have been made, more particularly by Krauss and Nikolai, to assure us of its proper field in clinical medicine. A complete review of the literature and an exhaustive work, theoretic part by Nikolai and clinical part bv Krauss. has just ap- peared in the German press. The work emphasizes the impor- tance of the electrocardiogram from the standpoint of the physi- ologist and the clinician as well. THE OVA OF SCHISTOSOMA JAPONICUM AND THE ABSENCE OF SPINES.* BY PAUL G. WOOLLEY^ M.D., AND OTTO V. HUFFMANN^ M.D. The observations recently set forth by Dr. Leiper^, and by Dr. Sambon in a discussion^, have led us to re-examine the ova of 6'. japonicum in the material which we have at hand. This ma- terial was described previously by one of us- together with a report of some comparative measurements of the ova of this species of trematode furnished by Dr. Shiga. We have now re-examined carefully several hundred ova in stained sections of tissues and a great number of others which we have teased free from unstained tissues which have been well preserved in Kaiserling's solution. In no instance did we find the least appearance of a blunt protuberance or spine on the outer envelope of the egg. In one or two instances the embryo itself caused a slight protuberance about the size of the spine repre- sented in Dr. Leiper's microphotograph, but without any of the other characteristic points reported by Dr. Leiper — for instance the thickening of the envelope about the protuberance. When examining the ova of 5". nmnsoni we have never ex- perienced any difficulty in recognizing the lateral spines, and if the blunt lateral spine of 5". japonicum, as depicted by Dr. Leiper, is a distinctive characteristic we should have been able to recog- nize it in the present series of examinations, even though we had overlooked it in an equally large number of examinations upon which our original measurements were based. With regard to the similarity of these ova and those of 'Anchylostoma diiodetiale: the ova of the latter are more nearly ovoid, while those of 5*. japonicum are somewhat flattened, so *From Parasitology, vol. iv, No. 2, July 18, 1911. 161 162 DA >' BRIDGE MEMORIAL that we would hardly speak of rolling them under the cover glass but rather of turning them over. REFERENCES. 1. Leiper, R. T. Cm, 1911). Note on the presence of a lateral spine in the eggs of Schistosomum japonicum. Trans. Sec. Trop. Med. and Hyg. iv, p. 133. (Discussion, p. 135.) 2. WooUey, P. G. (i. 1906). The occurrence of Schistosoma japonicuni vel cattoi in the Philippine Islands. Philippine Journal Science, i, p. 83. HAIRY OR BLACK TONGUE.* BY M. L, HEIDINGSFELD, M.D. The subject of hairy or black tongue has engrossed a varied de- gree of attention in dermatologic Hterature. A comparatively large number of the cases, chiefly from French and English sources, were reported at the time of the discovery and early mention of the affection. Brosin^ recorded some forty odd cases reported prior to 1888. The next large increment of cases oc- curred when investigators first took issue in regard to its para- sitic or non-parasitic nature, which has remained a more or less unsettled point of contention to the present day. Relatively few cases have been reported in recent years, not so much because the affection is possibly more rare or exceedingly infrequent, as be- cause little additional infonnation could be offered regarding its etiology, pathology and treatment. There are scarcely a hundred cases recorded in the literature at the present time, and if the spurious and unauthenticated cases were eliminated the remain- der would probably not total much more than half that number. The earliest report of the affection probably emanates from Rayer,- who in 1835 described, under the name discolorations pig- inentaires, several cases of black discoloration of the dorsal sur- face of the tongue. Eulenberg^ in 1853 described a black-coated tongue {eine schwarae Zwigenbeiag) in a two-year-old child af- fected with diarrhea, which persisted for several months. He first called attention to involvement of the filiform papillae, a fea- ture more carefully elaborated later by Gubler.* St. Germain^' in 1855 reported some transient cases of short duration in de- bilitated individuals, under the name nigrite de la langue. Ray- naud*' in 1869 independently described several cases as a new af- * Read in the Section on Dermatology of the American Medical Asso- ciation, at the sixty-first annual session, held at St. Louis, June. 1910, and reprinted from The Journal of the American Medical Association, Decem- ber 17, 1910, vol. Iv, pp. 2117-2123. 163 164 DANDRIDGE MEMORIAL fection, and first ascribed the condition to a parasitic cause. He pictured mycelia and spores unlike any previously described. As soon as Raynaud attributed a parasitic etiology, interest in the affection materially increased. Gallois^ was unable to confirm Raynaud's observations, and Richter^ states that he had observed the tongue epithelium to develop into thick, black, cylindrical "turf" (Rasen) without ever being able to discover Raynaud's fungus. FereoP likewise found no evidence of spores in his case and stated that their presence in hairy tongue must be of accidental rather than etiologic character. He considered the hypertrophy of the filiform papillae the essential pathologic fea- ture, and called the affection I'hypertrophie epitheliale filiforme. Within a few years Laveau,^" Lan^.ereaux^^ and Dessois^- reported some cases with which they confirmed Raynaud's parasitic etiol- ogy. Dessois attempted to confirm the parasitic nature of the affection by inoculation experiments on his own tongue, which, however, proved negative in character. He named the affection glossophytie. Rayer reported that not only were inoculation ex- periments negative, but morphologically similar spores were pres- ent on normal tongues. Pellarez,^^ a Spaniard, erroneously re- garded the condition as a vegetating growth, and Salter^* as- cribed the discoloration to an anomaly of pigmentation. Butlin" believed the fungi normally found in the mouth could, under special conditions, impart a black discoloration to the coating of a tongue. Schech^® described the discoloration under the micro- scope as light to dark brown and diffusely distributed over the hairs, without being interspersed with sharp, distinct accumula- tions of pigment or areas free from pigment. The hairs con- sisted of thickly crowded masses of long, thin epidermic cells, with a marked tendency to bristle and branch at the borders. They set forth the greatly enlarged, cornified and pigmented fili- form papillae. A remarkable feature was the absence of fine granular masses of cocci, bacilli and leptothrix, which are a part of the normal coating of the tongue. Schech found no evidence of fungi to support Dessois, and Sell was obliged to retract his former expressed views regarding its myotic character. Brosin^ regarded the affection as a hypertrophy of the papillae filiformes, with abnormal pigmentation and keratosis of the affected tissue. Fk;. 1. — SpeciniL'ns from patient with hairy or lihick tongue: A, separated from each other at the extremity; appearance, tuft -like; a single hair composed of several clcsely united shafts; B, stained hair of consider- al)le size; C. unstaired lilament coated with loose masses, composed largely of micro-organisms; D. hair resembling in appearance a stalk of Indian corn; K, one-half of hair measuring three-fourths inch; ten- fold magnification. HEIDINGSFELD 165 This view was supported by Rosenberg/^ Rydygier/^ WoUer- and/" Surmond-'^ and others, and their studies revealed the pres- ence of many forms of micro-organisms of incidental and non- pathogenic significance. Those who have confirmed the parasitic nature of the affec- tion in more recent years are Roth,-^ who found a micro-organ- ism abundantly present in two cases, to which he attributed the discoloration, and called the affection a keratomycosis. Dinkier-^ disclosed the presence of a filiform bacillus, but was unable to cultivate it. Lake"^ detected the presence of round spores. Ciag- linski and Hawelke^* and Sendziak-'^ were able to cultivate a black fungus to which they attributed etiologic importance, but only at room — not at body — ^temperature. Rosiowjew-® describes in his two cases, in addition to the ordinary mouth bacteria, a pecu- liar cladothrix, the cultures of which were black. Much infec- tious significance is attributed by Rostowjew to the occurrence of the affection in husband and wife. GottheiP^ illustrates the spores in his case, which showed only a black discoloration of the tongue, without a coat of hair-like prolongations. Lucet-^ describes the presence of small round or oval double contoured, highly refractive bodies, with hyaline or finely granular contents. They stained with compound solution of iodine and grew luxuri- antly on 5 per cent, glucose agar at '^7° C. Inoculation experi- ments on rabbit tongues were negative. Gottheil named the fun- gus Sac char omyces linguce pilosoR. Gaston and Laselet"* believed that the cause of the black discoloration was a fungus which they successfully cultivated. Gueguen^° is the latest observer to at- tribute this affection to a hitherto undescribed organism, the Oospora lingiialis. Equally large is the number of present-day observers and investigators who either ignore or regard as unten- able the theory of the parasitic origin of the affection and attrib- ute it to other causes. Levisseur^^ attributed the cause in his case to use of silver nitrate and chromic acid in the treatment of syphilitic plaques. SchnabeP^ and Schourp^^ regard the affection as a common one among syphilitics, dyspeptics and tobacco users. Audry and Dalous^"* and Hallopeau^^ have observed the affection in cases of Darier's disease. Mourek,^^ in his carefully reported and investigated case, states that micro-organisms were found 166 DANDRIDGE MEMORIAL sparingly and gave no evidence of anything of characteristic sig- nificance. The bacteriologic investigation was of negative char- acter. He believed the process is a hyperkeratosis and the dis- coloration the result of contact with food and other extraneous products. The epithelial cells cohered and became mechanically discolored, as in other keratotic affections of the skin. Vollmer^^ states that though the etiology and mode of production are ob- scure, he is of the opinion that syphilis, mercuriaiization, strong disinfectants, tobacco, etc., are predisposing factors. He regards the parasitic etiology as untenable. REPORT OF CASES. Case L— On May 25, 1909, Mr. A. D., aged eighty-five, was referred to my attention for a peculiar discoloration of the tongue, v/hich was the site of severe subjective pam and discom- fort. Examination revealed a brownish-black discoloration ex- tending anteriorly from the circumvallate papilla to within al- most one inch of its tip and one-half inch of the right lateral bor- der. The affected area was irregularly elliptical in outline, situ- ated for the most part on the right side of the tongue, but slightly transgressed the median line at its middle third. The patch was black at its center, with borders that gradually faded from brown- ish-black to yellowish brown. The remainder of the tongue and the mucous membranes of the mouth were bright red and normal in appearance. Salivation was very marked, and the patient com- plained severely of intense pain in the tongue, which v^-as also re- ferred to the ears. The patch was thickly covered with a soft, felt-like coating of hair-like processes, which on more careful examination and inspection were found to be inextricably inter- woven and matted together, in the manner of "a field of grain laid low by storm and wind," as previously described by Gubler, Raynaud, Stokes and Lake. An abundance of long hairy fila- ments, some of which measured three-fourths of an inch in length, could be readily removed with thumb forceps. The patient, an intelligent German, stated that his personal attention was first directed to his tongue some two months prior to the time of the examination, by pain and a sense of soreness in the tongue, and the black discoloration was then in evidence in its present un- changed form. No history of its incipiency or probable duration was obtainable. Biopsy. — On May 28 a biopsy was made for histologic study. Patient was observed daily. The pain became more intense and salivation more marked. On June 3 a marked swelling mani- Fic;. 2. — Hair-like tilameiits cut vertically and longitudinall}- to their long axis. Many intertwined filaments cut obliquely and transversely. Fila- ments reach ujnvard and forward in irregular parallels. Fig. 3. — Papilla-like bodies within the rete Malpis^hii : pro])al)le origin n hair-like filaments. H E I D I N G S F E L D 167 fested itself at the left lateral border of the tongue near its mid- dle third and remote from the hairy involvement ; the mass, which was deep-seated in origin, was firm and hard in consistence, ir- regular in outline. The lesion was diagnosed as an epithelioma and the case referred to a surgeon. The subsequent history con- firmed this diagnosis. As soon as ulceration took place the pa- tient experienced some sense of relief from his distressing pain. On February 15, 1910, the bed-ridden patient was still alive, al- though the disease had made great inroads on his previous fairly robust constitution ; death eventually took place March 5, 1910. The complicating malignant growth in this case was without ques- tion a mere coincidence, and has its analogue in the case of a forty-nine-year-old brickmaker, reported by Lediard, who had an epithelioma at the tip of the tongue, remote from the patho- logic hairy area. Case II. — R. K., aged nineteen, was first seen in consultation April 6, 1905. Patient stated that three months previously he noted an abnormal sensation in the tongue, resembling the pres- ence of a foreign body on the surface which could not be dis- lodged. On looking into a mirror he noted for the first time the black discoloration, became alarmed and forthwith brought the condition to the attention of his physician. The examination re- vealed an intense blackish discoloration of the tongue, with bor- ders imperceptibly fading to brownish-yellow, occupying a tri- angular area, extending from the circumvallate papillae anteriorly along the median dorsal surface of the tongue almost to its tip and lateral borders. The same soft felt-like coating of matted hair-like processes was observed as in the previous case, and a specimen was removed and preserved in alcohol for histologic examination. Pain and distress were entirely absent, and there were no subjective symptoms except as already noted. Patient was last observed on January 15, 1910, and during the interven- ing five years no appreciable change was detef^ted in the clinical appearance of the tongue. Patient persistently refused a biopsy, but readily permitted the removal of large numbers of hairy pro- cesses, some of which measured fully three-fourths of an inch in length. Syphilis was absent, and there was no history of drug- taking or the use of caustic or astringent applications. In addition to these two well-defined clinical cases, it has been my privilege to observe several rases of less marked character in connection with conditions of general dermatologic interest. The patients were, almost without exception, unaware of, or at least indifferent to, the manifestations on the part of the tongue, which were revealed merely by process of routine examination, and 168 DANDRIDGE MEMORIAL doubtless would have been dismissed with passing notice had not the unusual interest of the condition been understood. In most cases there was at least a moderate amount of felt-like covering, of hairy growth, in addition to the brownish or blackish discol- oration, and hairs from one-eighth to one-fourth of an inch could be readily removed and floated in water or alcohol. In some cases there was mere discoloration without an associated hairy growth, as reported by Gottheil, Stokes, Ciaglinski and Hewelke and Sendziak. This discoloration was soft, mushy in character, and could be freely but somewhat incompletely removed by light scraping. The cases occurred for the most part in early syphi- litics, and were observed in the process of the examination of the tongue for the presence or absence of mucous plaques, or the coated or non-coated state of the tongue in non-syphilitics. All of the cases occurred in males. Most, but not all, of the S3^ph- ilitics were using at the time astringent and antiseptic mouth lo- tions. The patches disappeared, however, in some of the cases, in spite of the persistent use of the astringent antiseptic mouth lotions. One patient, affected with gonorrhea but not with syphilis, was taking sandalwood oil internally, but the patch persisted for some time after the internal administration of the oil was with- drawn. It disappeared entirely after a lapse of several months. In two cases syphilitic infection was of long standing; one patient had an extensive leukoplakia of the tongue, and these areas were free from the yellowish-brown discoloration, which occupied an irregularly oval area near the center, anterior to the circumvallate papillae. Most, but not all, of the cases occurred in patients who used tobacco immoderately. Dietary indiscre- tions and gastrointestinal disturbances were in evidence in the majority, but not in all of the cases. The patches were evanes- cent and transient in all the cases, fading or disappearing with- out treatment or attention, and occasionally relapsing from un- toward local or general influences. These cases lacked the clean- cut clinical characteristic's of the first two well-defined cases, in which the color was more intense, the hairs longer, more numer- ous and interwoven, the patches thicker, more fur-like and sharply defined, and more persistent and stable in character. I / Fi :;. 4. — The same napilla-like bodies cut transversely and imparting tlu appearance of epithelial nests clustered in circles. Fi!'.. 5. — Su|)erricial urisjin tit the iiair-like rdament> H E I D I N G S F E [. D 169 am inclined to believe that several of the cases reported in the literature belong to this second class of — if I may be pardoned the term — spurious or pseudo cases. Microscopic Examination. — The microscopic appearance of the hairy-like filaments was fairly constant, when compared with each other and with those described in the literature. Specimens from the pseudo or spurious cases could not be diflferentiated microscopically, except for length and thickness, from those of the two well-defined ones. Specimens unstained and stained bv various methods were examined ; the unstained specimens for the most part showed a more regular and better preserved outline. The color of the unstained specimens is a diffuse yellowish- brown, as already noted by Schech, Mourek and others. The outline is an elongated cylinder, hair-like in general ap- pearance. The resemblance to a hair is accentuated in many in- stances by the presence of a zone analogous to the medullary canal. In many there are several of these zones of varying color intensity, and on close examination they are found to owe their presence to the fact that a single filament is often composed of two or more closely united shafts. These shafts are united the greater part of their entire length ; they become separate and distinct from each other a short distance from the distal extrem- ity, imparting a peculiar tuft-like appearance, not altogether un- like that observed in a pineapple (Fig. 1, A). Occasionally one of the united shafts will become dissociated at some more median point, and impart an appearance not altogether unlike that of the leaf to a stalk of Indian corn (Fig. 1, D). The resemblance to Indian corn becomes more marked if there are several lateral dis- sociations. Lateral deviations have been noticed by S^^hech and other early observers. On closer examination under higher magnifi- cation, the filaments are observed to be composed of thin, non- nucleated, stratified closely su'^erimposed epithelial cells. Their cornified, non-nucleated character can be confirmed if the fila- ments are macerated with gentle heat in a solution of potassium h^^droxid. The individual cells are superimposed in such a way as to produce serrated borders ; the serrations are constantly di- rected downward, producing a peculiar tesselated eflfect. which can be compared to the scales on the surface of a pineapple. This imbricated character has been frequently noted in the literature; it is not marked enough to conjure up the resemblance of a row of inverted funnels, as described by Brosin, nor is their order, as he states, ever reversed, so that they partake of the appearance of a harpoon or trident. For similar reasons, the spike-like ap- 170 DAN BRIDGE MEMORIAL pearance or resemblance to the head of a wheat-stalk, described by Mourek, is not to be discerned ; surface indentations were not observed to recall the "corncob" effect describe! by Levisseur. The serrations at the border are directed toward the base, and away from the rounded and cleft extremities, constantly enough to permit a ready differentiation of the distal from the proximal ■extremity. In well-stained specimens the filaments were observed under oil-immersion to be thickly studded wdth masses of cocci, which morphologically resembled the common pus germs. They were present in exceedino-ly large numbers, were intracellular and ex- tracellular, and often in such density as to resemble pure cul- tures of the common staphylococci. Larger and more deeply stained cocci and diplococci were interspersed here and there together with bacilli, leptothrix, and various forms of organisms commonly found in the mouth. In addition to the various stained micro-organisms, a few large, round, highly refractive, double- contoured bodies, some larger, some smaller, often in such prox- imity as to impart a budding character, were observed here and there in most of the specimens examined. They were not numer- ous enough to assume pathogenic importance, and to all appear- ances their presence partook of a coincidental character. Some unrecognizable fungi and micro-organisms were also observed ; the micrococci, however, predominated greatly over all other forms. Culture Exf>criuients. — Culture experiments were attempted in both genuine and spurious cases. The affected surfaces were carefully sponged with ether and a 5 per cent, glucose agar; nu- trient agar and blood-serum were carefully inoculated with re- moved filaments and nlatinum loon inoculations from the affected area. Some of the cultures were kept at 38° C, others at room temperature. The cultures uniformly remained sterile or became the seat of innumerable, small, glistening, white, superficial colonies, which morphologically and microscopically resembled in every particu- lar Staphylococcus albus. No fungus was evident even on pro- longed standing in any of the cultures examined. Histology. — A biopsy was obtained only in Case I, and the histologic report with accompanying illustrations is the first, to my knowledge, to he recorded for the affection. Under low power, the filaments when cut vertically and longitudinally to their long axis, are observed to reach upward and forward in ir- regular parallels (Fig. 2). Many of the intertwined filaments are cut transversely and obliquely. The filaments preserve for them- selves a feather-like appearance. When cut transversely to their long axis their continuity is preserved only a short distance, and ¥u.. 6. — Blood cavity strongly magnified, showing its intra-epithelial posi- tion. Cavity is lined with a layer of endothelial cells. Fk;. '. — Small 1)lood cavity within ilu cin.irrmis witli areas of edematous and degeneratetl epithelial cells at the rete papillary border. HEIDI NGSFELD 171 most of them appear as small, round or oblique fragments. The filaments can often be directly traced to their origin from papilla- like projections of the stratum corneum. The stratum corneum elongations promptly take on a fringe of serrated, more loosely arranged and deeper staining cells; ihey often coalesce within a short distance of their proximal extremities with one or more adjacent filaments, to form double, triple or quadruple filaments. Acanthosis is another, marked pathologic feature. The rete and the papillae are considerably hypertrophied, and there is a very extensive downward prolongation of almost every fourth, fifth or sixth interpapillary process of the rete ^Nlalpighi. The lower layer of columnar cells is sharply defined, well preserved and in a state of active proliferation. The pars papillaris and subjacent tissue are entirely devoid of any marked pathologic change save a diftused, mild infiltration of inflammatory products, tlie dis- tribution of which is limited almost exclusively to the pars pap- illaris. One of the most striking pathologic changes, and possibly second in importance only to the fidaments, is the formation of papilla-like bodies within the rete Malpighii (Fig. 3). They are differentiated from the rete, in Vv'hich they are situated, by a well- defined layer of more deeply stained columnar basal ceils. Their well-defined interpapillar}' spaces are devoid of fibro-connective tissue and filled with epithelial cells of the rete. They are ftir- ther differentiated from normal papilhe by their diminutive type. If cut obliquely or on cross section, they partake of the appear- ance of epithelial nests (Fig. 4), and it is not unusual to note six to twelve or more of such nests clustered in a circle. If cut longitudinally thev can be traced directly to the surface to points where the filaments take their origin (Fig. 5). Having assumed that these intra-epitheliuni placed papillae are the origin of the hairs, I have termed them "epithelial founts." The stratum corneum is more or less imperfectly preserved. In some pLices it is of normal thickness, structure and staining properties, and covers a fair extent of surface. In places it is almost entirely lacking, and, when present, rises perpendicularly from the surface to form the proximal extremities of the hair- like filaments. Where it is preserved, it is often covered or par- tially covered with a thick layer of partially stratified, nucleated epithelial cells. Groups of degenerated cells are occasionally ob- served at the tips of the papillae or in the epidermis near the pap- illary border (Fig. 6). These cells are often surrounded by a single layer of endothelial cells ; their yellowish color, small ho- mogeneous appearance, angular otitline, with interspersed darkly- stained lymphocytes, indicate that they are blood accumulation^. 172 DAN BRIDGE MEMORIAL Inasmuch as such accumulations have been observed and recorded in the corneous substance of cutaneous horns by Joseph and others, the analogy is plausible. These "blood-cavities" and the rete-papillary border occasionally contain large rounded, hyaline or faintly granular double culture bodies, which are apparently cell degenerations rather than pathogenic spores, although they bear a morphologic resemblance to spores to which pathogenic importance has been attributed (Fig. 7). They are often em- bedded in a mass of large, edematous vacuolated cells situated at the papillary border of the epidermis, which resemble the de- generative cell changes in Paget's disease. The pathology cannot be dismissed without a brief compara- tive reference to cutaneous horns, ichthyosis hystrix, leptothrix and hair. The histopathologic similarity which some of these affections bear to hairy tongue is remarkable to the degree with which their clinical characteristics are dissimilar; and vice versa, the affections which preserve the greatest degree of clinical re- semblance show the least histopathologic resemblance. Cutane- ous horns, which have little or nothing in common with hairy tongue, have much in common pathologically. They are com- posed of masses of cornified, or at least partially stratified, epi- thelial cells, arranged with wonderful cohesion into dense elon- gated columns, row after row, separated by valley-like clefts re- sembling the medullated canals of hair. Intra-epithelial spaces containing blood are also observed. The origin is purely epi- dermal, and the base rests on and is apparently developed from intra-epithelially placed papillae and interpapillary processes rest- ing above the area of the true papillae, and true interpapillary processes, unless the latter have disappeared from pressure atro- phy. The former papillae and interpapillary processes corre- spond to the intra-epithelially placed "epithelial founts" of hairy tongue. Ichthyosis hystrix, which preserves possibly more clinical than histopathologic resemblance to hairy tongue, preserves little his- tologic similarity except a marked hyperkeratosis. The hyper- keratosis, however, is arranged parallel rather than perpendicular to the surface, and the spinous processes are the result of kera- totic accumulations spread irregularly over the surface of four or five hypertrophied papillae. The inflammatory exudate is more H E 1 D I N G S F E L D 173 perivascular, less diffused in character and more circumscribed to the capillary vessels of the pars papillaris. Leptothrix, which has little or .nothing clinically in common with hairy tongue, shows a striking resemblance under the mi- croscope, in that the affected hairs are coated with an accumu- lation of loosely adherent cells and detritus containing myriads of micrococci and other micro-organisms. The morphologic resem- blance, under the microscope, of hair affected with leptothrix to the filaments of hairy tongue is very striking. An additional point of resemblance is the discoloration, which in leptothrix is often yellow or red, and in hairy tongue black to brownish-yellow, Pathogenically there can be little in common in the two aff'ec- tions. The gross clinical resemblance which filaments bear to hair is striking enough and gives the affection a misnomer. Remark- able in many of its microscopic features, the resemblance is micro- scopically and histopathogenically a paradox that requires no comment. In origin, development, essentials of structure and pathogenesis they naturally share nothing in common with hair. GENERAL DEDUCTIONS. Hairy tongue can be conveniently divided into two general classes : ( 1 ) True, idiopathic, or genuine cases, characterized by well-defined stable, black-brown or yellow-brown, thick, soft, fur- like patches covered with densely intertwined hair-like filaments, easily measuring from one-fourth to one-half inch in length; and (2) false, pseudo or spurious cases, characterized by thickish, yel- low-brown or greenish discolorations, of unstable, evanescent character, covered with a soft mushy detritus, occasionally con- taining short filaments measuring one-eighth to one-fourth of an inch in length. The true cases owe their origin to some anomaly of development, probably of congenital nature, in the sense that the germinal products from which they are developed are pres- ent from birth, but do not undergo growth and developmental changes until early adolescence or some later period in life. Such an origin is assumed and very generally conceded for moles, vas- cular, pigmented papillomatous and unilateral nevi, cutaneous homs,^® etc., and can be extended with equal propriety to this affection, all the more since the histopathology reveals an anom- 174 DAN BRIDGE MEMORIAL aly of development (whose striking similarity to cutaneous horns has already been alluded to) rather than any evidence of an in- fectious or inflammatory nature. An anomalous development and congenital origin is further evidenced by the fact that the true, idiopathic or genuine cases are of stable character, and re- main unchanged in size and form for indefinite periods, and are localized to definite areas. Such would not likely be the case if they were of infectious origin or inflammatory character result- ing from local or general causes. The pseudo or spurious cases are unstable and evanescent, and probably owe their origin to such local or general irritating and infectious causes as tobacco, antiseptics, astringents, syphi- lis, etc. The presence of the filaments is probably due to an in- flammatory hypertrophy of the papillae fiii formes. These cases in varying degrees of intensity can be frequently noted, partic- ularly in the early stages of syphilis, and constitute no uncom- mon affection. The diagnosis can be easily confirmed by remov- ing some of the grumous coating of the discolored tongues by means of fine forceps, and floating it in clear water or alcohol. The hair-like filaments can then be readily seen with the naked eye. The majority of cases recorded in literature probably be- long to this group. A parasitic origin for the affection could not be established either on clinical, histopathologic or bacteriologic grounds ; it does not develop or spread clinically like a parasitic affection. Inoculation experiments were negative in the sense that the affections could not be distributed to other unaffected parts of the tongue. It failed to spread to the abrasions and ex- coriations of an intercurrent cancer of the tongue. The histo- pathology reveals chiefly anomalous structural changes, and the absence of the marked inflammatory changes generally incident to chronic and acute infectious and localized irritations. The fundamental abnormality is the presence of abnormal papillae and interpapillary pro'^esses or "filament founts" situated within the epidermis, from which the abnormally elongated, stratified and keratosed filaments trace their direct origin. Some of the basal '"ells at the papillary-rete border showed vacuolated and edema- tous change, to which, however, no especial significance could be attributed. The filaments were freely studded with micro-organ- H E I D I N G S F E L D 175 isms which resembled Staphylococcus albus morphologically, to which likewise no special significance could be attached. A few double-contoured bodies were occasionally observed among the filaments and in the deeper structures, to which no important sig- nificance was attributed. The bacteriologic findings were, as already stated, sufficiently negative in character to preclude, in my opinion, a parasiti" etiology for the aflfection. REFERENXES. 1 Brosin : Monatsh. f. prakt. Dermat., 1888, vii, No. 1, Erganzh., p. 5. 2 Rayer : Traite theorique et pratique des maladies de la peau, 1835, iii, 573, article Nigrite. 3 Eulenberg: Arch, physiol. Heilk., 1853, xvi, 490. 4 Gubler : Bouche (Semeilogie) Diet, de Dechambre, 1869; quoted by Brosin : Note 1. 5 St. Germain : Comptes rend. Acad. d. Sc, 1855, March 28. 6 Reynaud : Seance de la Soc. med. d. Hop., February 26, 1869. 7 Gallois : Seance de la Soc. de Biologic, August 7, 1869. 8 Richter: Krankenmachende Schmarotzepilze, Schmidt's Jahrb., 1871, cli. 9 Fereol : Seance de la Soc. med. d. Hop., June 25. 1875. 10 Laveau : De la langue noire, These de doctorat, Paris, 1876; quoted by Brosin, Note 1. 11 Lancereaux : Seance de la Soc. med. d. Hop., December 8, 1876. 12 Dessois : De la langue noire. These de doctorat, Paris, 1878; quoted by Brosin, Note 1. 13 Pelarez: Gac. med. dc Paris, 1879, No. 52 (abst.). 14 Salter : Todd's Encyclopedia of Anatomy and Physiology, 1852, No. 6. 15 Butlin : Diseases of the Tongue, 1885, p. 31. 16 Schech: Miinch. med. IVoch., 1887, No. 14, April 5. 17 Rosenberg: Quoted by Mourek, Arch. f. Derm. u. Sxph., 1894, xxix, 369. 18 Rydygier : Beitrag zur selteneren Erkrank. der Zunge. Arch. f. klin. Chir., 1891. No. 41, p. 767. 19 Wollerand : Sur la langue noire papillaire, Vircliozv's Arch. f. path. Ana'., XXV. 2(i Surmond : La langue noire, Gaz. d. Hop., 1891. 21 Roth: Wien.. med. Prcsse, 1887, p. 935. 22 Dinkier : Ein Beitrag zur Pathologic der sogenannten schwarzen Haar-Zunge. Virchow's Arch. f. path. Anat., cxviii. 23 Lake: Black Tongue, Brk. Med. Jour.. 1891. p. 946. 24 Ciaglinski and Hawelke : Beitrag zu einer seltenen Erkrankung der Zunge. Zeitschrift f. klin. Med.. 1893, xxii, 626. 25 Sendziak: Beitrag zur Etiologie der sogenannten Schwarzen-Zunge. Moiiatslieft f. OJirenheilkunde, 1894, xxviii, 112. 26 Rostowjew: Hospitalz. Botkin, 1896. No. 8. 27 Gottheil: Arch. f. Pediat., 1889, p. 255. 28 Lucet: Arch, de Parasitol, Mav 20, 1901. 29 Gastou and Laselet : Tr. de Soc. Franc, de Dermat. et de Syph., March 18. 1909, xx. No. 5. 30 Gueguen : Arch, de Parasitol, 1909, xii. No. 8. 31 Levissenr: Ne^o York State Med. Journal, 1899, xlix, 42. 176 DANDRIDGE MEMORIAL 32 Schnabel : Haar-Zunge, Inaug. Dissert., Leipzig, 1904. 33 Schourp : Monatschr. f. Harnkr. u. sex. Hyg., in, No. 2. 34 Audry and Dalous: Jour, de mal. cutan., 1904, xvi, 801. 35 Hallopeau: Ann de Dermaf. et de Syph., 1896, series 3, vn, 744. 36 Mourek: Arch. f. Dermat. u. Syph., 1894, xxix, 369. 37 Vollmer: Arch. f. Dermat. u. Syph., 1898, xlvi, 13. 38 Philip : Momtsh. f. prakt. Dermat., 1904, xxxix, 630. HAND INFECTION APPARENTLY DUE TO BACILLUS FUSIFORMIS.* BY WILLIAM H. PETERS. While the actual role of Bacillus fusiformis in the production of lesions in the human body is still suhjudice, we cannot fail to recognize its importance as a factor, if we glance at the in- creased number of pathologic lesions from which it has been iso- lated. The organism has been observed in ulcero-membranous angina, hospital gangrene, noma, appendicitis, diphtheria, fetid bronchitis, gangrenous laryngitis, pyorrhea alveolaris, brain ab- scess and in the healthy mouth. According to Jungano and Distaso,^ Plant first described it in 1894 in a case of ulcerous angina, while Veillon and Zuber were probably the first to isolate the bacillus in pure culture. Vin- cent's descriptions appeared about two years after Plant's. The organism has been grown in pure culture by Ellerman, Weaver,- Tunnicliff,^ Leucowitz, Leiner, Repaci, and Ghon and Mucha. Five cases of unusual infection with fusiform bacilli and spi- rochsetes have been studied by me. Case I. — S. F., male aged four, was admitted to the Cincin- nati Hospital October 5, 1909. He had a typical lobar pneumo- nia with delayed resolution, which was followed by an abscess of the lung. Death ensued sixteen days after admission. Smear preparations of the pus obtained before death from the thorax, by aspiration, revealed fusiform bacilli and spirochsetes in great numbers and streptococci. The fusiform bacilli measured from 2.7 /x to 7.0 /i. by 0.5 /x. Apparently two varieties of spirochgetes were observed ; thick ones with irregular, loose windings, corre- sponding to the refringens type, and others composed of two or three turns and of regular amplitude. The same organisms were found in the sputum, together with a third type of spiro- chaete, viz., dentium. * Reprinted from The Journal of Infectious Diseases, vol. viii, No. 4. June, 1911, pp. 455-462. 177 178 DAN BRIDGE MEMORIAL Case II. — P. S., a white male, aged forty-five, was admitted to the Cincinnati Hospital October 3, 1910, with marked dyspnea, laryngeal stridor and an irregular pulse. He died one hour after admission. Post-mortem examination revealed a syphilitic ulceration and edema of the larynx and trachea and other ter- tiary lesions. Cover-slip preparations were made from the ulcer at the base of the larynx, demonstrating fusiform bacilli resem- bling those described by \^incent, and spirochsetes of the refrin- gens type. Case III. — F. S.. the patient, had a chronic fetid bronchitis. Smear preparations of the purulent secretions showed the pres- ence of Bacillus fusifonms in great numbers and an absence of spirochsetes. These cases are mentioned briefly with a twofold purpose, viz., demonstration of the organism in question and its relative significance when associated with respiratory disorders. Case IV. — J. K., aged thirty-eight, laborer. On March 17, 1911, at Gadsden, Ala., he struck a man in the teeth, injuring the index and middle fingers of the right hand. Intense swelling, edema and a foul discharge characterized the condition. Smear preparations made from the discharge on April 9 showed the presence of fusiform bacilli and streptococci. Xo spirochaetes demonstrable. Before proceeding with the case that was studied culturally as w^ell as microscopically, I should like to refer to the case re- ported by Hultgens,* a seven-year-old girl who showed partial gangrene of the left index finger. In smear preparations he found fusiform bacilli and spirochaetes. He doe^ not describe the spirochgetes, but calls them Spirochcota denticola. His patient had carious teeth and had been in the habit of biting her finger- nails. Film preparations made from her carious teeth showed the presence of these same organisms. Apparently no cultural studies were attempted. The source of infection makes this and the following case interesting, especially in view of the fact that no cases are reported of direct transmission from one individual to another. Case \^. — A. W.. aged thirty-four, bartender by occupation. On September 6, 1910, he struck a man in the teeth, injuring the base of the little finger of his left hand. Two days later the fin- ger was swollen and discharging a foul pus. He was admitted to the Cincinnati Hospital, with a temperature of 99.8°, pulse and w 'I ♦ 'V (■•<->' % Fic. 1. — Film preparation from infected hand. Case 5. deniunstrating B. fiisifortuis. XFOOO. Stained with carhnl-fuchsin. Fk;. 2. — Smear from infected hand. Case 5, demonstrating spirochaetes. Xl.OOi). Staired with polychrome methylene blue for twenty-four hours. PETERS 179 respiration normal. Two free incisions were made, and the hand immersed in a continuous bichloride bath. Nine days after in- jury the wound was not doing well ; had a chronic persistent ap- pearance and was still discharging. Eighteen days following in- jury the left hand and forearm were swollen and markedly edem- atous, and the discoloration assumed a purplish hue. The wounds were ragged, irregular, and surrounded by cauliflower-like ex- crescences, with evidence of deep destruction of the tissues. The appearance of these wounds was suggestive of epithelioma. The patient was unwilling to submit to further surgical interference and was discharged. He made a slow recovery, as was learned later, and was well fifty-four days after the injury. Smear preparations from the Vv-ound. made September 20, showed numerous leukocytes and almost pure culture of fusi- form bacilli and spirochsetes. The bacilli for the most part are long and regular, with pointed ends, and thicker in the middle. They lie side by side, between the cells, or end-to-end. and some- times in irregular clumps. In size the bacilli vary from 2.7 ju, to 8.1 /t in length by 0.6 fi in breadth. Ihe spiroch?etes are very nu- merous, and at least two types are visible. Most of them show three or four turns which are of irregular amplitude, correspond- ing to the refringens type. Their extremities are parallel to the long axis of the spiroch?ete. with two or three thick regular turns corresponding to Spirochceta recta, and another, with four or five regular turns, but which are much thinner, corresponds to Spiro- clicrta tmuis.^ The spirochsetes measure from 9.0 ju to 16.2 /i in length by less than 0.4 ix in breadth ( Spencer apochromatic 2 mm. ocular No. 8). Smear preparations forty-six days after the in- jury showed the same organisms. A mixed infection was evi- denced by the presence of a limited number of cocci and small bacilli. The spirochsetes were not so abundant, appeared thinner than when first observed, and did not stain so well. Slants of Dorset's egg medium were inoculated with the pur- ulent secretion taken from this case of hand infection. After an- aerobic incubation at 2)7° C. for three days, colonies of two kinds appeared, cocci and fusiform bacilli. By transplanting from the small colonies of spindle-shaped bacilli, pure cultures were obtained. Morphology and Staining Reactions. — In smear preparations from twenty-four-hour cultures, the fusiform bacilli are delicate pointed rods and usually straight. As they mature they become long, slender rods with pointed ends, and somewhat thicker in the middle. Verj^ frequently they are slightly curved. They measure 4.5 fi to 46.8 /u, in length by 0.6 fx in breadth. 180 DANDRIDGE MEMORIAL In some of the cultures wavy forms may be observed. The morphologic characteristics of these are not unlike those of the bacilli. The protoplasm reacts to aniline dyes and to light in the same way; and the presence of metachromatic granules is sug- gestive of fusiformis. The longer bacilli most frequently con- tain four or more metachromatic granules, while the shorter forms contain two. In old cultures the granules are stained less intensely or may be entirely absent. Suspended in Gram's iodine solution, they do not give the starch reaction. In making film preparations fro^m solid cultures, the bacilli often remain adherent throughout their length, forming bundles. Occasionally two bacilli may be seen lying side by side, so close together as to make one think that they divide longitudinally; however, there are no indications of terminal splitting. Some appear only half as thick as others. On the other hand, there is evidence in the film preparations that transverse division occurs. Some of the bacilli seem to be constricted, and here the proto- plasm is thinner and less granular. The fusiform bacilli as well as the spirochaetes are stained by Loeffler's methylene blue, poly- chrome methylene blue, carbol gentian violet, carbol fuchsin, and and by the Giemsa and Romanowski stains. Carbol fuchsin and polychrome meth)dene blue are the most satisfactory. Specimens were stained in polychrome methylene blue for twenty- four hours, washed with water and mounted in balsam. The spirochaetes stain less intensely than the bacilli. The definition of B. fusiformis is beautifully demonstrated by the aniline black method. Neither the bacilli nor the spiro- chsetes retained the stain in Gram's method, contrary to the state- ment of Jungano and Distaso. Cultural Properties. — The cultures were grown anaerobically by the pyrogallic acid method. The colonies, not unlike streptococ- cus colonies, are small and delicate, with slightly raised centers about 1 or 2 mm. in diameter. The best growth was obtained at 37° C. In the hanging drop the organisms show no active or progressive motility, but considerable vibratory motion, espe- cially at one end. So far as the viability of Bacillus fusiformis on artificial media is concerned, TunnicliflF found them alive fifty-five days Fig. 3.— Pure culture of B. fusifoniiis. Xl.lXMI. Stained with polychrome methylene hlue for forty-eight hours. ^ \ Fk;. 4. — Pure culture of B. fusifoniiis. Xl.CGO. Stained with polychrome methylene blue for forty-eight hours, showing wavy forms. PETERS 181 after inoculation. Cultures on Dorset's egg medium and Loeff- ler's blood serum have been found by myself viable twenty, forty and forty-seven days after transplanting. The viability of the culture is conserved for some time in the refrigerator or main- tained by frequent transfers. Twenty subcultures made during the past seven months have been grown successfully. Loeffler's blood serum and Dorset's egg medium are produc- tive of the most luxuriant growth, the colonies appearing as deli- cate irregular white masses with slightly raised centers. Growth is scarcely visible at the end of twenty-four hours, but after forty-eight or seventy-two hours' incubation the colonies measure 1 or 2 mm. in diameter. A flocculent growth is usually observed in the water of condensation. Ascites broth offers a very favor- able means of cultivation. The growth is heavy, luxuriant, floc- culent, and sinks to the bottom. By agitating the tubes this may be divided into small particles. On rabbit's blood agar luxuriant growth was obtained, resembling that seen on Loeffler's blood serum. When such a culture was placed under aerobic condi- tions, the culture medium darkened and was black a week later. In Dunham's peptone solution there was a slight flocculent growth which settled on the bottom. In litmus milk limited growth oc- curred after seventy-two hours at 37°, but no coagulation took place. When broth with a reaction of 1 per cent, acid to phenol- phthalein and containing 1 per cent, of dextrose, lactose, sacchar- ose, maltose or mannite was inoculated, no growth occurred, but the addition of 0.5 c.c. of defibrinated rabbit's blood to 6 c.c. of these various sugar broths yielded luxuriant growths. Arid pro- duction was marked at the end of seventy-two hours, excepting in saccharose. The litmus in dextrose and lactose broths was entirely reduced. The same luxuriant growth was obtained in litmus milk when 0.5 c.c. of defibrinated rabbit's blood was added. No growth appeared upon -(-1 agar or upon 1 per cent, glucose agar. When the stoppers were removed from the culture tubes a foul odor was given off' suggestive of skatol. The reaction for indol with potassium nitrite and sulphuric acid was negative. Resistance. — As far as I know, the resistance of the fusiform bacilli to moist heat has not been determined. Attempts were 182 DANDRIDGE Al E M O R I A L made to settle this point by heating ascites broth cultures and suspensions in 0.85 per cent, sodium chloride solution. As the controls in this series often showed no growth, the following technique was adopted : Seventy-two-hour cultures on Loeffller's blood serum were used. Anaerobic conditions were suspended and the rubber stop- per and pyrogallic acid plug replaced by sterile cotton and a rub- ber cap. The tubes were then suspended in a water bath for fifteen minutes at 50°, 55,° 60°' and 65° C. respectively. Sub- cultures were made from each tube and the result obtained was confirmed by an additional subculture from the first subculture. Controls were used throughout. The bacilli are killed by exposure to moist heat for fifteen minutes at 55° C. They are not affected by an exposure at .'0° C. for the same length of time. The fusiform bacillus is able to withstand the action of anti- formin, 1 per cent, solution, for five minutes without altering its viability. Sevcnty-tv^^o-hour cultures on Loeffler's blood serum were covered with the germicide for two and five minutes respec- tively, after which they were washed with sterile distilled water. The transplants showed luxuriant growths in forty-eight hours. When the colonies^ were covered with hydrogen peroxide, 15 per cent, solution, for five minutes and washed with sterile water, no growth appeared in the subcultures. A very luxuriant growth was obtained in the transplants from colonies which had been exposed to hydrogen peroxide for one minute. Cultures were subjected to the action of hydrogen peroxide for one, five, ten, fifteen and twenty minutes on two different occasions to verify the above results. Inoculation Experiments. — Two full-grown guinea-pigs were inoculated with ascites broth cultures. The first pig received 1 c.c. of a 72-hour culture intraperitoneally, and the other 1 c.c. subcutaneously. A w^hite rat and a wild rat, M. norzvegicus, were given 1 c.c. intraperitoneally. A large rabbit, weighing 1560 gms., was inoculated with 0.75 c.c. intravenously. There was an entire absence of any local symptoms, and at the autopsy, thirty days after inoculation, no pathological conditions were visible in these animals. The fusiform bacillus was recovered from the PETERS 183 peritoneal smear of the first guinea-pig, but there was no evi- dence of multipHcation. Tunnidiff's results were negative in guinea-pig experiments. In the review by Jungano and Distaso they conclude that Bacillus fusiformis is pathogenic for the guinea-pig and the mouse. The strain of Leiner was very virulent for the lower an- imals, and one of Repaci's cultures was also pathogenic. Veillon and Zuber were only able to produce a very mild grade of infec- tion with their strains. At the present time there seems to be a difference of opin- ion as to the relation of the spirochsetes to Bacillus fusiformis. Some authors believe that they are different organisms entirely, and that the presence of the spirochaetes increases the virulence of the bacilli. Others maintain that they are two forms of one organism in its cycle of evolution. Tunnicliff claims to have ob- served spirilla develop from the fusiform bacilli in her cultures after they had grown from two to five days. I was unable to note spirochsetes in any of the cultures. The terms spirilla and spirochaeta have been used indiscriminately in the literature, but I think we should adhere rigidly to the word spirocheta because the symbiosis occurring in the mouth is one of fusiform bacilli and spirochsetes. As was mentioned above, some of the cultures contained wavy forms, but no true spirochsetes were demonstra- ble. Ellerman holds to the same opinion. Future study may show that certain metabolic products of B. fusiformis favor the growth of the spirochsetes. Repaci iso- lated spirilla (spirochsetes?) from the mouth, which he claimed to be separate distinct organisms from B. fusiformis by reason of their chemical and biological peculiarities. Furthermore the successful cultivation of Sp. dentium, Sp. refringens and T. pal- lidum certainly seems to separate this group of organisms from any developmental forms of the bacilli. SUMMARY. 1. The substance of this article consists essentially in a pre- liminary study, microscopic and bacteriologic, of Bacillus fusi- formis. Its biochemical properties with special reference to its action upon proteids, will be discussed later. 184 DAN BRIDGE MEMORIAL 2. Two cases are recorded of direct transmission from one individual to another. 3. In two cases the fusiform bacilH were not accompanied by spirochaetes. 4. The organisms grow luxuriantly upon Dorset's egg medium, and in various sugar broths containing a small amount of de- fibrinated rabbit blood. 5. Mention is made of its resistance to moist heat, antiformin and hydrogen peroxide. In conclusion I wish to express my gratitude to Dr. Wm. B. \Mierry for his many helpful suggestions. REFERENCES. 1 Jungano and Distaso : Lcs anaerobies, 1910, p. 155. 2 Weaver: Journal Am. Med. Assn., 1906, 46, p. 481. 3 Tunniclifif : Journal Infections Diseases, 190(5, 3, p. 148. THE KURLOFF-BODY, A SPURIOUS PARASITE.* BY OTTO V. IIUIFMANX. M.D. Twenty years or more have passed since Kurloff first observed certain vacuoles or cell enclosures in the protoplasm of the large mononuclear leucocytes of the guinea-pig while working in Ehr- lich's laboratory. Since then improved staining methods and dis- coveries in the field of protozoolog}^ have made it possible to take new viewpoints in regard to these cell enclosures which are called Kurloff-bodies. Therefore it is not with surprise that we find Ferrata, Patella. Goldhorn, Schilling and others believing these bodies to be protozoan in nature. Patella, however, is the only one who claims to have observed a flagellate develop from a Kurloff-body, and of course this observation would put an end to all dispute if it could be verified. After Patella had observed a Kurloff-body develop a flagella and acquire motility, he undertook to prove that the Kurloft'-body is an intracellular phase in the life cycle of a flagellate commonly found in an infusion of the greens which may be fed to the guinea-pig. By isolating newly-born guinea-pigs and feeding them solely upon sterilized milk and bread, he succeeded in keep- ing the blood free of these bodies, but he did not observe his iso- lated gxiinea-pigs beyond the age of four months, because they died. It is important to note along with this that Jolly and oth- ers have found that the Kurloff-body does not appear in the cir- culation of the guinea-pig until it is at least three or four weeks of age. Consequent upon his observation of the development of a flagellate in the blood and the results he obtained in his feeding experiment, Patella jumped to the early conclusion that the Kur- loff-body is none other than the intracellular phase of a flagellate which occurs in an infusion of greens. That this was conjecture on the part of Patella is further shown by his belief that the Kurloff-body is identical with the Leucocytozoa {Hcemogrega- * From Parasitology, vol. iv, No. 4, January 8, 1912. 185 186 DANDRIDGE MEMORIAL rina)'^ of Bentley and Adie, for he could not have arrived at such a behef if he had had any first-hand knowledge of those organ- isms. Likewise in the controversy which ensued between him and Pappenheim, it was entirely irrelevant to base any argument upon some rod-shaped bodies once observed by Auer in a case of acute lymphatic leukemia in man, or upon a flagellated organism observed by Loewit in the blood of a patient post-mortem. It was Patella's observation that the KurlolT bodies were most numerous in the blood of guinea-pigs confined in damp, filthy cages, along with a similar observation of Balfour, who noticed that handling of the rats and dampness of the cages increased the prevalence of Hmnogreganina balfouri, as well as the fact that the Kurloff-body is absent in the newly-born guinea-pig, that led me to investigate the parasitic theory in regard to these bodies. My studies and experiments have been carried on continuously for one year, and I am greatly indebted to Professor Wherry for much assistance in pursuing the investigation. Inasmuch as the Kurloff-body was found not to be a parasite, I will simply out- line the results of my work. It was my first duty to corroborate, if possible, the observa- tions of Patella. Kurloff-bodies were patiently observed in wet blood preparations for long periods of time without the reward of seeing flagella develop. As the mononuclear leucocyte con- taining the Kurloff-body changes its own form or moves, the Kurloff-body undergoes a corresponding change. Several times I was surprised to see how active the Brownian movement of particles of so-called haemoconien became when in the vicinity of a Kurloff-body — but this was simply of passing interest. The fHagellate which occurs in an infusion of lettuce, endive or carrots, was found to be a species of Bodo, and the same species was found in the contents of the cseca of all the guinea-pigs examined. With a further view to Patella's theory, I examined the epi- thelium of the small as well as the large intestine for a possible ectoschizous or endoschizous phase of a parasite, and I likewise examined the cells of the mesenteric lymph nodes. All of the guinea-pigs contained Kurloff-bodies in the blood, but in none did I find a Kurloff-body in the mesenteric lymph nodes. * For literature see Parasitology (1910), iii, 71. H U F F M A N N 187 My next procedure was to examine all the organs of the body, to find in which portion of the body the Kurloft'-bodies occur most numerously. This was found to be in the pulp of the spleen. Here again wet preparations of blood and spleen pulp containing many Kurloff-bodies of all sizes were kept under observation for more than a month without noting any development or change in the Kurlofif -bodies. The warm stage and incubator were used to preserve some of them at the same temperature as that of the guinea-pig. As Kurloft observed, through very elaborate studies extend- ing over several years, that the large mononuclear leucocytes were not affected by splenectomy, I made no effort to repeat his ex- periments. The stained preparations were made from fresh blood, spleen pulp, and from the sealed specimens wdiich had been under ob- servation. Various methods of fixation were tried — Schaudinn's, warm formalin vapor, ether, acids, osmic acid vapor, etc. The ordinary dr>' blood film fixed by methyl alcohol, dried and stained by Giemsa, gives the most uniform results, the Kurloff-body be- ing stained a lighter shade of purple than the nucleus of the mono- nuclear leucoc}'te. If the methyl alcohol is applied to the blood before it has dried, or if the Giemsa solution is applied before the methyl alcohol has entirely evaporated, the Kurloff-body may appear as a sac containing precipitated stain. If fixed w^ith ether, the Kurloff-body appears more homogeneous and stains more nearly red. The smallest bodies occur as azurophilic granules, one or more in the protoplasm of the mononuclear leucocyte, and suggest an Anaplasma-Vike body. The bodies larger than a gran- ule are stained a purplish color; several may occur in one leuco- cyte, and they may indent the nucleus. The most common form is about equal to the nucleus in size, and is frequently associated with two or more small vacuoles in the protoplasm of the leuco- cyte. A distinct non-stained wall to the Kurloff-body may be evi- dent, especially when the body is smaller than the nucleus. The fact that Kurloft'-bodies occur in greater quantity in fe- male guinea-pigs than in male caused me to make a complete study of the generative organs and their secretions but no parasites could be discovered. 188 DANDRIDGE MEMORIAL So far all investigation had been based upon the assumption that the Kurlofif-body is a phase of an homoic parasite. As the ecto-parasites had never been given any consideration as possible transmitters of the supposed Kurloff-body parasite, I took as a working hypothesis that the Kurloff-body is an heteroic parasite. It was rather disquieting to begin with to find that very lousy or flea-infested guinea-pigs did not present more Kurloff- bodies in their blood than the less lousy or less flea infested. As I pro- gressed in the work I soon found that Kurloff -bodies were present in the blood of all guinea-pigs — I never failed to find them in a guinea-pig if I continued the search for several days. I might mention here with regard to the differential counting of leuco- cytes from day to day that the results were quite variable, such variations being dependent upon the factors of food, the degree of heat and friction applied to the ear just before withdrawing the blood, the previous number of times the ear had been cut and how recently; but in general the proportion of polymorpho- nuclear forms to the mononuclear forms is about equal. The mononuclear cells containing Kurloff-bodies vary from day to day as much as from 1 to 20 f>er cent, of all the leucocytes. To see what effect, if any, might result from keeping guinea- pigs free from ecto-parasites, I performed the following experi- ment. Four guinea-pigs were thoroughly combed and brushed. Two of them were etherized and bathed in ether, alcohol, and acetic acid solution so as to kill all lice and eggs and then naph- thalin was dusted and rubbed into their coat. This treatment was found unnecessary and not as good as the daily use of pyrethrum powder blown in amongst the separated hairs by an insufflator and the removing of all nits on top of the head by rubbing with a solution of 10-20 per cent, acetic acid. The guinea-pigs were placed separately in tin buckets which each day were scalded, dried, and supplied with dry sterilized saw-dust for bedding. To prevent the guinea-pigs from becoming infected with lice the buckets containing the animals were suspended from the ceiling. After a few days of such treatment I examined earh guinea-pig for ecto-parasites with negative results — but to ensure the com- plete extermination of any lice that might have been missed an assistant was detailed to carefully examine the pigs and treat them H U F F M A N N 189 with the powder and fresh dusty bedding every morning for several months. It was found that the removal of all lice made no appreciable difference in the number of Kurloff-bodies present. Two of the females gave birth to young under these conditions, and, while the young did not contain the larger, more mature Kurloff-bodies, they were found to harbor the smallest form of Kurloff-body, i.e., the azurophilic granule. During the summer months these four guinea-pigs which were free from ecto-parasites were placed in a wet muddy hutch pro- tected by fine wire screening and far removed from any source of infestation. Within a few days many of the mononuclear leuco- cytes contained from one to six azurophilic granules and within a week many of the mononuclear leucocytes contained the largest form of Kurloft"-body, i.e., the sac, much larger than the nucleus which is crowded to one side, containing granular matter and small rod-shaped bodies. These animals upon again being placed in the dry buckets soon showed a recession in the number of Kurloff-bodies oresent. Furthermore, I made a complete study of ths intestinal con- tents, excreta, and body juices of a large number of Gyropus gracilis, G. oralis, Ctenocephalus canis, Ceratophyllus fasciatus and Acanthia lectularia which had fed on guinea-pigs containing a high percentage of Kurloff-bodies. In the case of the lice and their ova, they were experimented with on the hypothesis that an organism might be liberated when the egg is ingested by the guinea-pig; sealed preparations of lice and ova mixed with gas- tric juice were observed ; and a large number of lice were fed to a guinea-pig having few Kurloft'-bodies, but nothing was dis- covered. Another hypothesis suggested itself to me by finding in several instances moulds and yeasts in the spleens of guinea-pigs imme- diately after the removal of these organs under aseptic pre- cautions. The fact that yeasts had been found in the spleen in cases of blastomycosis was encouraging. I thought that the Kurloff-body might be the result of the chemical activities initiated by a spore either living or after its digestion by a leu- cocyte. This point of view gained support from the observation that cultures made from blood alone always remained sterile 190 DAN BRIDGE MEMORIAL whereas cultures from the spleen occasionally gave a growth of a yeast or mould. Much of this work was repeated and carried out with much care, yet all of the results are conclusive as disproving Patella's assertion that the Kurlofif-body is an intracellular stage of a flagellate. It is important that all who experiment with guinea-pigs should be familiar with these cell inclusions which seem to be normal to the guinea-pig; for I find no less an observer than Mary Rowley, working with the assistance of the staff of the Rockefeller Institute, interpreting them as caused by the injection of blood from a case of fatal anemia. REFERENCES. Cesaris-Dcmel, A. (1905) : Sulla particolare struttura di alcuni grossi leucociti mononucleati della cavia, colorati a fresco. Arch, per le Set. Med., XX ix, 388. Ehrlich, P., uiid Lazarus, A. ( 1898) : Die Anamie. 1 Abth. Normale und path. Histol. des Blutes (Wien), p. 56. Ferrata A. (1907) : Ueber die plasmosomischen Korper und iiber eine metachromatische Farbung des Protoplasmas der mononuclearen Leuko- zyten im Blut und in den blutbildenden Orp^anen. Vircli. Arch., clxxxvii. Hiss, P. H., and Zinsser, H. (1910) : A Text-Book of Bacteriology (New York), pp. 617-633. (For references on blastomycosis.) Hunter, J. W. (1910) : The nature of peculiar bodies found in the leu- cocytes of guinea-pigs. Univ. of Penn. Med. Bull. Loewit, M. (1^8) : Ueber intranucleiire Korper der Lymphocyten und liber geisselfiihrenJe Elemente bei aknter Ivmpha'ascher Leukamie. Ceii- fralbl. f. Bakieriol. 1 Abt. Orig. xiv, 600. Pappenheim, A. (1907) : Riforma Med., No. 23. (1908) : Ueber eigenartige Zelleinschlusse bei Leukamie. Berl. klin. Woch., p. 60. Patella, V. (1907) : Riforma Med., Nos. 8, 9 and 20. (1908): Kurloff'sche Korper in mononuclearen des Meerschwein- schen Blutes und ihre protozoische Natur. Berl. klin. IVoch., p. 1846. Rawley, Mary W. (1908) : A fatal anemia with enormous numbers of circulating phagocytes. Journ. Ex per. Med., vc^ x, p. 78. Plate X, fig. 6. Schilling, V. (\9\\) : Ueber die feinere Morphologic der Kurloff-Kor- per des Meerschweinchens und ihre Aehnlichkeit mit Chlamydozoen-Ein- schlussen. Ccriiralbl. f. Bakteriol. 1 Abt. Orig. Iviii, 318. INVOLUTION OF THE THYMUS BY THE X-RAY.* BY ALFRED FRIEDLANDER, M.D. At the present time the problems of thymus physiology and pathology are being studied by numerous investigators from various viewpoints. The abnormal constitutional state, known as the status lymphaticus, is receiving much attention, especially with reference to its therapy. As is well known, the chief characteristics of the status consist of an enlarged thymus, general enlargement of the lymph node groups in various parts of the body, hypertrophy of the tonsils and of the pharyngeal lyTnphoid tissues, and of the intestinal follicles, together with enlargement of the spleen. From the clinical standpoint, particularly with reference to the production of symptoms dangerous to life, rhe enlarged thymus is of first importance. There has been mu^'h discussion as to whether or not a greatly enlarged thymus can produce the symptoms of thymic asthma by mere mechanical compression. But. whether these symptoms are due to such direct pressure, or whether there is the indirect effect of the enlarged thymus pressing upon the great vessels and nerve trunks in the so-called critical space of Grawitz. or whether finally there is a true toxemia resulting from excessive internal secretion (Svehla's hyperthymization), the fact remains that it is the enlarged thymus which gives rise to the threatening symptoms. It is doubtless true that there are cases of enlarged thymus without the complete syndrome of status lymphaticus, because in not a few of the cases of thymic death neither spleen nor lymph glands have been found to be enlarged. Indeed, as a matter of fact, in typical cases of status lymphaticus, symptoms as such arise practically always as a direct result of thymus enlargement. So far as the production of thymus pressure symptoms is con- * Reprinted from Archives of Pediatrics. October, 1911. 191 192 DANDRIDGE MEMORIAL cerned, mechanical compression, hyperthymization, indirect com- pression o£ great vessels and nerves may all be etiologically important, but the point of greatest clinical concern is that we have life-threatening symptoms produced directly as a result of the enlarged thymus. This fact has been recognized from the viewpoint of therapy because practically all the therapeutic efforts heretofore have been directed to the relief of the direct pressure effects of the enlarged thymus. It has long been recognized that medicines had little or no power to relieve thymic asthma. Within recent years surgical intervention in these cases has therefore been sought. The earliest surgical procedure for the relief of the pressure effects of the enlarged thymus consisted of the so-called thymo- pexy, i.e., suturing the thymus to the inner surface of the sternum. The results following this operation have not been satisfactory, and latterly it has been superseded by actual thymectomy — the removal of more or less of the gland itself. This operation has been successfully performed a number of times with complete relief of the pressure symptoms. But the mortality of the opera- tion itself is high. Then, again, aside from the danger of the operation itself, it seems probable, in the light of later researches, that the removal of all, or even of a greater part, of the thymus may be fraught with grave danger to the subsequent development of the individual. The complete removal of the thymus during the period of its functional activity has been followed in the lower animals (rabbits, guinea-pigs, dogs) by very marked changes in the central nervous and osseous systems, so that the animals have not developed normally at all. While the animals have survived the operation itself, death has subsequently occurred, in many instances, under circumstances leaving no room for doubt as to the role of the thymectomy in its production. While different observers have obtained slightly different results, the general picture after thymectomy has been about the same. Thus the findings of Basch,^ Lucien and Parisot- and of Klose,^ to mention just a few names, are all approximately alike. The results of complete thymectomy as obtained by Klose (loc. cit.) in dogs are as follows : "For the first two or three months after the operation the animals are apparently well-nourished — even over-nourished FRIEDLANDER 193 (stadium adipositas). But after this period there is a marked loss of weight. Marked changes ensue ; at first slowly, later with great rapidity. The general weakness and especially the weakness of the bones becomes very marked. The animals do not grow; become dwarfed. The appetite remains voracious. It is difficult to coax the dogs from their kennels. If they are forced to move, they stagger about aimlessly; spontaneous bone fractures occur frequently. There is marked tremor. The animals become dis- tinctly idiotic, attempting to eat stones, corks, parts of their own bodies. The hair falls out. Corneal ulcers resulting in blindness are common. The end picture of thymectomized animals is always that of coma thymicum, and this stage is reached in from six to fourteen months after the operation." There can be no question of the gravity of the operation of thymectomy, both as to immediate and secondary results, and this from both clinical and experimental observation. In July, 1907, I reported a case of status lymphaticus with enlarged thymus successfully treated by the X-ray.* I had been led to try the X-ray in this case because of the work of Heinecke^ on the effect of the X-ray on lymphoid tissue (to be referred to later). Since this time several similar cases have been reported, four from this city. In October, 1910, Rachford® reported two more cases, one of which was seen by me also. The value of the X-ray in cases of status lymphaticus with enlarged thymus may now be considered as established. It is a noteworthy fact, that although only the region of the thymus is exposed to the X-ray, the effects of the treatment are manifest not only on the thymus, but on the spleen and lymph glands as well. With the idea of investigating this finding experimentally and with the further idea of elaborating the technique of the use of the ray in these cases, this experimental study of thymus involution was undertaken. The radiologic part of the work was done by Dr. Sidney Lange, radiographer of the Cincinnati Hospital, and all actual details of the X-ray treatment, measurement of the tubes, cur- rents, etc., were under his supervision. Technique. — After some preliminary investigation, we decided to t?e rabbits in our work. In each series, rabbits of one litter we^e chosen, and in each series one rabbit was retained untreated 194 DAN BRIDGE MEMORIAL as a control. By a very ingenious arrangement of Dr. Lange's, the animals were so placed in relation to the tubes that only the region of the thymus and the immediate surroundings were ex- posed to the action of the X-ray. Particular care was taken to see that the region of the spleen could not come within the focus of the X-ray, The experiments were purposely varied. Thus in one series each animal (except the control) received only one exposure of a measured current. The animals were then allowed to live varying lengths of time in order that possible differences in the gland might have time to develop. In another series, the animals re- ceived varying numbers of treatments, with two or three days interval between exposures. In the next series the time of the exposure was changed. In another series all animals were given excessive doses frequently repeated, the attempt being made to induce complete atrophy. TABLE I. Series I. — Rabbits of a litter seven weeks old. Each treatment time 15 minutes. Current 2 milliamp. Tube= Walter 5. Dis- tance (anode to skin) 6 inches. Aluminum and leather filter. Weight of Number or Animal Desi.-jnation Before After Weight of of animal Treatment. Treatment. Thymus. Remarks. 1. Control ? 750.00 0.55 2. R. B. 760.00 840.00 0.32 — 9 treatments over 3^ weeks 3. R. E. 675.00 6S0.00 0.11 — 12 treatments over 4^ weeks 4. R. Ba. 740.00 790.00 00 — 15 treatments over 5^ weeks 5. Control ? 755.00 0.44 Series IL — Rabbits of a litter four weeks old. Each treatment time 20 minutes. Current 2 milliamp. Tube^ Walter 4. Each animal except controls received twelve treatments over three weeks. Weight of Number or Animal Designation Before After Weisht of Animal. Treatment. Treatment. of Thymus. Remarks. 1. Control — 275.00 0.22 2. Wh. B. 330.0 355.00 025 Killed at end of 3i/ weeks 3. Wh. H. 275.0 340.00 0.02 Killed at end of 4^/^ weeks 4. R. E. 290.0 355.00 0.01 Killed at end of 5 weeks 5. Control — 315.00 0.17 FRIEDLANDER 195 TABLE II. Series III. — Five rabbits of a litter four weeks old. Each animal, except the controls, received fifteen treatments on suc- cessive days, each treatment lasting fifteen minutes. Current 2 milliamp. Tube=Walter 4. Distance (anode to i-kin) 10 inches. In this series, the thymus in each of the treated animals disap- peared completely under the treatment. There v^as left merely a small mass of fat and connective tissue, without any glandular substance. The over-exposure had been purposely done in order to see whether this result could be obtained. Series IV. — In this series each treated rabbit was given a single exposure only. The time of exposure in each case was 720 milliamper-seconds. Tube=Walter 4. Distance 10 inches. The animals were all treated on the same day and then killed after lengthening periods of time. Number or Designation of Animal Weight of .\nimal before Treatment. Weight T At Autopsy. ime of Autopsy after Treatment. Weight of Thymus. Weight of Spleen. 2. Br. W. 3. R. B. 4. R. B. 5. R. E. 6. Control 568.00 568.00 450.CO 410.00 430.00 600.00 538.00 454.00 24 hours. 72 hours. 144 hours. 216 hours. 0.27 0.30 0.20 0.11 0.24 0.50 0.33 0.35 0.38 0.45 Animals of a litter five weeks old. TABLE III. Series V. — Animals of a litter four weeks old. In this series each treatment lasted ten minutes. Current 2 milliamp. Tube^ Walter 4. Distance 8 inches. The treatments were given daily on successive days, but the number of treatments varied for the different animals. All of these animals were killed two weeks after the treatments. W'eight Number or of Animal. Weight Number of Weight Weight Designation Before at Treatments of of of Animal. Treatment. Autopsy. Given. Thymus. Spleen. 7. R. E. 315.00 30^.00 3 0.05 0.19 8. L. E. 315.00 335.00 2 0.05 0.20 9. R. B. 310.00 332.00 4 ? (Shred) 0.18 13. L. C. 315.00 335.00 4 0.06 0.25 14. Control — 450.00 — 0.12 0.35 196 DAND RIDGE MEMORIAL Two of the animals of this series, to which five and six treat- ments respectively had been given, were found dead in the cages one morning. For fear that post-mortem changes might cloud the findings, these animals were excluded from the series. In the last series, only a few exposures were given, but these were given on successive days. Throughout the experiments the animals were weighed before any treatments were given, and again at autopsy, in order that we could be sure that no changes in the thymus could be ascribed to malnutrition of the animal. Loss of weight of the animals was observed but twice in all our experiments, amounting in one case to 30 g. (1-19 of body weight) and in the other to 10 g. (1-31 of body weight). Skin burns were never induced, except in the animals of Series III., which had purposely been over-treated. The current most generally used was 2 milliamp. The tube usually measured Walter=4. Distance (anode to skin) varied from 6 to 10 inches in the different series. At the autopsy, the thymus in each case was carefully dis- sected out, weighed, then immediately immersed in Zenker's solu- tion. In the later series the spleen and adrenal glands were likewise removed, the spleen in each case being weighed before immersion in the preserving fluid. The details of the series can be seen in the accompanying tables, but the following special points may be noted. (Tables I., II and III). Diminution of the weight of the thymus, both absolute and relative, to the body weight of the animals (as compared with the controls), was constant. This loss of weight was proportionate (a) to the number of exposures (Series I) ; (b) to the length of time which elapsed between the treatment and the autopsy (Series II, Series IV). In Series IV, where each animal received only one treatment, the weight of the thymus decreased almost in direct proportion to the length of time intervening between exposure and autopsy. In Series III, where each animal received fifteen treatments on successive days, each treatment lasting fifteen minutes, the FRIEDLANDER 197 thymus in each case disappeared completely under the treatment. There was left merely a small mass of fat and connective tissue without any glandular substance whatever. In Series IV and V the spleen and adrenals were removed at autopsy. The adrenals were not weighed. The spleens were. In Series IV, where each animal received a single treatment only, the relation of spleen weight to body weight in the control ani- mal was 1 :9(X). In the animal killed twenty- four hours after ex- posure this relation was as 1 :820; animal killed after seventy-two hours, 1:1300; animal killed after 144 hours, 1:1800; animal killed after 216 hours, 1 :1600. A similar loss of weight in the spleen, though not quite as marked, was found in the animals of Series V. Microscopic technique and findings : The organs to be studied were fixed in Zenker's fluid, hardened in alcohols and imbedded in paraffin. The stains ordinarily used were Van Gieson, hema- toxylon-eosin, Mallody's aniline blue and Borel's. The thymus: To sum it up briefly, the effect of the X-ray upon the thymus is that it induces a replacement fibrosis. By varying the number and the intensity of exposures given and the length of time the animal is permitted to live after treat- ment, it is possible to induce any degree of fibrosis, from the very slightest up to a complete disappearance of all glandular tissue. Indeed, by giving the animals very intense exposures on suc- cessive days we found it possible to cause a complete disappear- ance of the gland, the animals being killed directly after the last treatment. There was found in these animals only a small amount of fat and fibrous tissue. (Series III). That the X-ray has an elective action on lymphoid tissue was pointed out in 1903 by Heinecke.^ He found that in young ani- mals (rabbits, guinea-pigs and dogs) changes in the spleen oc- curred very promptly after exposure to the X-ray. There was a marked increase of pigment, disintegration of many cells and reduction in the size of the Malpighian bod?fes. In addition there was rarefaction of the cellular elements of the spleen pulp. An- alogous changes to those seen in the spleen follicles occurred in all the lymphoid groups of the body, in the follicles of the intes- tine and in the thymus. 198 DANDRIDGE MEMORIAL IMore recently, Aubertin and Bordet" and Rudberg^ have studied the thymus involution after X-ray in detail. Rudberg indeed has found that changes in the thymus 02cur as early as three and one-half hours after exposure. "There is a marked dis- integration of the small th^Tnus cells at this time, the nuclear fragments being taken up by the reticular epithelium or dissolved in the intercellular spaces in from twelve hours to two days. Ac- cording to the length and intensity of the exposure there may be a complete disappearance of the lymphoid elements, the gland taking on an epithelioid character." ^ These early changes we have been able to follow distinctly. Furthermore, we have succeeded in inducing various grades of fibrosis, up to the complete involution of the gland, by varying the number of exposures, the degree of intensity of current and the intervals between treatments, and the lapsed time after treat- ment to autopsy. This fact is of prime clinical and therapeutic importance. Taking the control, untreated animals as normal, with a thy- mus of course unchanged, we have been able to induce gradually increasing fibrosis up to the stage w^iere the thymus is completely sclerotic. A short resume of the histologic findings in this series c f increasing degrees of fibrosis of the thymus follows : 1. Animal 2 Br \V. One exposure only of 720 ]\I. A. Sec. The section shows that cortex and medulla are still distinct. There is a beginning disappearance of the small thymus cells, especially in the medulla, the cortex being still normal. There are distinct evidences of phagocytosis in some of the medullary reticular cells. 2. Animal 3 R B. One exposure only, of 72'd M. A. Sec. Animal killed seventy-two hours after exposure. (Series IV.) The beginnings of the fibrosis are already to be seen. There are areas in which the reticular structure shows up much more prominently than in the normal gland, because of the destruction of the small thymus c6lls. In such areas, the cells of epithelioid type predominate ; indeed, the tissue begins to assume an epithe- lial aspect. 3. Animal 4 R B. One exposure only, of 720 M. A. Sec. Animal killed 144 hours after exposure. (Series IV\) F R I E D L A N D E R 199 There is a distinct increase in the amount of intercellular sup- porting tissue, and the fibrils of connective tissue are more dis- tinct. But in this thymus the evidences of degeneration are also distinct. Mitotic figures are common, especially in the nuclei of the reticular cells, and there are areas scattered throughout the gland, showing definite evidence of regeneration. (The clinical significance of this regeneration of the thymus after exposure to the X-ray will be referred to later.) 4. Animal 2 B. Nine exposures, each fifteen minutes, given over a period of three and one-half weeks. (Series I.) Large areas of glandular substance are replaced by fibrous tissue, parts of which show enlarged spindle-shaped cells. In other portions the fibrous tissue is denser, and the young connec- tive tissue cells are no longer to be seen. The bands of fibrous tissue not only encircle the thymus lobules, but also run in be- tween the lobules, separating them. Along some of the interlob- ular fibrous bands there are well-marked hemorrhages. There is some thickening of the adventitia of the vessels. The Hassall corpuscles are well preserved. 5. Animal 4 R E. Twelve exposures, each of twenty min- utes, over three weeks. Killed after four and one-half weeks. (Series II.) The whole gland is sclerotic to the extent that fully half the tissue is fibroid. There is marked perivascular fibrosis. The Hassall corpuscles, though present, are atrophic. There is a ten- dency for the thymus tissue remaining to be arranged in groups or nests. 6. Animal 9 R B. Four exposures daily, but given on suc- cessive days. Each of ten minutes. Killed two weeks after last exposure. (Series V.) It is noteworthy that very intense fibrosis occurred here after only four exposures. But these were given on successive days. The Hassall corpuscles show a marked degeneration (kerato- hyalinization). The thymus cells remaining in many instances show fragmentation. The fibrosis here is much more marked than in the case of the animal just preceding, though this rabbit received twelve exposures. But these were given over a period of 200 DANDRIDGE MEMORIAL three weeks, while the four exposures in the case of Animal 9 R B were given on successive days, 7. Animal 4 R Ba. Fifteen exposures. Ea'^h of fifteen min- utes, over five and one-half weeks. (Series I). The fibrosis is very marked, and the tendency to grouping of the remaining thymus cells is very distinct. Rudberg has noticed a similar change in the thymus of animals receiving prolonged ex- posure. 8. Animal 3 Wh. H. Twelve exposures. Twenty minutes each. Over three weeks, killed at end of five weeks. (Series II.) A further degree of fibrosis is represented here. While this animal received only twelve exposures, as contrasted with fifteen in the case of the preceding animal, the intervals between the ex- posures were shorter. 9. Animal 13 L C. Four exposures on successive days. Each of ten minutes. Killed two weeks after last exposure. (Series V.) This thymus showed complete fibrous involution. The gland was converted into thick bands of fibrous tissue without any re- maining evidences of reticular structure. This animal received only four exposures, each of ten minutes' duration. But they were given on successive days. Table IV. Schema, illustrating increase of fibrous tissue approaching complete fibrosis, as illustrated in cases on opposite page : From the clinical standpoint of treatment of cases of status lymphaticus with enlarged thymus by the X-ray, it must of course be important to determine how the treatment should be given with reference to the number of treatments, duration of each treat- ment and order of succession. Partly with this end in view, the experiments were varied in the different series of animals. Tak- ing the degree of fibrosis as a guide, the following table has been prepared, showing the gradations of change from the normal con- trol organ to the practically completely fibrotic one. (Table IV.) A study of the table shows the following facts: The glands showing the least change were those to which only one exposure was given. Of the three in this group, the increase FRIEDLANDER 201 in fibrosis was (as was, of course, to be expected) in direct pro- portion to the length of time elapsing from the exposure to the autopsy. Thus the animal killed twenty-four hours after ex- posure showed less fibrosis than the one killed after seventy-two hours, and this one in turn less than the one killed after 144 Normal Gland, COMPLETE FIBROSIS. 0. — Normal animals. Not treated. Controls. 1. — 2 Br. W. One exposure, 720 M. A. Sec. Killed twenty-four hours after treatment. (Series IV.) 2. — 3 R. B. One exposure, 720 M. A. Sec. Killed seventy-two hours after treatment. ''Series IV.) 3. — 4 R. B. One exposure, 720 M. A. Sec. Killed 144 hours after treat- ment. (Series IV.) 4. — 2 B. Nine exposures, each of fifteen minutes, over three and one- half weeks. (Series I.) 5. — 4 R. E. Twelve exposures, each of twenty minutes, over three weeks. Killed at end of four and one-half weeks. (Series II.) 5. — 2 Wh. E. Twelve exposures, each of twenty minutes, over three ■weeks. Killed at end of three and one-half weeks. (Series II.) 6. — 9 R. Ba. Four exposures on successive davs, each of ten minutes. Killed two weeks after last exposure. (Series V.) 7. — 4 R. Ba. Fifteen exposures, each fifteen minutes, over five and one- half weeks. (Series I.) 8. — 3 Wh. H. Twelve exposures, each of twenty minutes, over three weeks. Killed at end of five weeks. (Series II.) 9. — 13 L. C. Four exposures on successive days, each of ten minutes. Killed two weeks after last exposure. (Series V.) 202 DAN BRIDGE M E Al O R I A L hours. It is to be noted that the current used in these single exposure cases was stronger than in the other experiments. The next thymus in the scale of fibrosis was that of an animal receiv- ing nine exposures of fifteen minutes each over three and one- half weeks. The changes here were a little less pronounced than in the cases of the next two animals, each receiving twelve ex- posures of twenty minutes each, over three weeks, these animals being killed at the end of three and one-half and four and one- half weeks, respectively. A greater degree of fibrosis was induced in an animal re- ceiving only four exposures, each of only ten minutes. But it is significant that these treatments were given on successive days, the animal being killed two weeks after the last treatment. The next degree of fibrosis was indticed by fifteen exposures of fifteen minutes each, over five and one-half weeks, and the following one by twelve exposures of twenty minutes each, over three weeks. The last degree of fibrosis, complete involution, was induced by four exposures on successive days, the animal being killed two weeks after the last treatment. This animal re- ceived exactly the same number of treatments as did Animal 4 R Ba, of the same series, in which the degrees of fibrosis induced was also very high. While it would, of course, be decidedly unsafe to make abso- lutely sweeping deductions from such a table as this, certain sig- nificant facts may at least be noted as being of therapeutic value. Intense fibrosis may be induced by a comparatively small num- ber of exposures if they are given on successive days. When, therefore, the symptoms of pressure from the en- larged thymus are very urgent, and when there is evidently very marked mechanical obstrtiction from the enlarged thymus, the X-ray treatments should be pushed, being given on successive days to get quick results The shorter the interval between the treat- ments, the more marked the results obtained. Four exposures on successive days (Animal 13 L C) gave a greater degree of fibrosis than fifteen exposures over five and one-half weeks. (Ani- mal 4 R Ba.) It is probable that the age of the animal would have something to do with the case of produ'^tion of fibrosis under treatment. F R I E D L A X D E R 203 The animals receiving only four treatments (on successive days) with high degrees of fibrosis, were rabbits four weeks old. In cases of thymic asthma, therefore, occurring in infants, the ear- lier treatment is begun the better the outlook. Where the symptoms are not so urgent, where therefore there is not the necessity for producing either so great a degree or so rapid induction of fibrosis, ihe treatment may be given at longer intervals. Clinically it has been noted that the symptoms of thymic, asthma, which gradually disappear under X-ray treatment, tend to recur after varying periods of time in some cases. This is doubtless to be explained on the basis of partial regeneration of the thymus after partial fibrosis has been induced. We are able to explain this and to demonstrate it in our experimental series; because we have been able to show definite evidences of regener- ation of thymus tissue in partially fibrotic glands. W^here such symptoms of thymic asthma recur therefore, it means that the artificial involution of the gland has not been carried far enough, indicating that a further course of X-ray treatment is needed. For instance, in the first case reported by Rachford (already alluded to), it is noted that after the first and immediate im- provem.ent under the X-ray, the child had "at intervals of about three months three very slight attacks characterized by cough and dyspnea, which occurred without apparent cause and which were promptly relieved by one or more mild X-ray treatments." As is well known, enlargement of the spleen and lymph node groups of the body constitute constant phenomena in true cases of status lymphaticus. In the original case of status (reported by me in 1907), which was treated by the X-ray, it was noted that though only the region of the thymus was exposed to the action of the X-ray, there was a marked decrease in size of the lymph glands and of the spleen coincidentally with the shrinkage of the thy- mus. The same condition was observed in the case under the supervision of Rachford and myself, and subsequently reported by Rachford.® In order to explain if possible or at least to confirm this find- ing, experimentally, the spleens of the rabbits were examined systematically in our later series. Attention has already been called 204 DANDRIDGE MEMORIAL to the fact that the region of the spleen was absolutely protected from the direct action of the rays in all our cases. A marked reduction in the size of the spleen in relation to the body weight of the animals was observed in our treated animals, as will be seen by reference to Tables II and III. But in addi- tion to this there was a very marked change in the histologic picture of the spleen of the treated animals. In his original studies on the effects of the X-ray on lymphoid structures, Heinecke^ found that in young animals, changes in the spleen occurred very promptly. There was a marked in- crease of pigment, disintegration of many cells, and reduction in the size of the Malpighian corpuscles. In addition there was a rarefaction of the cellular elements of the spleen pulp. Now these are precisely the changes which occurred in the spleens of our treated animals. The reduction in number, size and clear- ness of outline of the Malpighian corpuscles is very striking, and in our series was found to be correlated in degree to the amount of fibrosis in the corresponding thymus. The disintegration of the spleen cells (as studied under high magnification) was marked. The reduction in number, size, and clearness of outline of the Malpighian corpuscles is very pronounced. That some re- lation exists, functionally speaking, between thymus and spleen now seems assured. Indeed, in some of the later researches on thymus physiology the spleen is definitely referred to as the "or- gan of substitution" for the thymus after the period of functional activity of the latter. Without attempting any discussion of this question, it may be noted as significant that both clinically and experimentally, change in size (and in our experimental series in histologic picture) of the spleen occurs pari passu with the arti- ficial involution of the thymus. And this though in both in- stances the region of the spleen is absolutely protected from any direct action of the X-ray. In our later series the adrenals of the rabbits were carefully examined, but no histologic change was found in the adrenals of any of the treated animals. The experiments certainly seem to justify the belief that in the X-ray we have a therapeutic agent of great value in the treat- ment of enlarged thymus. The fact that in our clinical cases of status lymphaticus concomitant changes occur in other portions FRIEDLANDER 205 of the lymphoid tissues of the body, that experimentally we were able to induce changes in the spleen, both go to prove that the X-ray is a valuable agent in the treatment of status lymphaticus itself. For if by exposing only the region of the thymus to the action of the Roentgen ray, we can cause diminution in size of the spleen and of the lymph nodes, can change a lymphocytic to a normal blood picture, it would seem that we have made some distinct advance in the treatment of status lymphaticus. Cer- tainly the X-ray is far safer than the dangerous operation of thymectomy. Apparently it is not followed by subsequent ill effects, either. Thus it is interesting to note that at this writing, the first patient treated by the X-ray (over six years ago) is in excellent condition. He shows absolutely no evidence of any- thing like a lymphatic constitution. His development has been perfectly normal, his general health excellent. The other cases are all in excellent condition also. SUMMARY. 1. Internal treatment is of no avail in cases of enlarged thymus or status lymphaticus. 2. Surgical intervention, i.e., thymectomy, has been success- ful in a number of cases. But (a) the operation is an exceed- ingly dangerous one. (6) Complete thymectomy in lower ani- mals is invariably followed by subsequent developmental changes, manifested in the central nervous and osseous systems chiefly, and invariably leading to the death of the animal. 3. In the X-ray we have an agent which is at the same time safe and efficacious in the treatment of enlarged thymus and status lymphaticus. 4. By means of the X-ray it is possible to induce not only an involution of the thymus, but also in cases of status lymphat- icus to reduce the size of the spleen, of the lymph nodes and to change the lymphocytic blood picture to the normal one. 5. By variation in the number and frequency of X-ray ex- posures, it is possible to bring about the involution with varying degrees of rapidity. Where the symptoms of thymic asthma are urgent, the exposures can be given on successive days, thus in- ducing prompt results. 206 DANDRIDGE MEMORIAL 6. Experimentally it has been shown to be possible to induce any degree of fibrosis of the thymus from the very slightest to absolutely complete sclerosis. 7. Clinically the dosage of X-ray can therefore be regulated according to the necessities of the case. 8. A thymus partially involuted by the X-ray is capable of regeneration. The danger of loss of thymus function (as in the case of complete thymectomy) is thus obviated and the metab- olic changes after thymectomy averted. 9. The use of the X-ray in these cases is without danger to the individuals, as proved by the subsequent normal develop- ment of our treated cases. It is a pleasure to acknowledge a debt of gratitude to Dr. P. G. Woolley, for his interest in and critical supervision of the ex- perimental work. REFERENCES. 1. Basch. Jahrb. f. Kindcrhk., 1906, Ixiv, 1903, Ixvii. 2. Lucien and Parisot. Arch, de Med. Exp., 1910, No 10. 3. Klose. Arch. f. Kinderhk., 1910, Iv. 4. Friedlander. Archives of Pediatrics, Julj-, 1907. 5. Heinecke. Mucnch. Med. ^voch., 1903, p. 2.090. 6. Rachford. American Journal of Medical Science. October, 1910. 7. Aubertin and Bordet. Centralb. f. Inn. Med., 1909, xxx, 976. 8. Rudberg. "Thymus Involution after X-Ray." U p.'-.ola, 1909. 9. Rudberg quoted bv Pappenheimer. "Histology of the Thymus." Journal of Medical Research, February, 1910. THE ROLE OF ACIDOSIS OF THE TISSUE AS A FAC- TOR IN THE PRODUCTION OF AN ATTACK IN PAROXYSMAL HEMOGLOBINURIA. BY OSCAR BERGHAUSEN, B.A., M.D. During January, 1910, a colored man suffering from paroxysmal liemoglobinuria was admitted to the Cincinnati Hospital. He gave a history of passing blood-colored urine, particularly upon exposure to the cold. While producing congestion above the el- bow in order to obtain blood from the median vein for a Wasser- mann determination, it was noticed that at such times there was obtained a blood serum which was laked. This led me to inves- tigate more closely the effect of carbonic acid gas upon the v/ashed corpuscles obtained from both the patient and from a normal in- dividual, and the effect of salts in controlling this hemolysis was studied. This forms a complete report of the work which was done, and which was briefly referred to by jMartin H. Fischer in his work on "Edema." History. — Patient, H. C, colored male, aged twenty-six, sin- gle, entered Cincinnati Hospital, December 31, 1909, suft'ering from pains in the back. Personal History. — Did not have ordinary diseases of child- hood. Rheumatism about six years ago. Returned from the South about one year ago where he had been for several years. While there he had a chill every evening, for which he took quinine. Several years ago he says he was troubled with gall- stones. Admits syphilis and gonorrhea. Is not a heavy drinker. Denies the use of drugs or highly seasoned foods. Onset. — Patient has been working on the river, where he was exposed to the rough weather. Was com.pelled to labor hard and perspired. Eight days ago the patient began having pains in left side in region of kidney. Says that his urine was bloody for several days. Present State. — On admission, a fairly well developed man. Temperature 97°. Conjunctiva yellow tinged. Chest Inspection. — Negative. Palpation. — Vocal fremitus increased in right upper lobe. 207 208 DANDRIDGE MEMORIAL Percussion. — Diminished resonance over right upper lobe. Auscultation. — Prolonged expiration and roughened breath- ing over right upper lobe. Moist rales over the entire lung area. Heart. — Nothing abnormal found. Abdomen. — Pain in left lumbar region. X-ray shows nothing abnormal about the kidney or ureter. January 9, 1910. Patient has intermittent attacks of hemo- globinuria, which usually come on in the afternoon. During the intervals, the urine is clear. Cystoscopic examination shows that the hemoglobinuria is bilateral. He was now transferred from the surgical to the medical service. During the next five days he passed bloody urine only once. On January 15, 1910 the blood picture showed — RedTcells 3,200,000 White cells 7,000 Polys 59.0 per cent. Large lymphocytes 14.5 per cent. Small lymphocytes 19.0 per cent. Eosinophiles 4.0 per cent. Transitional 3.8 per cent. No abnormal cells, red cells are anemic. During or immed- iately after an attack the blood picture seems to approximate the normal. About three days after one attack, the count showed polys, 46.0 per cent. ; lymphocytes, large and small, 50-0 per cent. ; eosinophiles, 4.0 per cent. The temperature would vary from subnormal and normal to 99.2°-100.2° F. On January 29, it reached 104° F., due to an attack of acute tonsillitis, which quickly subsided and was not accompanied by an attack of hemoglobinuria. The fecal examin- ation, made on January 10, 1910, showed a yellow formed stool, no free fat, a few meat fibres well digested, no parasites. Blood culture, negative. Noguchi deviation of complement test, distinctly positive. The patient improved while in the hospital, the treatment being rest, warmth, light diet. Potassium iodide was given in- ternally. The attacks became fewer in number, and the patient was discharged on February 26, 1910, feeling much improved in health. EXAMINATION OF THE URINE. On January 2, 1910, the urine passed was light amber in color, spectroscopic examination was negative, likewise the guaiac, bile and Ehrlich's aldehyde reaction tests. On January 3, 1910, the urine was black in appearance, the spectroscopic examination gave a double line, one in the green and one in the yellow fluids, the guaiac test was positive, the bile B E R G H A U S E N 209' test was unsatisfactory, and Ehrlich's aldehyde reagent gave a distinct scarlet color in the cold, with the corresponding spectrum- On January 5, the urine was smoky in color, the spectroscopic examination was negative, the aldehyde reaction was positive, a scarlet color, in the cold. Microscopic examination showed the presence of granular casts, no corpuscles and no parasites. On January 6, a Bier's congestive bandage was applied to both upper arms over a period of ten minutes. In two and one- third hours the urine passed was dark, contained albumin, spec- troscopic examination showed presence of hemoglobin, and Ehrlich's aldehyde reaction was positive in the cold. On January 7, the morning urine was amber in color, spectro- scopic examination was negative, no albumin, the aldehyde re- action was positive in the cold. The sediment snowed casts, but no corpuscles. EXAMINATION OF THE BLOOD SERUM AND CORPUSCLES. On January 7, at noon, a congestive bandage was applied and the blood removed from the arm vein. A portion of this blood was defibrinated at the bedside, and the serum after centrifuging was distinctly laked. Another portion was set aside in a sterile test tube and kept at — 10° C, and still a third portion was kept at 37° C. The blood serum which separated in both tested tubes was distinctly hemolytic. The blood serum was then examined for the presence of syphilitic antibodies according to the Noguchi modification, and a distinct inhibition in hemolysis was obtained. The patient's corpuscles were then again obtained, washed three times in normal salt solution and subjected to the action of an- other syphilitic serum as follows : Corp. suspension. Normal salt solution. Syphilitic serum — Webb. Hemolysis. 1. 2. 3. 1 drop 1 drop 1 drop 1 c.c. 1 c.c. 1 c.c. c.c. 0.5 c.c. 1.0 c.c. Since no hemolysis resulted after incubation at 37° C. and allowing to stand until the next morning, it was determined to test the action of another syphilitic serum after adding comple- ment, which was done January 8, 1910: Patient's Guinea- washed pig comp. Syphilitic Salt corpuscles. 40perct. serum — Webb. solution. Result. 1. 1 drop 0.1 0.1 c.c. 1.0 c.c. 2. 1 drop 0.1 0.2 c.c. 0.8 c.c. 3. 1 drop 0.1 0.4 c.c. 0.6 c.c. 4. 1 drop 0.1 0.8 c.c. 0.2 c.c. 210 DANDRIDGE MEMORIAL The controls using the patient's washed corpuscles without added syphilitic serum, also my own washed corpuscles in place of the patient's in the above experiment, were also negative. Evidently the syphilitic bodies or antibodies played no great part in the production of the hemolysis. OTHER FACTORS WHICH MAY INDUCE AN ATTACK- The effect of cold in producing an attack of hemoglobinuria was spoken of by the patient himself. It was cleaily shown above that by simply placing a congestive bandage upon the upper arm, at first the blood serum become laked, and later the urine was colored red and contained hemoglobin. It was further found that by simple catheterization, a typical chill was developed, which was later followed by the passing of a highly-colored urine con- taining blood coloring matter. The increase of temperature associated with the attacks can be readily explained by the action of the liberated hemoglobin upon the system. Vaughan proved this beautifully in animals when he found that laked blood corpuscles of either man or rabbit after filtration cause an elevation of temperature when in- jected into rabbits either intra-abdominally or intravenously. HOW IS HEMOLYSIS ACCOMPLISHED? The presence of a specific amboceptor which has to do with causing a solution of the corpuscles in vivio is assumed by many authors. Donath and Landsteiner were the first to show that in the cooled extremity the patient's corpuscles were acted upon by the specific amboceptor, and thus prepared were_ acted upon by the complement in the general circulation, leading to hemolysis. This was confirmed by later observers. Hymans later showed that the blood serum of hemoglobinuric cases contained specific substances which in the presence of free CO2 acted^upon the corpuscles of the patient at lower temperatures (8°-16° C.), leading to their hemolysis. They state further that the blood serum and corpuscles of a normal individual are not hemolized in this manner. The Donath-Landsteiner phenomenon was not observed in every case, however. Cases of paroxysmal hemo- globinuria are reported in which sufficient cooling of an extremity did not lead to an attack. Likewise by placing a congestive bandage about an extremity attacks have not always been pro- duced. This has been explained by some as due to the fact that following one attack the complement has been absorbed and must again be produced in sufficient amount in order to cause hemolvsis. Evidently existing theories do not account for the many variations which occur in the blood stream of patients suffering BERGHAUSEN 211 from paroxysmal hemoglobinuria. All observers seem to pay especial attention to the specific amboceptors, to the complement, and a few to the presence of free carbonic acid, but none seem to regard the presence of other dissolved substances, particularly the salts, as playing any important factor- With the object of ascertaining the part which the salts play in the phenomenon of hemolysis, the following experiments were undertaken: ACTION OF ACIDS ON THE CORPUSCLES AND SERUM. Lactic Acid.. Washed Normal corpuscles, salt sol. Lactic acid. Result. 1. 1 drop 1 c.c. 1 drop cone. sol. Immediate hemolysis and conversion. Gradual hemolysis. Gradual more rapid. Gradual more rapid. ATMOSPHERE OF COo. (a) Serum. By passing a current of dried COo gas into a test tube con- taining hemoglobinemic serum, a rapid reduction took place. By exposing diluted and undiluted hemoglobinemic serum contained in small Petri dishes, to an atmosphere of dried COo gas, a re- duction likewise took place, the rapidity depending upon the dilution. The controls made by exposing similar serum to the action of air over night suffered no reductions. (b) Corpuscles in Normal Salt Solution. 2. 1 drop 1 c.c. 1 drop (1-10 dil.) 3. 1 drop 1 c.c. 2 drops (1-10 dil.) 4. 1 drop 1 c.c. 4 drops (1-10 dil.) Patient's washed Normal Atmosphere of corpuscles. salt sol. CO2 exposure. Result. 1. 5 drops Jan. 7, 1910. 5 c.c. Over night Complete hemolysis. 2. 5 drops Jan. 10, 1910. 5 c.c. Three hours Slight hemolysis. 3. 5 drops Jan. 12, 1910. 5 c.c. One hour Complete hemolysis. My own corpuscles similarly washed and treated showed no hemolysis in one hour, complete hemolysis by the next morning. Both lactic and carbonic acid cause rapid solution of the cor- puscles with reduction, the rapidity depending upon the dilution. This was to be expected. Normal salt solution delayed this action. The corpuscles obtained from the patient suffering from paroxysmal hemoglobinuria seemed to be less resistant to the action of the carbonic acid gas, even in the presence of normal salt solution. 212 DANDRIDGE MEMORIAL (c) Corpuscles in Sodium Citrate Solution. Defibrinated patient's corpuscles were washed three times in 1-5 per cent, sodium citrate solution. Five drops were added to 5 c.c. citrate solution and exposed to CO2 atmosphere for three hours at room temperature. They were then taken out and centrifuged. No hemolysis had taken place. Patient's corpus- cles in normal salt solution similarly exposed showed complete hemolysis. Corpuscles similarly treated with sodium citrate so- lution and normal salt solution, and exposed to room temperature, showed no hemolysis. The experiment was repeated, using my own corpuscles, and similar results were obtained. The corpuscles, both from the patient and myself, after wash- ing in 1.5 per cent, sodium citrate solution and exposing to CO2 atmosphere for three hours, were again washed, suspended in normal salt solution and exposed to CO, gas. Complete hemolysis resulted in three hours. (d) Corpuscles in Normal Salt Solution and Sodium Citrate Solution in CO. 2 Atmosphere. Washed corpuscles, Normal Sodium After four 5 drops. salt sol. citrate sol. hours' exposure. 1. Patient's 5.0 c.c. C.H. 2. Delaney's S.O c.c. C.H. 3. Patient's 1.0 c.c. 0.5 C.C. No H. 4. Delaney's 1.0 c.c. 0.5 c.c. No H. S. Patient's 1.0 c.c. 0.75 c.c. Trace H. 6. Delaney's 1.0 c.c. 0.75 c.c. No H. 7. Patient's 1.0 c.c. 1.0 c.c. No H. 8. Delaney's 1.0 c.c. 1.0 c.c. No H. The results of these experiments would tend to show that corpuscles in normal salt water suspension are readily hemolized in an atmosphere of COo, and that the addition of a slight amount of another neutral salt is sufficient to inhibit this action. (e) Corpuscles plus Serum in an Atmosphere of COo. Washed Exposure corpuscles, Delanej^'s three hours ; 5 drops. serum. room temperature. 1. Patient's 0.3 c.c. No H. 2. Delaney's 0.3 c.c. No H. In this case a normal serum was sufficient to prevent the hemolytic action of CO, upon the corpuscles obtained both from the patient and another normal individual. B E R G H A U S E N 213 DEDUCTIONS. In the above experiments it was noticed that the corpuscles of patient suffering from paroxysmal hemoglobinuria were some- what less resistant to an atmosphere of carbonic acid gas, as com- pared to corpuscles from a normal individual. This difference was not very marked, however- The chief difference lies in the blood serum of the patient. Contrary to the findings of Ilymans, it was found that normal corpuscles in normal salt water suspension were also, although more slowly, hemolized in an atmosphere of carbonic acid gas. Sodium citrate solution', strength 1.5 per cent., was sufficient to prevent hemolysis of both the patient's and normal human cor- puscles in atmosphere of carbonic acid gas at room temperature. Apparently the salt concentrations of the blood serum is the factor which determines whether the corpuscles shall be hemo- lized or not. As shown above, normal serum has sufficient salt dissolved to prevent hemolysis of both the patient's and normal corpuscles in an atmosphere of CO, at room temperature. Krokiewicz states that inactivated (55° C.) serum from a hemoglobinuric patient, no longer hemolizes the patient's cor- puscles in an atmosphere of CO,, after adding fresh human serum as complement. By adding this serum he merely increased the salt concentration of the serum which previously was poor in salts. The paroxysmal-like attacks have been variously ascribed to the action of cold, congestion and trauma, locally or remotely produced. It would appear that changes locally in the tissues must be necessary before a state of hemoglobinemia or hemoglo- binuria can be produced. In view of the fact that cold, trauma and passive congestion may all lead to an attack, and since the three conditions are associated with the production of an ex- cessive acidity of the tissues, it is not unreasonable to suppose that the organic acids thus formed play some part directly in the production of the attacks. The corpuscles may be less resistant, they may be subject to the action of a specific hemolysen, and yet an additional factor acting locally in the tissues seems neces- sary for an attack to be produced. In the presence of the proper salt concentration the corpuscles are protected against the hemo- 214 DAN BRIDGE MEMORIAL lytic action of any organic acids. This naturally suggests the giving of neutral salts as a therapeutic agent to prevent the onset of attacks in patients suffering from paroxysmal hemoglobinuria. In conclusion, I wish to thank Dr. E- W. Mitchell, the staff physician, for his kindness in permitting me to report this case^ also Prof. Martin H. Fischer for valuable suggestions. REFERENXES. Martin H. Fischer: Edema. Philadelphia, 1910, pp. 173. Donath and Landsteiner : Munchener Med. Wochenschrift, 1904. Erich Meyer and E. Emmerich : Ueber paroxysmale Hamoglobinurio. Deutsches Archiv f. klin. Med., 1909, Bd. 96. Hymans v. d. Bergh : Blut Untersuchungen iiber die Hamolyse bis der paroxvsmale Hamoglobinurio. Berl. klin. Woch., 1909, Nos. 27 and 35. Czernecki : Wien. Klin. Woch., 1909, No. 42. Krokiewicz: Wien. Klin. Woch., 1911, No. 14. V. C. Vaughan, J. C. Gumming, J. H. Wright: Zeitschrift f. Immunit., May 13, 1911, pp. 473. THE EFFECTS PRODUCED BY NUMEROUS INJEC- TIONS OF INDOL AND TYROSIN IN EXPERI- MENTAL ANIMALS: A CONTRIBUTION TO THE STUDY OF CHRONIC INTES- TINAL INDICATIONS.* L. H. XEWBURGH, M.D., AND PAUL G. WOOLLEY, M.D., The term "chronic intestinal auto-intoxication" was first applied by Herter to a pathological state arising from an excessive ab- sorption of substances resulting from the action of bacteria on the contents of the lower bowel. Herter demonstrated that two groups of bacteria could be distinguished by their biochemical re- action in the normal adult feces. The one group is fermentative, the other putrefactive. The products of the fermentative group (chiefly lactic and acetic acids) are innocuous, whereas the putre- factive group manufacture substances which are thought to be capable of giving rise to symptoms, when absorbed from the bowel in sufficient concentration. Certain putrefactive bacteria are always present in the adult feces. The colon bacillus is found in varying numbers from infancy onward, but although putre- factive, is, according to Herter, not the chief offender- He be- lieved that the harmful decomposition products w^ere for the most part dependent upon the overabundance of anaerobic micro- organisms. Using Gram's method of staining and appropriate anaerobic methods of cultivation, he found that persons suffering from excessive intestinal putrefaction harbored enormous num- bers of anaerobes in the colon and that the B. aerogenes capsulatus (Welchii) w^as usually the dominant organism. Often typical colon bacilli were absent. As the condition improved, the colon bacilli returned and the gas bacilli and related organisms were greatly decreased in numbers. Among the products formed by the putrefactive bacteria from the contents of the colon are indol, skatol, methyl mercaptan, and many other decomposition pro- * Reprinted from The Lancet-Clinic, April 13, 1912. 215 216 DANDRIDGE MEMORIAL ducts which have not yet been isolated. It is thought that the absorption, in sufficient concentration, of members of this group of substances may give rise to a variety of symptoms. Forchheimer has studied this subject from the clinical side. Among the symptoms noted by him in an analysis of seventy- seven cases from his general practice are stomach troubles, de- bility, constipation, flatulence, headache, neuralgic pains, Rigg's disease, albuminuria, indicanuria, cardiac neuroses, vascular and myocardial changes, muscular pains, and in most cases a moderate secondary anemia. Huchard, in his studies on arteriosclerosis, approached the .subject from a somewhat different angle; but he also was im- pressed with the importance of intoxications, presumably of intestinal origin, as an etiological factor in arteriosclerosis. He taught that arteriosclerosis is usually the result of arterial hyper- tension ("presclerosis"), and that the latter is usually called forth by an intoxication. The intoxication is of alimentary origin and results from the functional insufficiency of the kidney which prevents certain products of albuminous digestion from being eliminated. He supports this contention by citing some experi- ments which his assistant, Tournier, performed. The latter found that the urine of persons suffering from presclerosis is less toxic than normal urine. That is, there is a retention of toxic products. When the patient is fed on a milk-vegetable diet the pressure falls to normal and other toxic symptoms disappear. Thus, we gather from Huchard's writings that a diet containing the usual amount of meat may be a source of symptoms, but only when the kidney is insufficient- He does not tell us what the toxic substances are or how they are formed. Moreover, his conclusions are subject to criticism because of the quite obvious fallacy of his statement that decreased toxicity of the urine is evidence of retention of toxic bodies. Our experiments had the following objects in view: 1. To see what lesions, if any, we could produce by injecting certain of these bodies, thought to have toxic properties, into animals, over long periods ; and 2. To see what relation these bodies bear to the condition named presclerosis by Huchard. NEWBURGHANDWOOLLEY 217 In order to carry out the first object we have injected white rats intraperitoneally with saturated aqueous solutions of indol. We have chosen indol because it was present in almost every instance in the urine in Forchheimer's cases, and because it is formed in large amounts by the putrefactive bacteria when grown on proteid media, and because some of the constitutional effects attributed to it in experimental work are observed in clinical cases in which it is present. That the indol was continuously in circu- lation is shown by the fact that the urine always gave a strong indican reaction. We also ran a parallel series, using tyrosin instead of indol. The tyrosin series had a somewhat different basis. In our pre- liminary report, we stated that we had been led to suspect that the pigmentation of Addison's disease might be a result of varia- tion in either the content of the chromaffin tissues in tyrosinase, or in the overabundance of tyrosin or some related substance in the body. The idea arose from a suggestion of v. Fiirth that melanin and related bodies are the result of the action of tyro- sinase or related oxidases upon the aromatic constituents of the protein molecule, a suggestion which, as Adami says, has been supported by Halle, who demonstrated that tyrosin is converted into adrenalin by a ferment in the adrenal. Adami suggests that pigmentation in Addison's disease is produced when this ferment is deficient, that is, when the tyrosin is not converted into ad- renalin by the adrenal, but into melanin in the skin. These suggestions induced us to attempt to discover whether prolonged injections of tyrosin would stimulate the adrenals to increased activity with resulting hypertension, or whether evidences of hyperfunction being absent melanosis would result. We also suspected that indol might cause adrenal changes for these reasons: Presclerosis, whose chief symptom is increased blood pressure, is due, according to Huchard, as stated above, to an intestinal intoxication. Since adrenalin raises blood pressure, and since intestinal intoxication is thought to raise the blood pressure, it might be that indol does this in part or wholly through its effect on the adrenal glands- For these reasons it seemed advisable to run these two series of experiments at the same time. In the preliminary report we summarized our results as follows : 218 DANDRIDGE MEMORIAL "After these injections (indol and tyrosin) we found the- medullas of the adrenals hyperplastic and apparently hypertro- phic ; and that evidences of chromafifin activity increased in pro- portion to the number of injections. The chrome reaction was similarly increased. We also found very slight interstitial changes in the kidneys." We now wish to report what further results we have obtained : Our experimental data are given below. The descriptions apply mainly to the adrenal glands. TYROSIN SERIES. Protocol 4. — White rat, six injections of 1 c.c. saturated aque- ous solution of tyrosin each week. Total injections, 12. No macroscopic changes. Microscopic : Very moderate amount of dilatation of sinuses of adrenal. Medulla solidly cellular; chrome reaction distinct; thickness of medulla 72.5; average width at cortex 31.0- Protocol 5. — White rat, six injections of 1 c.c. saturated aque- ous solution of tyrosin each week. Total injections, 21. No macroscopic changes other than cloudy swelling of liver, kidney and heart muscle. Microscopic: Islands of medullary substance reach as far as glomerulosa ; chrome reaction brown- ish, rather than yellow ; very little dilatation of sinuses ; medulla very solid ; considerable fatty metamorphosis of cortex ; almost none in medulla. Thickness of medulla 70; width of cortex 31. Protocol 12. — White rat, six injections of 5 c.c. saturated aqueous solution of tyrosin each week. Total injections 8. Mucoid cystic tumor of lung. Thyroid about twice normal size. Liver, spleen, kidneys, adrenals, enormously congested- The adrenals have a succulent, translucent appearance. On sec- tion they show a soft chocolate-colored medulla occupying the whole gland, save for a narrow rim of cortex. The darkness and fluidity of the medulla are striking. Microscopic: Adrenal, very well marked chrome brown reaction with a considerable fatty change in the medulla ; cortex also shows fatty degeneration and well-marked congestion ; some dilatation of sinuses of medulla, though not excessive ; chromaffin, as a rule, compact. Thickness of medulla, 70. Width of cortex, Z7. Protocol 7j. — White rat, six injections of 5 c.c. saturated aqueous solution of tyrosin each week. Total injections, 13. Small mucoid cystic tumor of lung. Liver, spleen, kidneys, adrenals enormously congested. Other macroscopic changes as in No. 12, except that thyroid not enlarged- Microscopic: Ad- renals, intense chrome reaction ; considerable fatty change ; con- siderable dilatation of sinuses ; medulla has not a compact appear- NEW BURGH AND \V O O L L E Y 219 ance ; cortex, very moderate parenchymatous change ; some islands of medtdlary substance in the cortex. Thickness of me- dulla. 50. Width of cortex, 41. Protocol i8. — White rat, six injections of 5 c.c. saturated aqueous solution of ty rosin each week. Total injections, 40. Tyrosin Series. Rat Rat Rat Rat Rat Rat 4—12 5—21 12— 8 13—8 18-40 19—50 injections injections injections injections injections injections 1 1 5 5 5 5 Medulla. c.c. each 72.5 c.c. each.... 70.0 c.c. each 70.0 c.c. each.... 50.0 c.c. each 66.5 c.c. each 66.5 Cortex. 31.0 31.0 37.0 41.0 41.0 41.0 Index 2.3:1 2.3:1 1.9:1 1.2:1 1.6:1 1.6:1 Average 65.9 hidol Series. 35.3 1.8:1 Rat Rat Rat 6—12 7—20 14—13 injections injections injections 1 1 5 c.c. each 72.5 c.c. each.... 72.5 c.c. each. . . .57.5 30.0 31.2 37.5 2.4:1 2.3:1 1.5:1 Average 67.5 Control. 32.9 2.0:1 Rat Rat Rat 20-0 1^- 3—0 injections injections injections c.c. each. . . .60.0 c.c. each 60.0 c.c. each 45.0 30.0 40.0 25.0 2.0:1 1.5:1 1.4:1 Average 55.0 31.6 1.7:1 Salt Solution. Rat 21—20 injections 5 c.c. each 62.5 40.0 1.3:1 Adrenals congested, most marked in cortex. Medulla com- pact ; accumulation of chromaffin substance in cells, giving an appearance not seen in controls. Cells themselves plump, so that the whole appearance gives one the im.pression of hyperactivity. Thickness of medulla. 66.5. \\'idth of cortex. 41. Protocol iQ. — White rat, six injections of 5 cc. saturated aqueous solution of tyrosin each week. Total injections, 40. Appearances similar to those in Protocol 18. Protocol 6. — White rat, six injections of 1 c.c. saturated aque- ous solution of indol each week. Total injections, 12. No macroscopic lesions. Microscopic: xVdrenal shows very moderate dilatation of the sinuses ; apparently no clear yellow (lipoid?) reaction; solid compact arrangement of the chrom- affin ; very little congestion ; cortex not remarkable. Thickness of medulla. 72.'^. Width of cortex, 30. Protocol /. — White rat. six injections of 1 c.c. saturated aque- ous solution of indol each week. Total injections, 20. 220 DAXDRIDGE MEMORIAL No macroscopic lesions. Microscopic: Adrenals show marked congestion; chrome reaction very well marked. Cortex shows little parenchymatous change; few isolated islands of medullary substance in cortex; chromaffin tissue very solid. Thickness of medulla, 72.5. Width of cortex, 31.2. Protocol 14. — White rat, six injections of 5 c.c. saturated aque- ous solution of indol each Vv'eek. Total injections 13. Urine shows intense indican reaction ; no glycosuria. Adrenals on section show a dark brown medulla, which, however, is not soft. Adrenals : medulla moderately congested and of a greenish brown color. Thickness of medulla, 57-5. Width of cortex, 37.5. COXTROL SERIES. Protocol J — White rat. No treatment. Protocol 16. — W'hite rat. No treatment. Protocol 20. — White rat. No treatment. Protocol 21. — White rat, six injections of 5 c.c. normal salt solution each week. Total injections 20. General appearance of adrenals not unlike those of protocol 3. Thickness of medulla, 62.5. Width of cortex, 40- SUMMARY. The measurements given were made as follows: A Leitz III micrometer ocular was used with a Leitz 3 objective. The draw- tube of the microscope was kept at the same length for all sec- tions. The width of the cortex of each adrenal was read off merely by comparing divisions on the micrometer scale. The thickness of the medulla was read in the same way. Several sections were used (paraffin sections with hematoxylin and eosin stain after bichromate fixation for each determination), and these sections were made transversely from the second part of the glands. We should add to the above data that in no case did we observe anything more than cloudy swelling and congestion of the glan- dular organs of the animals, and that these changes were rarely, if ever, more extreme in the controls. Whenever any remark- able change has presented itself it has been noted in the proto- cols. DISCUSSION, The lengthening of the series of experiments mentioned in our preliminary report shows that the volume of the medullas of the NEWBURGH AND \V O O L L E Y 221 adrenals does not increase in proportion to the number of injec- tions, nor to the amount of substance injected, in either the indol or tyrosin series. As a matter of fact the reverse seems true. But it also seems possible that the activity of the chromafifin cells is increased. However that may be, there seems to be no associated changes in other glandular organs, and this is especially interesting in the case of the liver and kidney- No blood-vessel changes were ob- served in any case. But if there seems to be no systematic increase in the medulla it is also true that there does seem to be relative increase in the volume (estimated in width) of the cortex, and that this appar- ent increase bears no direct relation to the amount of lipoid metamorphosis. If this should turn out to be a fact it will be of interest from the standpoint of the production of epinephrin. It has been suggested that the early stages of epinephrin production occur in the adrenal cortex — that the cortex contains a substance that might be called pre-epinephrin, and that the material becomes epinephrin only when modified by the action of chromaffin cells. Such an hypothesis would account for the increase in volume of the cortex and for the apparent increase in the activity of the specific cells of the medulla. For the purely clinical part of the work we have selected the first seven cases with a persistent indicanuria who have presented themselves. Their ages ranged from thirty to sixty-five years. In no case was the blood pressure over 150 Hg., and this latter reading was obtained from the oldest patient in the group. Ac- cordingly, none of our seven cases shovv^ed an abnormally high presure, so that none of them can be placed in Huchard's pre- sclerosis class. It may then be fair to state, as far as our small material permits, that indicanuria is not synonymous with pre- sclerosis, and that indican, in and of itself, does not cause an ab- normally high pressure. Whether this would be so in the presence a renal insufficiency, or whether indican can cause changes which then result in the condtion called presclerosis, we do not know. As regards the blood pressure in relation to the intensity of the indicanuria: — In two cases, which we were able to follow a long time, the pressure gradually fell as the indican disappeared 222 DANDRIDGE MEMORIAL from the urine. The first case, a man of sixty, started with a pressure of 150 mm. Hg. on April 10, 1911, which on June 1, 1911, when the indican reaction had disappeared, was 134 mm. Hg. On April 15, 1911, when the test for indican was very marked the pressure was 150 mm., but on May 15, when the reaction was still fairly strong, the pressure was down to 115; whereas it had again risen to 134 mm. by June 1, when there was no indican in the urine. The other patient, a man of thirty-four years, started with a pressure of 123 mm. on March 21, 1911, which fell to 103 mm. by June 12, 1911 ; the indican during this period gradually disappeared. A third man, of fifty-five years, with an initial pressure on May 23, 1911, of 143 mm., in whose urine the indican reaction did not diminish, had the same pressure on June 13, 1911. CONCLUSIONS. No definite conclusions are justified by the work here reported, but we may say that we have some evidence that certain sub- stances (indol and ty rosin) have a slight effect upon the adrenal glands and that these glands are more markedly afifected than the liver and kidneys. We have found no evidence in our very meager material to support the belief that indicanuria is in any way responsible for the symptom-complex named "presclerosis" by Huchard. We do not wish to give the impression, however, that we believe that the group of bodies, of which indol is one, does not cause symptoms in man. We believe that symptoms are produced when these bodies are present in sufficient concentra- tion. We would like to suggest that "sufficient concentration" does not depend upon rate of production ; in other w^ords, that there is probably never sufificient indol produced in the intestine to cause symptoms so long as the oxidative and eliminative func- tions are normal. Certainly by no means are all persons with persistent indicanuria sufferers from intestinal autointoxication. It is equally true that there is a group of individuals with per- sistent indicanuria whose symptpms are relieved when the in- dicanuria disappears. These persons are sick, not because too much indol is being formed, but because it is not removed with sufficient rapidity. NEW BURGH AND W O O L L E Y 223 In support of this view we quote from Herter: "It may be re- garded as settled that the liver, muscles, intestinal epithelium (and other cells) normally exert a protective action to the ner- vous system in screening it from the effects of an injurious per- centage of indol in the blood, by the ability of these structures to quickly bind any indol which comes to them. It may, more- over, be regarded as established that the same dose of indol ad- ministered to two human beings of about equal weight may reg- ularly give rise to more pronounced nervous manifestations in one than in the other. While these inequalities may be partly due to differences in the rapidity of absorption, no striking dif- ferences due to this factor were noticeable in the excretion of indican in the urine, and it appears more probable that the dif- ferences in the observed toxic effects were dependent on in- equalities in dift'erent persons in respect to their ability to oxidize indol and to pair it with sulphuric acid." Experiments performed by A. N. Richards and J. Howland show the effect of imperfect oxidation on the fate of indol- To reduce the oxidizing processes in the cells, animals were poi- soned with hydrocyanic acid. "Rats, mice, guinea-pigs and dogs, subjected to subcutaneous injections of potassium cyanide too small in themselves to cause marked symptoms, were later sub- jected to . . injections of indol. The result almost regularly observed was that the convulsive twitching which is character- istic of the action of phenol and of indol was of greater inten- sity and longer duration in the animals subjected to potassium cyanide than in the control animals." REFERENCES. Herter: Bacterial Infections of the Digestive Tract. New York, 1907. The Macmillan Co. Forchheimer: Chronic Intestinal Autointoxication. American Jour. :Med. Sc, 1907. July. Huchard : The Diseases of the Heart and Their Treatment, 1909. Woolley and Newburgh : Journal A. M. A., 1911, Ivi, 1796. V. Fiirth : Quoted bv Adami. Adami : Principles of Pathology, 1910, vol. i, p. 670. Richards and Howland : Quoted by Herter. CONTRIBUTIONS TO A COLLOID-CHEMICAL ANALY- SIS OF ABSORPTION AND SECRETION.* MARTIN H. FISCHER, M.D. I. For a number of years past both theoretical and experimental evidence has been accumulating which would make the colloids of the cells and changes in their state the chief factor responsible for the amount and variations in the amount of water held by the cell. Such a conclusion stands in sharp contrast to that which has been more generally held, according to which but small im- portance, or none, has been assigned to the colloids in this matter. The latter view gained its main support from the fact that since the first osmotic investigations of Hugo de Vries and W. Pfef- fer, both animal and plant physiologists have very generally adopted the view that living cells represent osmotic systems simi- lar in general construction to the osmotic cells of our physico- chemical laboratories ; and as in these osmotic cells of our labora- tories pure colloids show practically no osmotic pressure, it was reasoned that they could also show no osmotic pressure in the living, supposedly osmotic, systems of the biological worker. The serious objections that can be lodged against the osmotic conception of water absorption by cells, even as modified by the excellent researches of the past fifteen years, are familiar to everyone. It was in an attempt to account for some of the most notable of these objections that the role of the colloids in the general problem was again considered. These studies showed that variations in the water content of various cells are easily explained not only from a quantitative but also from a qualita- tive standpoint on the basis of their colloidal constitution, for the variations that are observed in cells when subjected to diflferent external surroundings are identical with those which can be in- duced in dififerent emulsion colloids when subjected to the same * Reprinted with additions from Kolloidchemische Beihefte, ii, 304, 1911. 225 226 DANDRIDGE MEMORIAL external conditions. In this manner it was found possible to explain without recourse to any belief in the osmotic constitution of the living cell all the phenomena that had previously been explained on this basis, as well as the notable exceptions which biological workers were agreed could not be so explained. And hence the conclusion that the colloids of the tissues and changes in their state are chiefly responsible for the variations in zuater content, that cJiaracterize the living cell. The question that next presented itself was whether the facts accumulated from study of isolated cells could be utilized to ex- plain the special problems of absorption and secretion as we ob- serve them in any of the higher animals. The absorption and secretion of water by a multi-cellular or- ganism seems at first sight to be decidedly different from the ab- sorption and secretion of water as observed in a single cell — say an ameba or a muscle cell. It is an easy matter to think of an ameba as a spherical mass of colloidal material saturated with water, and under changes in its physico-chemical surroundings or through direct changes in its own chemical composition so altering this colloidal material as to make it take up or give off water. As I view it, this simple conception does as a matter of fact constitute the heart of the entire problem of water absorp- tion and secretion as observed in this animal. But in a multicellular organism biological facts confront us which do not at first seem to be interpretable on any such simple basis as that outlined for the ameba. In the mammal, for ex- ample, we find whole organs set apart, seemingly endowed with powers of absorption only while others functionate seemingly only as secretory organs. It becomes hard, for example, to see : just what relationship exists between a mucosal cell of the small intestine concerned almost exclusively with an absorption of water from the lumen of the gut, or a kidney cell concerned equally exclusively with a secretion of urine, and the ameba or muscle cell which now absorbs and now secretes water either in response to its own physiological demands or under the condi- tions with which experimentally we are pleased to surround it. And yet on closer analysis the difference between the two is not so striking. First of all, we appreciate the fact that the mucosal FISCHER 227 cell is an absorbing cell only so long as we look at it from the side of the lumen of the gut. If we regard it from the blood vessel side, the mucosal cell is a secreting cell, for what it ab- sorbs from the gut it gives up to the blood. Similarly, the kidney cell is a secreting cell only because we usually look at it from the point of view of being a producer of urine — as a matter of fact, everything that goes to make up the normal urine was absorbed from the blood. But even if we look at the matter from the nar- rower point of view, the intestinal cells under certain circum- stances become secreting cells in that they secrete substances into the lumen of the intestine; and according to the judgment of some authors, certain kidney cells may reabsorb materials that have been secreted by others. In essence, therefore, secretion and absorption in the higher animals is not different from absorption and secretion as observed in an ameba or any isolated tissue cell. That which remains, therefore, to characterize absorption and secretion in the higher animals is merely this, that under normal circumstances and viewed from the point of view of the organism as a whole, absorption and secretion occur predominantly in one direction. What requires special analysis in the higher animals is, therefore, n6t absorption and secretion per se, but the condi- tions existing in the multicellular organism which make it pos- sible for certain organs to act chiefly as absorbing systems, while others act predominantly in secreting systems. This is what cre- ates all the problems that are conveniently grouped under the general heading of the special physiology of absorption and se- cretion, as observed in the higher animals. Let us see, first of all, if we cannot define in general terms what must be the conditions which lie at the bottom of the pre- dominant functioning of certain cells and tissues in one direction, and this on the basis of our belief that the colloidal constitution of the living cell is primarily responsible for the phenomena of water absorption and secretion by the cell. An ameba or an isolated cell or tissue derived from a higher animal and kept in a solution of any kind is surrounded by this solution on all sides. Could we imagine the chemical processes within these cells held in abeyance, then we can see how these cells would after a time succeed in getting into a state of equilib- 228 DANDRIDGE MEMORIAL rium with their surroundings. When such an equilibrium has been estabHshed, the cells neither absorb nor secrete water. Only as this equilibrium is disturbed, either through changes in the surroundings of these cells or through the specific chemical changes occurring in the cells, can we expect a renewed absorp- tion or secretion. Under quite different conditions do we find the individual cells of the multicellular organism existing in the intact living body. While in a certain sense the internal activities of the ameba may be compared with those of the individual cells making up, say the intestinal mucosa, and there exists a certain analogy between the fact that both are surrounded by a liquid medium, here the anal- ogy stops. For while the ameba is surrounded on all sides by the same liquid medium, the cells of any of the absorptive or secret- tory organs, found for instance in a mammal, are through dif- ferent portions of their cell protoplasm in contact with entirely different media. The cells constituting the intestinal mucous membrane, for example, are bathed on one side by intestinal con- tents ; on the other by blood or lymph, or both together. Such cells, like any other absorptive or secretory cells similarly situ- ated, find themselves therefore, in the predicament of trying to get into equilibrium with as many different media as surround them. It is in trying to do this that all the phenomena that we call absorption and secretion in the higher animals are produced. As I have pointed out elsewhere,^ it is in the attempt to get into equilibrium with the intestinal contents on the one side, and the blood on the other, that the mucosal cell (better, the colloidal membrane separating the intestinal contents from the blood), ab- sorbs the intestinal contents and transfers them to the blood. According to my views, the body of a multicellular organism — a mammal, for example — is built up of a system of emulsion colloids which in the resting state are saturated with water. To be counted in with the structures that make up this water-satu- rated colloidal system and composing an integral part thereof, are the blood and the lymph. The entire system will not take up any more water, or give up any except as chemical changes are first produced in it which either increase or decrease the capacity of the tissue colloids for water. We can see how such chemical FISCHER 229 changes, when occurring in a multicellular organism, might be of such a character as to affect the constitution of the entire mass of colloidal material that composes its body ; or they might affect only smaller parts of the whole. In the former case we should get either an absorption or a secretion of water by the organism as a whole, in the latter we should get only a limited or localized absorption or a secretion of water by the parts involved. Under the latter circumstances, yet another thing is possible. Chemical changes might be going on in one part which were leading to an absorption of water, while other changes were going on in an- other part which were leading to a secretion of water. On this basis I have tried to show how conditions are so arranged in the body as to favor almost constantly the absorption of water from the gastro-intestinal tract, while at the same time they favor the secretion of the urine from the kidneys. The following pages form a continuation of this study of ab- sorption and secretion in the higher animals, and deal particularly with the problem of absorption from the peritoneal cavity. They represent an attempt to interpret this problem also in the light of our colloidal conceptions of water absorption. The conclusions drawn are based in part on my own experiments, in part on the experiments of the numerous investigators who have worked in this field, but who have interpreted their findings differently from the way in which I have taken the liberty of doing. In view of the excellent running accounts of absorption that may be found by consulting R. Heidenhain,^ E. Waymouth Reid,* Ernest H. Starling,^ H. J. Hamburger,^ E. Overton,^ Otto Cohn- heim,^ or Rudolph Hober,^ it is needless to attempt any detailed definition of the present status of our knowledge of absorption. This is shown in a masterly way by these authors. Depending upon whom we consult we find suggested, as the forces active in this matter, variations in hydrostatic pressure, filtration, or the two combined; diffusion and osmotic pressure, with modifica- tions of both as determined by different media, different mem- branes and different solutions ; imbibition ; and when these physi- cal forces are found wanting, then the "peculiar" forces of living matter are called upon for help. How unsatisfactory are these explanations is clearly enough evidenced by the divergence of 230 DAN BRIDGE MEMORIAL scientific opinion and the mutual criticism that finds expression in the individual writings of these authors, and this in spite of the fact that the experimental grounds upon which they base their opinions agree very well with each other. My own experiments that are referred to below were extremely simple in character, made purposely so in order to eliminate the many and great errors that creep into these absorption experi- ments, as soon as anesthetics, operations, animal boards and elab- orate pieces of apparatus are employed. Had it not been for the use of these, one might have contented himself with mere inter- pretation of the experimental facts already found by previous au- thors. How some of these procedures affect absorption will be pointed out at the proper place. I used healthy guinea pigs which were kept on a liberal diet of timothy hay, corn and oats, with water ad libitum. In order to permit comparison with each other the animals in each set of experiments were taken from the same cage and treated exactly alike. No anesthetic being necessary, none was given. The var- ious solutions and the water, after warming to 38° C, were in- jected into the peritoneal cavity by means of a hypodermic needle. The animals were held only during the few moments necessary for the injection, after which they were allowed to run about in their cages. At the end of a specified time they were killed by a blow on the head, immediately opened, and the unabsorbed liquid contained in the peritoneal cavity aspirated, by means of a pump, into small flasks. The amount of fluid recovered was then measured. Let it be noted that what is discussed primarily in these pages is the absorption of water from the peritoneal cavity. A priori no one would be inclined to look upon the absorption of any so- lution as representing a single process, and yet, in practice, this is done and has been done constantly. On all sides we see dis- cussed the absorption of a solution as such. The absorption of a solution represents the composite of the absorption of the sol- vent, and the absorption of every individual substance dissolved in that solvent. Absorption of solvent and absorption of dis- solved substance may mutually affect each other (see below), but this does not make them identical, nor does it make the absorption FISCHER 231 of the solution a single process. Excellent experimenters have gone so far as to look upon the distribution of a dissolved sub- stance (such as a dye) in a tissue as evidence for the fact that the solvent in which that substance was originally dissolved was present there, or at Icc.st had passed that way. This is a most serious mistake. 11. 1. When any liquid is injected into the peritoneal cavity and we find that after a time this has been absorbed, we know from anatomical considerations that this must have passed into the lymph and the blood streams after having traversed the cells and intercellular substances which originally separated these two cir- culating fluids from the liquid that was injected. If we try to formulate the problem in terms of physical chemistry, then our purpose is to discover how the absorption of a solution that has any composition we may choose to give it, is accomplished by two colloidal circulating liquids (which, for the sake of brevity, we will regard as sols) that are separated from this solution by a solid colloidal membrane (a gel). It is of interest for our fur- ther discussion to first call to mind which of these two liquid colloids plays the more important role in this absorption. Inas- much as the peritoneal cavity is usually regarded as an immense lymph space, one might on a priori grounds be inclined to look upon the lymphatic circulation as that chiefly concerned in the problem of absorption from this cavity. And yet that the lymph plays a subordinate part and the blood circulation the chief role is indicated not only by E. H. Starling and Tubby's ^*' finding that dyes appear in the urine after injection into the peritoneal cavity before the lymph coming from the thoracic duct shows any color, but also by the finding of Orlow^^ who noticed no in- crease in lymph flow after intraperitoneal injections of salt so- lution, and that of H. J. Hamburger^- who found peritoneal ab- sorption unimpaired after ligation of the thoracic duct. But, after the point is established that absorption from the peritoneal cavity is brought about chiefly through the agency of the blood, we have yet to say why this is the case. It is evident that the answer to this question bears both a quantitative and a qualitative element. In the higher animals the lymph circulation 232 DANDRIDGE MEMORIAL stands quantitatively far behind the circulation of the blood. Other things being equal, the blood would therefore absorb more than the lymph in proportion as the blood flow through a part ex- ceeds quantitatively the lymph circulation through the same part. But chemical differences between the two play, to my mind, an equally important part. The total colloid content of the blood is higher than that of the lymph.^^ But, beyond this, the blood suf- fers rapid temporary changes in chemical composition that the lymph* does not suffer.^* Chief among these are the quantitative variations in the content of oxygen and (especially) of the carbon dioxide as induced through respiration. Further changes in the composition of the blood are wrought through the diffusion of metabolic products into and out of it, when the blood passes through the kidneys, active muscles, the liver, etc. While some- what similar changes are induced in the lymph when this passes through various organs, the rapid variations that we find in the blood are for obvious reasons lacking. But these more marked and rapid changes in the blood, combined with its more rapid cir- culation, mean at the same time more marked and rapid chai;ges in the surroundings of the various tissue cells about which this cir- culating medium passes. The equilibrium with their surround- ings which these cells endeavor to establish is therefore continu- ally being disturbed because of these changes in their surro'.-nd- dings ; and, so long as this happens, so long must the cells absorb or secrete. And hence the more important function of the blood circulation over that of the lymph circulation is this problem of absorption in the higher animals. 2. Let us now turn to the problem of the absorption of water from the peritoneal cavity. When water is injected at body temp- erature into the peritoneal cavity of guinea pigs it is rapidly ab- sorbed, as the following table shows : ^^^^^ ^- Amount of fluid Amount of water in c.c. recovered Guinea pig Weight in grams injected in c.c. after one hour a 413 20.8 S.4 b 535 20.8 S.4 c 544 20.8 4.8 d 460 20.8 4.9 * Almost one-fourth of the blood is prote in Blood plasma contains to each 100 parts almost 9 parts of protein; lymph contains 3.4 to 4.1 parts. FISCHER 233 There is nothing new about this observation. Where we en- counter difficulty is in saying why the water is absorbed. Against the generally accepted belief that water is under such circum- stances absorbed because the osmotic pressure in the cells lining the peritoneum is higher than that of the distilled water, serious objections can be raised. We know that the peritoneum does not retain this water, but gives it up to the blood (chiefly). On the osmotic basis this secretion into the blood could therefore occur only because the blood had a higher osmotic concentration than the cell contents. As a matter of fact we know that body cells, lymph and blood have, to all intents and purposes, the same osmotic concentration. The still more serious objection that this osmotic conception of water absorption ignores entirely the im- portant part played by the intercellular substances need not be discussed here. That an injection of water into the peritoneum makes the cells here take up water because of an increased hydro- static pressure directly induced by the injection, or aided by the contractions of the abdominal muscles, etc., is also scarcely tenable. The injection, first of all, does not appreciably increase the intra-abdominal pressure; and secondly, absorption occurs when the abdomen is opened, or in a dead animal (see below). We have no difficulty in interpreting the absorption of water from the peritoneal cavity as a colloidal phenomenon. In order that the absorption of zmter m-ay occur, the emulsion colloids of the peritoneum must only he unsaturated zmth zvater. But when we consider the fact that after a few cubic centimeters of water have been absorbed from the peritoneal cavity, more may be ab- sorbed and this may be repeated almost without limit, then we have to conclude that under normal circumstances the tissues com- posing the peritoneum are constantly unsaturated zi'ith water. What we really have to discuss, therefore, are the conditinos that combine to keep the colloids of these tissues unsaturated with water in the living animal. The first of these conditions is the continuous production of acid (carbon dioxide) in the tissues composing the peritoneum. In consequence of this acid production in these tissues their capacity for water is increased, and they absorb water from any available source. If water is present in the peritoneal cavity they 234 DANDRIDGE MEMORIAL will take it up. But this would only lead to a swelling of the peritoneal tissues. We wish to emphasize that by ''peritoneal tissues" we mean cells plus intercellular substance. As in this process an upper limit might soon be reached and absorption cease, this alone cannot lead to the continuous absorption which we found to exist. Therefore, we need to introduce a second variable, and this is found in the circulation of the blood and the lymph. Through these the carbon dioxide produced in the cells is constantly being carried away. But to carry this away from the tissues is to reduce the capacity of the colloids of the peri- toneum for water, which, in consequence, they now give up. As long as the circulation is maintained in a normal way absorption from the peritoneal cavity must therefore be continuous, for zuJtile the tissues of the peritoneum are on tlie one side busy in absorbing zmter they are, on the other, busy in giving it up to the blood along with their carbon dioxide. What the blood does with this water is beyond the scope of this paper to discuss, but it may not be out of order to point out that it also carries the water in combination with the colloids found in the blood. As the arterial blood, low in carbon dioxide (representing, as we have said, a liquid colloidal solution satu- rated with water), enters the capillaries, there diffuses into it the carbon dioxide that is being produced in the cells. Through this the capacity of the blood colloids to hold water is raised, they find themselves in an unsaturated condition, and so are able to absorb water from any available source. This could be water directly, though in the living body it means that the blood robs any tissue of its water that is holding it with less avidity than that repre- sented by the colloids of the blood. In the case under discussion the blood absorbs water from the tissues composing the perito- neum. The peritoneum, in its turn, takes water from the perito- neal cavity, if any is present there. The now venous blood, with its higher water content, passes to the lungs, where the carbon dioxide escapes. When this happens the blood colloids are unable to longer retain the water absorbed previously, and this becomes "free" in the blood. It is this "free" water that under normal conditions the kidney extracts from the blood, and, by a process FISCHER 235 the reverse of that which we have described for peritoneal ab- sorption, secretes as urine. ^^ 3. The conclusion that only "free" water can be secreted by the kidneys can be supported in a number of ways. Any method by which w^e can get "free'' water into the blood is a method which produces a proportionate increase in urinary output. If water is introduced in a "bound" state, in other words, in combination with a colloid, then no secretion is obtained^''. Xow, since absorption represents the mirror image of secretion, it ought to be possible to establish a similar series of experimental facts for absorption, and so apply a first test to the ideas of peritoneal absorption ad- vanced above. If only "free" water can be secreted, then "free" water ought to prove itself most readily absorbable ; and, since colloidal solutions cannot be secreted by the kidney, colloidal so- lutions ought to prove themselves non-absorbable from the perito- neal cavity, except as they first suffer changes in state which makes them liberate the water contained in them. As the follow- ing experiments of Table II show, this is the case: Table II. Amount of fluid Weight Amount and character in c.c. recovered Guinea pig in grams of solution injected after one hour a 533 20.8 c.c. water 5.4 b 537 20.8 c.c. white of egg (natural) 18.4 c 5^5 31.2 c.c. water 1 .(> d 563 31.2 c.c. white of egg (natural) 27.7 Table III. Amount of fluid Weight Amount and character in c.c. recovered Guinea pig in grams of solution injected after one hour a 417 20.8 c.c. water (control) 5.4 b 397 20.8C.C. l-12mol. NaQ 11.8 c 419 20.8 C.c. i^ mol. NaCl 13.0 d 488 20.8 c.c. 1-6 mol. NaCl 14.6 e 445 20.8 c.c. 14 mol. NaCl 19.9 4. The theoretical interpretations of the findings of Table III are about os follows : When, in place of the pure water, a sodium chloride solution is introduced intraperitoneally we may assume that the water of this solution tries to diffuse into the cells just as though the salt were not there. But, at the same time that this is occurring, the salt is also diffusing into the peritoneum. Just w^hy this happens is discussed below. But the presence of this salt in the colloids of the peritoneal tissues will make these tend to give up their 236 DANDRIDGE MEMORIAL water. The salts will, therefore, tend to counteract the effect of the carbon dioxide in the cells. The normal fall which tends to make the water move from the peritoneal side of the peritoneal absorbing membrane to the vascular side will now be counteracted by one occurring in the opposite direction. The normal streaming of water which tends to make for an absorption from the perito- neum will be met by a counterstream which tends to make for a secretion from this structure. The end result, so far as absorp- tion is concerned, will represent the algebraic sum of the two. If this second stream is not a great one there will be only a slight reduction in the rapidity with which the water is absorbed. This is what happens with the dilute salt solution. But, as the concen- tration of the salt increases, this counter current must become more and more manifest, so tl[iat, as in the last experiment (e) given in Table III, practically no absorption (of water) occurs within the time limits set for the experiment. 5. In equimolecular concentrations different salts affect to very unequal degrees the absorption of water by colloids swelling in the presence of an acid. So also, and in the same general order, do they affect the absorption of water by the peritoneum. Ta^^^ IV. Amount of fluid Weight Amount and character in c.c. recovered Guinea pig in grams of solution injected after one hour a 643 20.8 c.c. ^ mol. sodium chloride 7.0 b 594 20.8 c.c. Ys mol. sodium acetate 10.0 c 551 20.8 c.c. % mol. sodium nitrate 12.6 d 409 20.8 c.c. % mol. sodium sulphate 20.0 e 496 20.8 c.c. Ys mol. sodium citrate 23.4 f 492 20.8 c.c. % mol disodium phosphate 25.6 Table V. Amount of fluid Weight Amount and character in c.c. recovered Guinea pig in grams of solution injected after one hour a 343 20.8 c.c. J/^ mol. potassium iodide 3.4 b 335 20.8 c.c. % mol. potassium bromide 8.8 c 322 20.8 c.c. J/^ mol. potassium chloride 11.0 d 290 20.8 c.c. 3^ mol. potassium sulpho- 13.4 cyanate e 355 20.8 c.c. J^ mol. potassium nitrate 13.4 f 354 20.8 c.c. % mol. potassium acetate 16.8 g 363 20.8 c.c. ^ mol. potassium tar- 18.9 trate (died 40 minutes after injection) h 386 20.8 c.c. J/^ mol. potassium citrate 20.5 (died 15 minutes after injection) FISCHER 237 Table VI. Amount of fluid Weight Amount and character in c.c. recovered Guinea pig in grams of solution injected after one hour a 452 20.8 c.c. J^ mol. potassium chloride 12.8 b 396 20.8 c.c. J^ mol. ammonium chloride 13.7 c 484 20.8 c.c. J^ mol. magnesium chloride 19.4 d 476 20.8 c.c. J^ mol. calcium chloride 24.2 e 502 20.8 c.c. ^ mol. strontium chloride 24.4 As Tables IV, V and VI show very clearly, every one of the salts employed markedly retards the absorption of water from the peritoneal cavity. This harmonizes entirely with the fact that the presence of every salt inhibits the absorption of water by such an emulsion colloid as fibrin, gelatine or serum albumin which is swelHng in the presence of an acid. But the parallelism between the two processes is much closer than this. We note in Table IV, for example, where the effects of equimolecular solutions of sodium salts are compared, that the sulphate, citrate and phos- phate have an effect far above that of the chloride, acetate or nitrate in preventing absorption. In Table V, where the effects of a series of potassium salts are compared, the order of the anions is again the familiar one observed in studies on pure colloids. Table VI brings out the same fact for a series of dif- ferent kations. That the results should be so nearly identical with the effects of various salts on pure colloids is really some- what surprising when we remember that in such experiments as these one is compelled to w^ork with a very considerable experi- mental error, arising from the fact that in each of these series of experiments several animals are used, that we cannot control the amount of water consumed by the animals just before being used, that we cannot escape the specific poisonous effects exerted by the different salts employed, etc. Nevertheless the experimental re- sults are point for point almost identical with the findings on pure colloids. This indicates to my mind how predominant is the col- loidal element in this problem of absorption. 6. As compared with the effect of electrolytes, various non- electrol)les affect the absorption of water by colloids in the pres- ence of any acid only slightly. The following gives the results obtained w^hen solutions of various non-electrolytes in concentra- tions osmotically about equivalent to the solutions of the various salts used above, were injected intraperitoneally : 238 DANDRIDGE MEMORIAL T^^^"V"- Amount of fluid Weight Amount and character in c.c. recovered Guinea pig in grams of solution injected after one hour a 425 20.8 c.c. 14 mol. ethyl alcohol 5 8 b 434 20.8 c.c. J4 mol. methyl alcohol 2.1 c 464 20.8 c.c. water (control) 5.6 d 583 20.8 c.c. ^ mol. urea 11.7 e 569 20.8 c.c. 14 mol. glycerine 18.2 f 687 20.8 c.c. 14 mol. glycerine 17.4 g" 521 20.8 c.c. J4 t^o\. cane sugar 25.7 h 725 20.8 c.c. ^ mol. cane sugar 27.0 i 522 20.8 c.c. % mol. dextrose 26.3 j 710 20.8 c.c. ^ mol. dextrose 29.0 It is clear from this table that ethyl and methyl alcohols do not delay the absorption of water from the peritoneal cavity. On the other hand, urea, glycerine and the two sugars used, produce a very decided inhibition. The sugars even produce a secretion of fluid into the peritoneal cavity exactly as we found certain bi- valent and trivalent anions and kations to do in Tables IV and VI. The effects of ethyl and methyl alcohol agree with the findings on pure colloids. In the case of glycerine and the sugars the effect on the peritoneum is much more pronounced than would be ex- pected from the action of these compounds on fibrin or gelatine. Just how the result is to be explained remains conjectural. The concentrations employed are rather high, and so we have to re- member the fact that while non-electrolytes do not markedly inhibit the absorption of water by various colloids in low con- centrations, they do this in the higher concentrations. A second factor is that the water is bound to these non-electrolytes (glycer- ine and the sugars) more intimately than to the various salts. In other words, the water is not "free," but in a bound state as in the colloidal solutions represented by egg albumin, blood, etc. Finally, these sugar and glycerine solutions produce a degree of "irrita- tion" of the peritoneum (acid production in the cells?), as evi- denced by a redness and a slightly wrinkled appearance that is entirely lacking when other solutions are employed. 7. Both alkalies and acids when injected intraperitoneally delay the absorption of water, as indicated in the following table: FISCHER 239 '^•^^"'V"^- Amount of fluid Weight Amount and character in c.c. recovered Guinea pig in grams of solution injected after one hour a 544 20.8 c.c. water (control) 4.7 b 545 20.8 c.c. 0.01 normal NaOH 6.2 c 543 20.8 c.c. 0.02 normal NaOH 11.0 d 568 20.8 c.c. 0.04 normal NaOH 10.6 e 460 20.8 c.c. water ( control ) 4.8 f 460 20.8 c.c. 0.01 normal HCl 7.4 g 447 20.8 c.c. 0.02 normal HCl 12.4 h 450 20.8 c.c. 0.03 normal HCl 12.0 Just how these results are to be interpreted on the colloidal basis remains at this time somewhat conjectural. From the con- centrations employed and the appearance of the animals on post- mortem examination it has seemed to me that both produce an excessive swelling of the peritoneal tissues. This excessive swell- ing would delay absorption, not alone by occluding the lumina of the capillaries supplying the peritoneum and so decreasing the absolute blood flow through these tissues, but by so increasing the avidity of the peritoneal tissues for water that the blood passing through them is not enabled to take the water away from them with its usual ease. Tabi-E IX. Recovered Amount from second of fluid pouring in Amount and recovered of 20.8 c.c. Hours Weight character of in c.c. after water after Guinea pig dead in grams solution injected 1 hour 1 hour a just dead 331 20.8 c.c. water 7.6 b just dead 396 20.8 c.c. water 9.0 c 1.00 333 20.8 c.c. water 9.4 15.3 d 2.30 351 20.8 c.c. water 9.3 15.0 e 7.30 395 20.8 c.c. water 8.0 f 24.00 375 20.8 c.c. water 12.5 g 48.00 353 20.8 C.C. water 17.0 h 0.15 267 20.8 C.C. i/^ mol. NaCl 13.2 i 0.15 295 20.8 c.c. % mol. 10.6* Na.S04 j 0.15 299 20.8 c.c. i/^ mol. 11.4* sodium citrate * A part of the peritoneal fluid was accidentally lost. 8. The above table shows how water and various salt solutions are absorbed from the peritoneal cavities of dead animals. The guinea pigs were killed by a blow on the head, and injected sub- sequently in the same way as in the experiments with living ani- mals already detailed above. After the liquids were injected the 240 DANDRIDGE MEMORIAL animals were turned about for a few times to allow the liquids to spread through the peritoneal cavity, and were then laid quietly on their bellies for one-half hour, after which they were turned on their backs for one-half hour. The table shows that water is readily absorbed from the perito- neal cavities of dead animals. How is the result to be explained? The answer is not essentially different from that given for the living animal. An acid production in the tissues is again re- sponsible for increasing the capacity of the tissue colloids to hold water. Only, while we attributed this to carbonic acid in the living animal, we can attribute it in the case of the dead animal not only to this acid but in addition to lactic and the other acids that we know are produced post mortem. The longer an animal is dead, the higher we may assume becomes the concentration of the acids in the various tissues. On this basis we might expect a progressively greater absorption of water with every increase in the length of time that an animal is dead. But this could hold only within certain limits, for in pure colloids we know that with a progressive increase in acid concentration the absorption of water increases only up to a certain point, after which a decreased absorption is noted. The same is evident in Table IX, where animals long dead (/ and g), show a decidedly lower absorption of water than animals dead only a short time. As is sufficiently well indicated by the results obtained with animals h, i and / various salts retard the absorption of water from the peritoneal cavity of dead animals as they do in living animals, and, we would add, for the same reason. III. 1. The foregoing paragraphs which show that the same condi- tions which retard the absorption of water by such an emulsion colloid as fibrin or gelatine, retard in almost identical fashion the absorption of water from the peritoneal cavity, prove, it seems to me, that the two processes are in essence the same. What is next in order is to compare this process of peritoneal absorption with the processes of absorption as observed in other regions of the mammalian organism to see if the conclusions drawn regarding absorption as observed in the peritoneal cavity cannot be extended FISCHER 241 to cover at least some of these. Of chief interest in this connec- tion, because of its physiological importance, is the question of absorption from the intestinal tract. To any one conversant with the wealth of experimental data on alimentary absorption that has been accumulated by Voit and Bauer,^^ R. Heidenhain,^® Franz Hofmeister,^" H. J. Ham- burger,-" Rudolph Hober,-^ G. B. Wallace and A. R. Cushny,^^ Otto Cohnheim,-^ E. Waymouth Reid,^* and G. Kovesi,-^ the following are familiar facts : When water is introduced into a segment of intestine it is rap- idly absorbed. All salt solutions, so far as the water in them is concerned, are absorbed less rapidly than in pure water. The concentration of the salt solution is an important factor in this phenomenon. When sodium chloride solutions of various con- centrations are compared, it is found that they are absorbed the more slowly the higher the concentration of tr.e salt. If suffi- ciently strong solutions are employed there mi.y first result a pouring out of liquid into the lumen of the gut, so that the solu- tion becomes diluted, after which it is slowly absorbed. When the absorption of equimolecular (or better, osmotically equivalent) solutions of different salts is studied, it is found that these are absorbed at very different rates. The effect of the pres- ence of any salt in a solution upon the absorption of water from that solution may be expressed as follows : With a given base, the anions arrange themselves in the following order, where that which retards the absorption of water least is given first : Chloride, bromide, iodide, nitrate, sulphate, phosphate. With a given acid, the order of the kations is as follows (R. Hober), that least ef- fective in preventing the absorption of water being given first: Potassium, sodium, calcium, magnesium, barium. It is easy to see that the order of the various salts is practically identical with that found above in the experiments on peritoneal absorption. The position of the acetate, tartrate and citrate, not given in the above ion lists, can be determined by consulting the tables of Wallace and Cushny, when it is found that these two occupy a place in the absorption of water from the gut which is the same as that occupied by them in the case of peritoneal absorption. With any of these salts as with ordinary NaCl the delay in 242 DANDRIDGE MEMORIAL the absorption of the water grows in every instance with the con- centration of the salt. A point is finally reached where such water as is introduced into the intestine is not only not absorbed, but water is secreted into the gastro-intestinal tract. This point of concentration lies high in the case of sodium chloride, sodium bromide, etc., but very low in the case of sodium sulphate, phos- phate, tartrate, citrate, etc. This is one of the chief reasons why the last named are known as "saline cathartics." Point for point, therefore, the absorption and secretion of water by the perito- neum is identical with th2 absorption and secretion of water by the gut, and both are comparable with the absorption and the secretion of water by simple colloids when placed in like sur- roundings. The identity of the processes of absorption from the peritoneal cavity and from the intestinal lumen goes even further than this. The rapid absorption of aqueous solutions of various alcohols from the intest'nal tract shows that these non-electrolytes do not interfere with the absorption of water here even when they are present in concentrations osmotically equivalent to those of the active salts. Neither do the alcohols delay the absorption of water by the peritoneum. Sugar solutions and glycerine, on the other hand, behave in the intestinal tract so far as the absorption of water from their solutions is concerned, as they do when intro- duced intraperitoneally. The slow absorption of water, or, in response to a solution of sufficiently high concentration, the actual secretion of water into the gut, is evidenced not only by direct experiment but by every-day clinical experience. Are not the sugars, when consumed in any considerable quantities, cap- able of producing watery stools (independently of any previous fermentation with the production of organic acids), and do not glycerine enemas produce the same secretion of water into the bowel that results when enemas containing any of the saline ca- thartics are employed? Furthermore, we have interesting parallels of experiments which show that water when united with an emulsion colloid is incapable of being absorbed without first being freed. Protein solutions (such as egg white) are practically not absorbed from the intestinal tract unless proteolytic ferments are present which, FISCHER 243 by acting on the proteins chemically, destroy their markedly emul- sion colloid character, and so liberate the water held by them. In this way also can we understand the behavior of cellulose and especially agar-agar in preventing constipation. The com- monest cause of constipation resides in the too perfect absorp- tion of water from the gastro-intestinal contents. It is a time- honored custom to suggest the addition of vegetables to the diet of such individuals. In addition to the action of the salts, (ci- trates, tartrates, etc.) obtained from vegetables and the effects of the production (through fermentation) of certain organic acids in the bowel which alone tend to prevent a too great ab- sorption of water from the gastro-intestinal contents, the high cellulose content of such a diet (that is to say its high emulsion colloid content) makes it impossible for the mucosa to get the water out of it. Since cellulose is not changed (except very slightly by certain bacteria) in its passage through the gastro- intestinal tract, it retains all the water with which it was saturated before being consumed, or with which it saturates itself in its course through the alimentary tract. The same explanation holds for agar-agar or the feeding of any of the Japanese sea weeds from which this is prepared. Agar-agar is a typical emulsion colloid which is incapable of being affected chemically in its pas- sage through the gastro-intestinal tract (L. B. Mendel and Saiki), and so any water that it may have absorbed before being swal- lowed, or may absorb in the gastro-intestinal tract, is retained. In this way the inspissation of the gastro-intestinal contents (and so the constipation) is prevented. 2. Elsewhere,-^ I have pointed out how secretion from such an organ as the kidney is the mirror image of absorption, as it occurs from the alimentary tract, for example. As a high carbon dioxide content of the blood (venous blood) favors the absorp- tion of water, so only a low content (arterial blood) will main- tain the secretion from the kidney. As water united to emul- sion colloids cannot be absorbed, so water united to emulsion colloids cannot be secreted. All the substances that interfere with the absorption of water from the alimentary tract favor the se- cretion of urine, those that interfere most with the absorption of water (saline cathartics) being those that induce the greatest 244 DAN BRIDGE MEMORIAL diuresis (saline diuretics) etc. The "selective" absorption of dissolved substances from the alimentary tract corresponds with a "selective" secretion from the kidney. In both cases this rep- resents an attempt to establish an equilibrium in the distribution of each of the dissolved substances either "absorbed" or "secre- ted" betw^een the three phases constituting any absorptive or secretory system. / would now like to point out that the formation of lymph is entirely analogous to the secretion of urine and is governed by similar laws- The "secreting membrane" in this case is found in the cells and the intercellular substances that separate the blood capillaries from the lymph capillaries. It is, of course, clear that these cells and their intercellular substances constitute the bulk of the body tissues. Anything that makes these cells with their intercellular substances yield up water increases lymph flozi^. Let us first call attention to the fact that an increased arterial circulation to a part increases lymph flow. A classic experiment in this line is the observation that an increased lymph flow from the neck is obtained when the salivary glands are active (supplied with much arterial blood). Under such circumstances various tissues in the neck are rapidly freed of their carbon dioxide (and other acids). This decreases the capacity of their colloids for water, and so they give it up, in part to the blood, in part to the lymph. All salt solutions, when injected into the blood in sufficiently concentrated solutions, increase lymph flow. \Mien sodium chlor- ide, sodium bromide, etc., are employed, these have to be injected in (osmotically) stronger solutions than when sodium sulphate, sodium phosphate, etc. are used. The same thing happens in ex- perimental diuresis. These experiments on the formation of lymph are easily explained by saying that the salts diffuse into the tissues and make these give up their water which then passes in part into the blood, but in part again, into the lymphatics. A similar explanation can be given of the "lymphogogue" action of various sugars. Physostigmine and pilocarpine increase lymph flow ; atropine and morphine decrease it. In the doses ordin- arily used, the former makes in toto for an increased supply of oxygen and the more rapid removal of carbon dioxide from the FISCHER 245 cells, the latter for a decreased one. While the former means a decrease in the capacity of the tissue colloids to hold water, the latter means an increase; these in turn mean a giving up of fluid to the lymph in the first case, and none available for such a pur- pose in the second- 3. In this connection a word may not be amiss in calling attention to the useful purpose served by the vasomotor mechan- ism in this whole problem of absorption and secretion. Changes of both a quantitative and a qualitative character must of course follow the changes consequent upon any variation in the calibre of the blood vessels supplying a part. With blood of a given composition, it is evident that with a vaso-dilatation more blood will flow through a part, and so the opportunities for absorption or secretion whether of water or dissolved substances be in- creased. But such quantitative changes in the blood flow through a part affect at the same time the chemical and physico-chemical character of the cells in that part, and so a series of qualitative changes in the character of the absorption or the secretion are added to the quantitative changes already noted. It is these facts that we have to bear in mind when we attempt the analysis of the various phenomena that characterize absorption and se- cretion as observed, for example, in a mammal. The organs that are predominantly secreting organs (kidney, salivary glands, stomach, pancreas) are all supplied with large arteries and when these glands are active, their arteries are di- lated. The supply of highly arterialized blood which makes pos- sible the secretion of gastric juice (as it makes possible the secre- tion of urine) makes it impossible at the same time for this organ to act as an absorptive organ. And experimentally we know the stomach to act indifferently well in this direction as far as water absorption is concerned. Other substances can, of course, be ab- sorbed from the stomach (alcohol, salts) and be secreted into it (various salts) independently of any absorption of water. Failure to absorb water only means, of course, that the stomach wall, and the (arterial) blood coursing through it is saturated with water — the three phases of the system are in equilibrium so far as their water content is concerned. In so far as any dis- solved substance is not distributed in such a way through the three 246 DAN BRIDGE MEMORIAL systems as to be in equilibrium, it must move into the stomach wall and the blood be absorbed, or out of these (be secreted) into the gastric contents until the equilibrium is established. When the rich supply of arterial blood to a secreting organ fails, no secretion occurs, as can be seen particularly well in the kidneys, the salivary glands, etc., when their blood supply is cut down either through experimental constriction of the arteries supply- ing them, or when the vaso-constrictor nerves are stimulated. It is true that no secretion may occur with even an abundant arterial flow to the secreting cells, but this is only possible if the nonnal chemistry of the cells constituting the secreting mem- brane is first interfered with, as after poisoning with atropine, which so interferes with the chemistry of oxidation in the cells that they are put in a state of lack of oxygen in spite of all that is flowing by them. We can also understand the meaning of some of the morpho- logical changes observed in the cells of any secreting organ so situated as to have alternate periods of rest and activity. While the process differs somewhat in different cells, it may be stated in general that the cells become larger during rest, and smaller during activity. The interpretation of this very simple fact is very complicated as given by different authors. Need we say more than that they absorb water (become edematous) when arterial blood is scarce and they cannot get rid of their carbon dioxide easily ; and that they secrete water, that is, shrink, when the car- bonic and other acids that may be produced in the cells when oxygen is scarce, are removed through a better arterial blood sup- ply? With the swelling of the cells during a period of rest there is an accumulation of granules in the cells. Most extravagant interpretions have been made of their physiological significance. Need they be anything more than protein (including mucin) pre- cipitates occurring in the bodies of the cells because in the period of glandular rest the reaction of the cell protoplasm tends to move toward the acid side ? When the granules disappear during glan- dular activity it simply means a reversal of the process — they go back into solution as the reaction moves back toward the neu- tral point or the alkaline side. The changes observed during rest and activity of the salivary glands, pancreas, etc., therefore FISCHER 247 become similar to the changes of "cloudy swelHng"" observed in the liver or kidney in various pathological states (including inter- ferences with the arterial blood supply to the cells making up these organs). 4. After what has been said it is evident that no very great differences exist between the essential nature of absorption and of secretion. Secretion is only the mirror of absorption. This truth seems simple enough, and yet it cannot be said that it has received any special attention from the workers in experimental medicine or physiology. And yet it ought to, for absorption and secretion in a complex animal bear a reciprocal relation to each other. It is because this fact has been ignored that much of the present confusion exists in our ideas regarding absorption and secretion. An adult organism in order to continue alive has to maintain a certain constancy of physico-chemical composition. It follows that if it absorbs anything it must secrete this again within a reasonable time thereafter. It is in this "reasonable time" and the conditions that are at the bottom of the fact that this "reason- able time" has to intervene between the absorption and the secre- tion of any substance that makes us lose the connection between the two, even when we deal with the absorption and secretion of substances (water, certain salts) which are not chemically changed in the body. When these facts are borne in mind, the surprise expressed by some authors that atropine or morphine which decrease various secretions do not similarly decrease ab- sorption from the gut or the peritoneal cavity disappears. Hardly! These substances favor the formation and accumula- tion of acids in the tissues of the body, therefore, no secretion. Hence we should discover an increased absorption of water after use of these drugs, which, in fact, we do. Other anesthetics act like morphine, and other drugs like atropine- When we use such agents in our experiments we have to remember what they do, and not ignore them when we come to interpret our findings. Operations, animal boards and physiological apparatus produce collectively effects similar to drugs, so these too must not be ignored. It is for this reason, as I stated above, that all these procedures must be reduced to a minimum if we would complete 248 DANDRIDGE MEMORIAL our analysis of just what constitutes the physiology and the path- ology of absorption and secretion. IV, After these remarks on the general nature of absorption and secretion, let us return for a moment to the explanations of these phenomena that have been given by other authors, and select from them not only the elements which we ourselves think to be correct, but point out at the same time with the help of a few examples, how certain experiments which have long stood as the bulwark of "physiological" or "vitalistic" interpretations of certain life phenomena are easily explained on the colloidal basis, and how experiments that have been held to support other theo- ries of absorption fall in with the colloidal one. 1. For half a century various authors have held that filtra- tion plays an important part in the absorption of liquids. Ac- cording to definition, filtration represents the passage of a liquid through a separating membrane of some sort in consequence of differences in hydrostatic pressure. On this basis it has been held that a liquid is forced from the lumen of the gut or from the peritoneal cavity into the blood because of a pressure within the gut or peritoneal cavity (produced through gas or the action of muscles of various kinds) which exceeds the pressure in the blood. Such a belief has been supported by the experiments of Leubuscher and H. J. Hamburger,^^ who found that with an increase of intra-intestinal or intra-abdominal pressure there resulted an increase in absorption, at least up to a certain point. Without, for a moment questioning the correctness of the ex- perimental finding itself (a serious experimental error enters into it) we know that such an intra-intestinal or intra-abdominal pressure is not necessary for absorption. E. Waymouth Reid-^ found absorption (of water) to occur from the intestine of the dog, when the pressure within the gut was decidedly lower than that in the mesenteric veins, and Hamburger himself describes experiments in which he observed a ready absorption of water from the peritoneal cavity when the abdomen of the animal was opened or when the animal was dead. After what has been said above regarding water absorption as a colloidal phenomenon FISCHER 249 these findings are entirely to be expected. What is needed is an interpretation of Leubuscher and Hamburger's experiments with changes in pressure. Leubuscher's result has been explained by saying that through increased intra-intestinal pressure the folds of the intestinal mucosa are smoothed out, and so an increased surface of the gut is rendered available for absorption. But this explanation has not been accepted as complete by Hamburger, who found an increased absorption from the gut with every increase in pressure up to a certain point, even after surrounding the intestine with a wire cage which prevented its unfolding. In explanation of Hamburger's result, I would agree with the view that with the first increase in pressure the flow of blood out of the veins is favored. In consequence of this the blood flow through the gut is favored ana so the conditions for ab- sorption- With a further increase in pressure, the blood vessels are compressed, and now the blood flow is diminished, in conse- quence of which a decrease in absorption is observed, as Ham- burger found. I am not even inclined to accept the view of those authors, who, while unwilling to look upon filtration as an important factor or as the most important factor in the passage of liquid from one region to another, nevertheless consider that it is of some physiological importance. To my mind, this cannot have a magnitude any greater than, say, the theoretical "solubility" of quartz in water, for the membranes in health through which water is supposed to be forced are built up of emulsion colloids, and the differences in pressure available in the body for filtra- tion through the membranes existing here, have a value approxi- mating zero, when compared with the enormous pressures re- quired in the laboratory to force water through the thinnest layers of such emulsion colloids as gelatine. 2, The question of osmotic pressure (even as modified through the conception that the surface layer of the cells is lipoidal in character) in the problem of water absorption from the gut needs no special discussion — its inadequacy to explain the phenomena of absorption as observed here is admitted on all sides. That it continues to be widely held as of fundamental biological importance results no doubt from the fact that we 250 DAN BRIDGE MEMORIAL have had nothing more adequate to substitute for it ; and any number of biological workers have been unwilling to believe that a present inability to explain on a purely physico-chemical basis all the phenomena observed in the processes of absorption or secretion presages that such an explanation will never be forth- coming, and that, in consequence, support is lent "physiological" or "vitalistic" conceptions of absorption or secretion. It seems to me that on the basis of what has been said in these pages and in some of my previous papers, we are now in a position where we not only may, but must, discard the osmotic conception of cell behavior so far as water absorption is concerned. We must also discard it so far as the absorption of dissolved substances is concerned. If cells were surrounded by semi-permeable films, as is de- manded by the osmotic theory of water absorption, dissolved substances would neither get into them nor out of them. Yet both these processes must be possible, as well as the movement of water into and out of cells, otherwise their life would cease. Dissolved substances get into and out of cells by diffusion. The role of this factor has been recognized and discussed as active in the processes of absorption and secretion since the days of Carl Ludwig. R. Heidenhain succeeded in minimizing the value of this process in the analysis of the whole problem by showing that an absorbed fluid or a secretion usually differs in quanti- tative composition from the source from which it was derived. On this is based his belief in the selective "physiological" char- acter of absorption and secretion. There is nothing surprising about these phenomena to us. We expect them, in fact. As has been said, a solution is never absorbed {or secreted) as such. Whenever a solution is seen to be absorbed (or secreted), we are observing the composite of the absorption (or the secretion) of the solvent plus the absorption (or secretion) of each individual substance dissolved in that solvent- When any solution is intro- duced into the intestine, for example, each one of the dissolved substances diffuses into the wall of the intestine until an equi- librium is established in the distribution of each of these sub- stances between the (liquid) phase represented by the solution and the more solid phase represented by the (colloidal) intes- FISCHER 251 tinal wall. Similarly, every substance present in the intestinal wall tends to diffuse out into the solution to the establishment of an equilibrium. In biological material it has been very generally assumed that the distribution of dissolved substances between two such phases attains an equilibrium when the concentration of any dissolved substance is the same in both. Such an a priori conclusion is entirely unjustified. We deal in this problem with the distribu- tion of a dissolved substance between water and a colloid, and, as we know from the facts now available on this subject, equi- librium may be reached when the dissolved substance is con- tained in less, the same, or a higher concentration in the colloid than in the solution surrounding it. Now, while the absorptive membrane is trying to get into equilibrium with the solution to be absorbed on the one side, it is also trying to get into equi- librium with the blood on the' other. The whole absorptive system therefore really consists of three phases, (1) the material to be absorbed, (2) the colloidal absorbing membrane, (3) the liquid colloidal blood. The problem of the "selective" absorp- tion of the dissolved substance is the problem of the agencies concerned in establishing an? equilibrium between all the various dissolved substances in these three phases. As is familiar to everyone, the factors of greatest importance in such a problem are the character of the various colloids con- cerned, and their physico-chemical state as determined through the presence of acids, alkalies, salts and various non-electrolytes ; the nature of the dissolved substance to be absorbed, as its rate of diffusion ; the presence or absence of lipoids in the colloidal absorbing membrane and in the blood, etc. In other words, the laws of adsorption, of partition, and of chemical combination are all at work. To the process of simple diffusion in this matter of absorption (or secretion) become added therefore a series of secondary phenomena that obscure its purity. To illustrate what has been said, let us try to follow the rela- tively simple process of the absorption of a strong (so-cal'ed hypertonic) sodium chloride solution when this is introduced into the peritoneal cavity, or into the intestine. Both the water and the salt begin immediately to diffuse into the absorbing mem- 252 DANDRIDGE MEMORIAL brane. As this progresses, the concentration of the sodium chloride in the absorbing membrane rises. This rise in concen- tration so affects the colloids of the absorbing membrane ihat they stop taking up water, or, if sufficiently strong, an actual secretion of water into the peritoneum or the gut may follow. While this is occurring, an equilibrium is tending to be estab- lished between the concentration of the sodium chloride in the solution undergoing absorption and the sodium chloride in the absorbing membrane. But this is never attained under normal circumstances, because the salt in the absorbing membrane is at the same time trying to get into equilibrium with the sodium chloride in the blood. Now, since this is circulating, it is evident that the equilibrium is constantly being broken down toward the side of the blood- In consequence of this, more and more salt must move over into the blood (be absorbed). But, as this occurs, the state of the colloids of the absorbing membrane again returns to a more "normal" state and so the absorption of water, which could not occur before, can again take place. With a dilute (a hypotonic) solution of sodium chloride the water does not meet with so great a resistance to absorption, and it is possible for a dilute salt solution to become more and more concentrated as the water is (the more rapidly of the two) ab- sorbed from it. Even salt solutions isotonic with the blood must be absorbed. Though such a solution cannot be absorbed on the osmotic basis because no osmotic differences exist in such a case to make the water move, there is no difficulty in interpreting what happens on the colloidal basis. Let the colloids of the absorbing mem- brane take a little water from the isotonic solution and salt must quickly follow, for now its concentration is no longer in equi- librium with that of the sodium chloride in the absorbing col- loidal membrane. Then more water goes in, and then more salt, until all is absorbed. Or we could start the absorption by having a little salt go in first and then the water, etc., for if the truth be told we do not yet know just what concentration characterizes the "isotonic" solution, nor shall we until the colloidal consti- tution of living matter has been adequately taken into account. In a final word, let it be added that, on the basis of these FISCHER 253 conceptions of absorption, we experience no difficulty in under- standing why any solution remaining for longer periods in the peritoneal cavity or in the intestine may, while it is being "ab- sorbed," has substances found in the blood or tissues appear in it which it did not originally contain. As dissolved substances diffuse out of a solution undergoing absorption into the absorb- ing membrane until an equilibrium is established, just so, of course, must the substances contained in the absorbing mem- brane tend to diffuse into the solution. It has been generally held that this diffusion of salts (and other substances) out of an absorbing membrane into a solution that is being absorbed con- stitutes "an attempt to establish osmotic equilibrium between the two." As a matter of fact such a conclusion is premature if nothing more. We do not yet know all the factors involved in determining the point of equilibrium in the body in the distri- bution of the various dissolved substances between the phases concerned. One thing, however, is certain and that is that the final equilibrium is not a simple osmotic equilibrium. This is clearly enough evidenced not alone by the well-known fact that the physiological behavior of different salts, in this process of absorption, for example, bears no relation to the osmotic con- centration of the dissolved substances, but by the further fact that the distribution of most substances between a colloid and a solution is practically never the same in both. The "selective" character of absorption" and secretion depends upon the fact that the absorption and secretion of water in the living organism is a process entirely separate from the absorption and the secretion of dissolved substances, and of the latter each moves at its own rate, and is influenced in its mvvem£nt by factors that may not affect the others in the same way or to the same degree. When these facts are remembered the "selective" character of both absorption and secretion cease to produce astonishment — it would be more marvelous were it not selective. 3- The workers in physiology and experimental medicine, who have called attention to the "secretory" and "physiological" activities of absorbing and secreting membranes and to the "physiologische Triebkraft" situated in them, are deserving of blame or praise depending upon whether they have used these 254 DANDRIDGE MEMORIAL words in the despairing attitude of those biological workers who believe that life phenomena will never be interpretable solely in the terms of the physical sciences, or as convenient heads under which to group certain of the phenomena of absorption and se- cretion which could not be so analyzed at the time that they pros- ecuted their scientific studies. But the necessity of retaining these terms, even in the latter sense, may now largely disappear. The "secretory" activities of absorbing and secreting membranes as evidenced through their "selective" absorption and secretion of water and dissolved substances we have already discussed in the preceding paragraphs. The "physiological" activity of such membranes retains a meaning only in the sense that the absorb- ing and secreting membranes of multicellular organisms contain living cells and in each of these there are occurring well ordered series of chemical and physico-chemical reactions which are capable of influencing the colloidal constitution of these mem- branes. To do this is to influence the nature of the phases and the conditions of equilibrium in our secretory systems, in other words, secretion and absorption. But these reactions are not impossible to analyze. The need for the "physiologische Triebkraft" also disappears. Such was originally called upon for help in the contemplation of such a fact as that the absorption of a solution can occur from the intestine, for example, when the pressure under which it stands in the lumen of the gut is less that the pressure of the blood in the mesenteric veins through which it is being absorbed (E. Waymouth Reid). Such a view regards absorption as a process in which water is forced into the tissues. This is not what happens. It is sucked in, and such a process can occur even when the hydrostatic pressure in the veins happens to be a few millimetres above that in the lumen of the intestine. The pressures produced in the swelling of emulsion colloids are enormous as compared with the highest hydrostatic (arterial blood) pressures ever observed in animals possessed of a circu- lation. The use of "physiological" poisons to illuminate the "physiological" element in absorption or secretion proves noth- ing. Such poisons simply constitute a direct or indirect means of altering the physico-chemical state of the absorbing or se- FISCHER 255 •creting structures. And is it not the problem of physiology to state in terms of physics and chemistry just what this "normal" absorption and secretion is? When we use a "physiological" poison we have to explain the action of the poison along with what constitutes "normal" ab- sorption and secretion. Nothing has perhaps so effectively hampered the acceptance of the belief that absorption and secretion would ultimately prove themselves completely analysable physico-chemically, and fostered the continuation of the "physiological," "secretory," etc., notions of absorption and secretion as a series of experi- ments first described by R- Heidenhain, and more recently re- peated in modified form by E. Waymouth Reid and Otto Cohn- heim. The most striking of these is the often quoted experi- mental finding that a dog will absorb his own blood serum. A word regarding the experiments of this character serve to show how they are interpretable on the basis of the colloidal theory of water secretion and absorption. In not one of these experiments, except zvhere the possibility of the presence of proteolytic fer- ments is not excluded, is the serum or plasma completely ab- sorbed. The reason why some is absorbed, but never all, is clear from the following: Blood serum and blood plasma are not blood ; they are blood minus much of its emulsion colloid content. They are not solu- tions in which all the water they contain is bound to colloidal material as in normal blood, but they contain "free" water over and above that necessary to saturate the colloids remaining in the "serum" or the "plasma." When they are introduced into the intestine they are therefore absorbable but only in so far as they contain free water (and a certain proportion of salts, urea, etc.) The absorption comes to a halt as soon as water has been absorbed down to the point where water is combined with colloid. In these experiments, things are therefore not the same on both sides of the absorbing membrane. The animal does not absorb serum or plasma as such, much less what these authors seem at times to try to have us believe, namely, something identical with blood itself. The animal absorbs some water and a few dis- solved substances, and it does this for the same simple reasons 256 DANDRIDGE MEMORIAL that it absorbs under similar circumstances an ordinary "physio- logical" salt solution. 4. Of the different factors that are catalogued in our treatises on physiology, and which have at various times and in various ways been looked upon as active in this problem of absorption and secretion, only one remains to be discussed — that of imbibi- tion. What Adolph Fick^° has called molecular imbibition is but another term for what we to-day call the absorption of water by an emulsion colloid. It is, therefore, of interest that mention is made of imbibition as being important in the general problem of absorption as far back as 1881.^^ But the real significance of imbibition as a factor concerned in absorption was only pointed out more recently by H. J. Hamburger-^- This author correctly emphasized the theoretical importance of his observation that anim.als absorb various solutions from their peritoneal (and other serous) cavities after death. While we cannot agree with the details of his ideas outlining the way in which the forces of imbibition act normally, a discussion into which it is not necessary to go here, there is no disputing his claims that imbibition plays a role. But Hamburger does not regard imbition as the most significant factor in absorption, and continues to hold to the ideas of filtration, osmotic pressure and the "mitschleppende Wirkung" of the circulation as also concerned in the process. Nor does this author suggest any way by which a fluid absorbed by imbibi- tion is again gotten rid of. In view of all this it seems to me that we owe a special debt to Franz Hofmeister,^^ who, as early as 1891, pointed out that the salts which make (partially) water soaked gelatine discs give off their water (secrete it) are identical with the so-called saline cathartics, and suggested that the two processes are in essence the same. In spite of the nu- merous papers on alimentary absorption and secretion, and on the mode of action of the saline cathartics that have appeared since Hofmeister's writings, there seems little question that we are destined to return to Hofmeister's conclusions, and find in them not only an explanation of the mode of action of these cathartic salts, but a model of that which constitutes the essence of absorption and secretion. 5. The analysis of the problems of absorption and secretion FISCHER 257 could already be carried with entire safety beyond the limits outlined in this and previous papers which have had as their chief aim the mere establishment of the thesis that the colloids and their physical state determine both the quantitative and the qualitative character of the absorption and the secretion of water and dissolved substances by protoplasm.^* This will be the pur- pose of a future communication. In passing, however, attention must be called to the excellent service that will be rendered the further analysis of the problem by the theories of the colloidal state which are becoming progressively more clearly defined. Especially helpful to the biological worker must become the con- clusions of Wolfgang Pauli,^^ and his co-workers,^^ more par- ticularly Hans Handovsky,^^ and Karl Schorr.^* With them we could, for example, define every increase in the absorption of water by a tissue as an increase in the degree of the hydration of the colloids contained in it, while secreticii itself and the various processes that favor secretion represen, in toto means which decrease such a hydration. The theoretical elucidations of the process of absorption and secretion of dissolved substances will necessitate that adequate use be made of Wolfgang Ostwald's^^ work. Ostwald has shown that the mathematical formulas of adsorption are appli- cable to the process of absorption (intoxication) as shown in certain fresh water animals (Ganimartis) when they are placed in solutions of various kinds. It is evident that these animals swimming about in a solution are no differently situated than a group of cells, say in the mucous membrane of the intestine which are bathed by such a solution. But Ostwald has developed the biological significance of what represents in a sense the mirror image of the absorption formula, namely, the washing- out formula. This may be used to express mathematically the "toxic effect" of distilled water upon these animals — an effect brought about by the diffusion of the salts contained in the animal out into the distilled water- It is evident that the leaching out of dissolved substances from the kidney by the pure water originally secreted from the organ constitutes the parallel of this "toxic effect" of the distilled water on Gammanis. Ostwald has further shown that the effect of a solution having but one salt 258 DANDRIDGE MEMORIAL dissolved in it is the composite of the absorption effect of that salt plus the washing-out effect of all the other salts contained in the animal but absent from the solution that is being experi- mentally employed. This phenomenon has its analogue in the experimental absorption of any pure solution from the intestinal tract of a mammal, for example, in which, as was noted above, there is a "secretion" of dissolved substances from the intestinal wall into the gut, while the dissolved substance originally intro- duced is being "absorbed," SUMMARY. In this paper is continued the discussion of absorption and secretion in the higher animals from the viewpoint of colloid chemistry. Absorption and secretion are defined as mirror images of each other, not alone because the one process is the biological reverse of the other, but because the conditions that favor the one, liinder the other, and vice versa. After reviewing the evidence which shows that no essential difference exists be- tween absorption and secretion in a unicellular organism and absorption and secretion in a multicellular organism, it is pointed out that all which remains to characterize absorption and secre- tion in the multicellular organism is its one-sided character — that the intestine is, for example (predominantly), an absorbing organ, while the kidney is (predominantly) a secreting one. This difference between the behavior of any unicellular organism and the individual absorbing or secreting cell of a multicellular organism is brought into connection with the fact that while the former is surrounded on all sides by the same medium, the latter is in contact with different media at different parts of its proto- plasm. Absorption and secretion in the former represent the single attempt of getting into equilibrium with the one medium surrounding it ; in the latter, the attempt to get into equilibrium with two or more media. Out of the latter grows the fact that absorption and secretion in the higher animals occur predomi- nantly in one direction. The fact is emphasized that the absorption or the secretion of any solution is never a single process — it is the composite of the absorption or the secretion of the solvent plus the absorption or FISCHER 259 the secretion of each individual substance dissolved in that solvent. A series of experiments on peritoneal absorption is then detailed. It is pointed out that the absorption of the solvent, the water, from the injected solutions is identical with the absorption of water by such emulsion colloids as fibrin or gelatine when these are exposed to the same external conditions. Peritoneal absorption is next shown to parallel point for point absorption from the intestinal tract, and both of these are then shown to be the mirror image of secretion as occurring from the kidney. Evidence is adduced to show that the formation of lymph is analagous to the secretion of urine. The absorption and secretion of dissolved substances, and their selective character, are held to be dependent upon the unequal distribution of the dissolved substances between, what we may call broadly speak- ing, three phases (water, secreting or absorbing tissues, blood) that constitute every absorptive or secretory system in one of the higher animals ; and it is pointed out how this is entirely analagous and explainable on the same grounds as are inequalities observed in the distribution of dissolved substances between three such phases as water, a solid colloid and a liquid colloid. The prevailing theories of absorption and secretion are touched upon in brief review and criticized. Filtration is held to be of no real interest in the problem under physiological conditions. Diffusion is looked upon as of fundamental importance both in the matter of determining the rate of absorption and secretion and their character, though owing to the colloid constitution of living matter diffusion does not appear in as pure a form in bio- logical material as in a homogeneous solvent. The osmotic con- ception of water absorption is cast aside. It is briefly indicated how experiments which are designed to support "physiological," "secretory" or "vitalistic" conceptions of absorption or secretion do not do so, but are interpretable in the terms of the colloidal theory of water absorption and the inequalities in the distribution of dissolved substances between the various phases constituting the absorptive or secretory system. As of greatest value in the theoretical formulation of the problem are held certain scattered remarks to the effect that imbibition plays a role in the process of absorption (von Wittich) and the clearer experimental demon- 260 DAN BRIDGE MEMORIAL stration of this fact by Hamburger; and in the problem of secre- tion Hofmeister's clear-cut expression of the truth that secretion of fluid into the intestine under the influence of the saline ca- thartics is identical with the loss of water by swollen gelatine plates when immersed in solutions of these same salts. BIBLIOGRAPHY. 1 Martin H. Fischer: American Journal of Physiology, 20, 330 (1907) ; Pfliiger's Arch., 124, 69 (1908) ; Journal of the American Medical Asso- ciation, 51, 830 (1908); Pfliiger's Arch., 125, 99 (1908); Ibid., 125, 396 (1908); Ibid., 127, 1 (1909); Kolloidchemische Beihefte, 1, 93 (1910); a running account is found in "Edema," New York, 1910. 2 Martin H. Fischer: "Edema," 184, New York, 1910. 3 R. Heidenhain : Hermann's Handbuch der Physiologic, 5, Leipzig, 1883; Pfliiger's Arch., 56, 579 (1894). 4 E. Waymouth Reid : Schafer's Text-Book of Physiology. 1, 261, London and Edinburgh, 1898; Phil. Trans. Royal Soc, 192, 231 (1900); Journal Physiol., 26, 436 (1901). 5 E. H. Starling: Schafer's Text-Book of Physiology, 1, 285, London and Edinburgh, 1898. Oppenheimer's Handbuch der Biochemie, 3, 206. Jena, 1909. 6 H. J. Hamburger : Osmotischer Druck und lonenlehre, 2, 95, Wies- baden, 1904. 7 E. Overton : Nagel's Handbuch der Physiologic, 2, 774, Braun- schweig, 1907. 8 O. Cohnheim : Nagel's Handbuch der Physiologic, 2, 607, Braun- schweig, 1907. 9 R. Hober : Koranyi-Richter, Physikalische Chemie und Medizin, 1, 295, Leipzig, 1907. 10 Starling and Tubby: Journal of Physiol., 14, 140 (1894); Starling: Schafer's Text-Book of Physiology, 1, 304. Edinburgh and London, 1898. 11 Orlow: Pfluger's Archiv, 59, 170 (1895). 12 H. J. Hamburger: Arch. f. Anat. u. Physiol., 281 (1895). 13 C. Schmidt : Vierordt's Daten und Tabellen, 97, Jena, 1888. 14 J. Munk and Rosenstein : Arch. f. Physiol., 376, 1890. 15 Martin H. Fischer: Edema, 180, New York, 1910. See chapter on urinary secretion. 16 James J. Hogan and Martin H. Fischer : Kolloidchemische Beihefte, 3 (1912). 17 Voit and Bauer: Zeitschr. f. Biol., 5, 536 (1869). 18 R. Heidenhain: Pfliiger's Arch., 56, 379 (1894), 62, 331 (1896). 19 Franz Hofmeister: Arch. f. exp. Path. u. Pharm., 28, 210 (1891). 20 H. J. Hamburger : Osmotischer Druck und lonenlehre, 2, 168, Wies- baden, 1904, where reference to his earlier papers will be found. 21 Rudolph Hober : Pfluger's Arch., from 70 on ; see his many papers during the years 1898 to date. 22 G. B. Wallace and A. R. Cushnv: Am. Journal Physiol., 1, 411 (1898) : Pfluger's Arch., 77, 202 (1899). 23 Otto Cohnheim: Zeitschr. f. Biol., 21, 85 (1897); 22, 56 (1898); 26, 427 (1901). 24 E. Waymouth Reid: Journd of Physiol., 21, 85 (1897); 22, 56 (1898); 26, 427 (1901). 25 G. Kovesi: Centralbl. f. Physiol., 11, 553 (1897). 26 Martin H. Fischer : Edema, 184, New York, 1910. FISCHER 261 27 For a discussion of the nature and the cause of cloudy swelling see Martin H. Fischer: Kolloid Zeitsch., 8, 159 (1911); 8, 201 (1911); or Nephritis, New York, 1911. 28 H. J. Hamburger: Osmotischer Druck und lonenlehre, 2, 176, Wies- baden, 1904. 29 E. W. Reid: Philosoph. Trans. Royal Soc, 192, 231 (1900). 30 Adolph Fick : Medizinische Physik., 3te Aufl., 31, Braunschweig, 1885. 31 W. von Wittich : Hermann's Handbuch d. Physiol., 5, 2ter Theil, Leipzig, 1881. 32 H. J. Hamburger : Osmotischer Druck und lonenlehre, 2, 108 and 164, Wiesbaden, 1904. 33 Franz Hofmeister: Arch. f. exp. Path, und Pharm., 28, 210 (1891). 34 For a discussion of the role of lipoids in absorption, which I hold do not act as lipoidal films about cells, see my Edema, 85 and 160, New York, 1910. 35 Wolfgang Pauli : Kolloid Zeitschr., 7, 214 (1910). 36 Wolfgang Pauli und Hans Handovsky: Biochem. Zeitschr., 18, 340 (1909). Z7 Hans Handovsky: Kolloid Zeitschr., 7, 183 and 267 (1910), where references to earlier papers will be found. 38 Karl Schorr: (Cited by Pauli and Handovsky). 39 Wolfgang Ostwald: Pfliiger's Arch., 120, 19 (1907); Kolloid Zeit- schr., 2, 108 and 138 (1907); Uo. Ostwald und A. Dernoscheck: Kolloid Zeitschr., 6, 297 (1910). THE RELATION BETWEEN THE CYTO-RETICULUM AND THE FIBRIL BUNDLES IN THE HEART MUSCLE CELL OF THE CHICK.* HENRY LEWIS WIEMAN. In the great mass of literature that has appeared on the subject of the striated muscle, no account apparently exists of the histo- genesis of the heart muscle of the chick. This seems rather strange in face of the fact that the chick always has been the classic subject for embryological research. The present study was undertaken for the purpose of determining the structures existing in the heart muscle cell of the chick, especially for com- parison with results of similar work that has already been done on other vertebrate forms. The particular phase of the histogenesis treated in this paper is the relation between the cyto-reticulum of the embryonic cell and the fibril bundles as found in the adult muscle tissue. To avoid any possible confusion or misunderstanding, a definition of terms here at the outset will perhaps not be amiss. By cyto-reticulum, the writer means the deeply staining net- work found traversing the cytoplasm of early embryonic cells. The fibril bundles, corresponding to the "Muskelsaulchen" of Koelliker, 02, are the striated longitudinally disposed masses run- ning the length of the adult cell. Each fibril bundle is composed of more elementary parts called fibrils. On account of the abundance of material and the ease with which the various stages in the development of the cell can be se- cured, the chick is very well adapted to a study of this kind. The one serious objection is that the various structures of the cell are not as well differentiated as in some other forms. To Professor Guyer, at whose suggestion this work was taken up, the writer is much indebted for valuable assistance. * From the American Journal of Anatomy, January, 1907. 263 264 DAN BRIDGE MEMORIAL METHODS. A detailed study of the cytoplasmic structures of the heart muscle cell requires the use of a very high magnification. To secure good definition, it was found necessary to make sections 3 fx in thickness. Sections of 4 to 10 /a thicknesses were used for general structure and form of the cell. Sections were cut in paraffin. Of the different fixing agents used, none gave more satisfac- tory preparations than Kolossow's, 92, solution. None was found to surpass it in faithful preservation and differentiation of the cytoplasmic structures. The tissue is killed and hardened by treatment for 15 minutes with a 1 per cent, osmic acid solution. This is followed by immersion for the same length of time in a reducing mixture of pyrogallol and tannin. The tissue is next washed in a 0.25 per cent, solution of osmic acid, and then in water. After being passed through graded alcohols, the tissue is cleared in xylol, and embedded in paraffin. This method followed by Delafield's hematoxylin or methylene blue, counterstained by 0.5 per cent, solution of acid fuchsin in 70 per cent, solution of alcohol gave excellent results. The chromatin structures of the nucleus and the cyto-reticulum appear almost black, while the un- differentiated cytoplasm is red. Acid fuchsin alone without the nuclear stains also yields good preparations. One objection to Kolossow's solution is that it does not pene- trate rapidly enough, and as a result, especially in adult tissue, the structure of the cells in the interior could not be made out as well as that of those in the peripheral portions of sections. Another killing fluid which gave good results was Gilson's mercuro-nitric fixing mixture, followed by iron hematoxylin for staining. This method produces more uniformly penetrated prep- arations, but does not show the cytoplasmic reticulum to such good advantage as the osmic acid method. Hermann's platino-aceto-osmic mixture was also tried. After treatment with this solution the tissue is stained with alcoholic safranin for 24-28 hours. The preparation is then treated with gentian violet according to Gram's method. This method was not as satisfactory as either of the foregoing. Picrosulphuric-acetic acid was used with good results where W I E M A N 265 general structure was the object sought. This fluid is made by adding a 5 per cent, solution of acetic acid to Kleinenberg's picrosulphuric acid solution. Treatment with the above is fol- lowed by staining successively with carmalum and Delafield's hematoxylin. Besides section methods, maceration was employed. This pro- cess was used with satisfactory results in studying the general structure of the entire cell of the adult tissue. Of the various methods tried, treatment for twenty-four hours with a 20 per cent, solution of nitric acid, followed by staining with Delafield's hematoxylin and acid fuchsin, gave the best preparations. THE ADULT HEART-MUSCLE CELL. Examination of the adult tissue shows it to be composed of an anastomosing network of fibers, the demarcation of which into cells is rather uncertain. Apparently a fiber is arranged into cyl- indrical cells the length of which exceeds many times the diameter. The tapered ends of the cells seem to fit together much in the man- ner of a dove-tailed joint. The nucleus is oblong in shape and occupies a more or less central position, although it is sometimes seen very close to the periphery of the fiber. The contractile substance, the fibril bundles, consists of deeply staining longitudinal masses running the length of the cell. Sur- rounding the fibril bundles and separating each one is the undif- ferentiated sarcoplasm. The fibril bundles are divided by cross striations at right angles to the longitudinal axis into alternating broad, deeply staining bands, and narrower bands more lightly stained. The broad, heavily stained bands correspond to the "Ouerscheibe," or "Briicke's doubly refractive substance" of mam- malian heart muscle (MacCallum, 97). By carefully focusing up and down, a very narrow, deeply staining band can be seen crossing the light bands. This is the "Zwischenscheibe," or "Krause's membrane," which structure is not very distinct nor readily made out. The continuation of this line, however, can be plainly seen in the sarcoplasm surrounding the fibril bundle. The Querscheibe are slightly larger in diameter than the more lightly stained parts between. The sarcoplasm surrounding the fibril bundles is not homo- 266 DANDRIDGE MEMORIAL geneous, but is divided into disc-like parts which could be es- pecially well seen in peripheral cells when partially macerated. In preparations of this kind, the discs were found separate from each other, while the fibril bundles remained intact, that is, they did not break up into corresponding lengths. This, it seems,- would militate against the idea of Krause's membrane being con- tinuous with the line of demarcation between two adjacent sarco- plasmic discs. If the latter were the case, it would seem that the fibril bundles should show a tendency to break and separate along the line of Krause's membrane. This did not happen. Hence it may be what appears to be Krause's membrane may only be the line of demarcation between two successive sarcoplasmic discs seen through the lightly staining parts of the fibril bundles. Teased tissue showed the fibril bundles each to be made up of smaller longitudinally disposed parts, the fibrils. The fibril bundles were in all cases surrounded by sarcoplasmic discs. In the adult tissue the fibril bundles are more abundant in the periphery of the cell than toward the center, which is composed for the most part of a network of undifferentiated protoplasm. In most cases the cells are so closely applied that it is difficult to distinguish cell walls. These sections show the fibril bundles as dark, deeply staining patches surrounded by the sarcoplasmic discs. Some of these discs are further subdivided into what MacCallum, 97 , has described as "small sarcoplasmic discs." Between the cells, and connecting them, may be noticed a num- ber of threads, which resemble very much the strands of the reticular structure of the interior of the cell. Just what the origin and nature of these structures are could not be determined. A study of these structures would doubtless throw oome light on the question of whether the heart muscle fiber is a syncytium or not. No structure analogous to the "protoplasmic bridges" of mam- malian heart tissue or the "stratum granulosum terminale" (Prezwoski, as quoted by MacCallum, 97, p. 611), of human heart muscle, was found connecting the ends of the cells. Such, in brief, are the structures met with in the heart muscle cell of the adult chick. W I E M A N 267 EMBRYONIC DEVELOPMENT. To study the different stages through which the ceil passes in its development, sections from embryos varying in length from 8 mm. (15 somites), to 22 mm. (8 days), were examined. Cells characterized by a certain structure are not confined to any one stage. In the following account cells are said to belong to a certain stage because they were first noticed in that stage, al- though they may be, and frequently are, seen in sections from tissue several days older. Thirty hours (i^-soniite stage). — Cells of this stage exhibit in longitudinal section a characteristic short, broad cylindrical form. The ends of the cell taper rather abruptly from the center. The nucleus is large and oval ; its short diameter being but slightly less than the diameter of the cell. Large chromatin masses may be seen as heavily stamed, irregularly shaped clumps, and a very fine network traverses the nucleus. The cytoplasm exhibits a pronounced reticular structure, with large and irregular meshes. At the intersections of the threads of this network, the staining is somewhat heavier, marking off these parts more distinctly than the rest of the reticulum. Cells of this general description are typical of the heart tissue in its very earliest state of formation. They can be readily dis- tinguished from the unmodified mesenchyme cells, in that they do not show the branched structure of the latter. Seventy-tzvo hours {3-day stage). — Up to this period in its de- velopment, the cell differs but slightly from the description given above. At this time, however, several changes are to be noticed. The cell has become larger and the tapering ends have increased in length. The points of intersection of the threads of the cyto- reticulum are more distinctly marked than before by accumula- tions of heavily staining material, spherical in form. These are also shown in cross sections. The nucleus is oval in form though somewhat smaller than in earlier stages. The chromatin masses have decreased in size. Ninety-six hours (4-day stage). — The cell has increased enor- mously in size, especially in its longer diameter. The deposits on the cyto-reticulum are larger and stand out very clearly and dis- tinctly. The meshes of the cyto-reticulum are still very irregular 268 DANDRIDGE MEMORIAL in form. The nucleus does not seem to have undergone the same increase as the cytoplasm, and its chromatin masses have become smaller and more evenly distributed. Some of the meshes of the cytoplasmic network are divided into smaller parts, the small sarcoplasmic discs of MacCallum, 97. 1 20- 1^0- hours' stage. — The cyto-reticulum has undergone a striking change. Instead of the irregular structure of the pre- ceding stages, we find a definite arrangement of the network into rectangular meshes. The deposits on the reticulum have increased in bulk in such a way that in longitudinal section they appear as oval-shaped bodies. This re-arrangement of the meshwork is apparently the first step in the laying down of the fibril bundles. Subsequent de- velopment shows that the longitudinal strands bearing the deposits represent the axes of the fibril bundles, and the deposits, the Querscheibe of the adult tissue. The transverse threads, accord- ing to MacCallum, 98, give rise (in the mammal) to Krause's membrane. However, this will be referred to again later. Cross sections show the meshes of the reticulum to be further subdivided, but few of the original size remaining. It is to be noted that one or two very large, irregularly shaped meshes are present in this section. Apparently these areas, in later stages, become divided into smaller parts, just as the neighboring cyto- plasm has already become divided. Evidently this is the manner in which the growth process in the cell takes place, the cytoplasm in the smaller meshes increasing greatly in bulk and then, by sub- division, producing a number of meshes approximately the size of the first. The nucleus is oblong in longitudinal section, and roughly cir- cular in cross section. The chromatin masses are usually small. It appears that Eycleshymer, 04, in his work on skeletal muscle- cells of Necturus, found just the opposite change to take place in the size and distribution of the chromatin gi-anules, i. c, in younger stages the karyosomes were evenly distributed in the nucleus, and in later stages collected in large masses. 1^0-140-hours' stage. — The most interesting phase of the entire development is seen at this period. The evidence met with in this stage furnishes the most decisive proof in favor of a definite W I E ^I A N 269 relationship existing between the cyto-reticulum of the embryonic cell and the fibril bundles of the adult. Longitudinal sections present a very marked appearance of cross striations. On ex- amination it is found that these striations are produced by a growth, principally in length, of the deposits on the cyto-reticulum of previous stages. These heavily-stained bands stand out as clearly as if stamped with a die. Sections at this period present all gradations of striations as may be seen. The transverse strands of the cyto-reticulum are not very prominent. The taper- ing ends of the cells show an enormous increase in length. It is to be noted that the striations first appear in the elongated ends, at least they show a greater degree of development in this part of the cell. These markings cause the ends of the cell to stand out more prominently than the other regions, and it is now very difficult to distinguish cell walls in longitudinal sections. How- ever, by means of the heavy striations, one can see how these slender projecting ends have made their way between other cells, and thus trace the formation of the syncytium-like structure of the adult tissue. In the later stages, when the cell exhibits uniform striation, the course of the ends of the cells cannot be so well followed. The accompanying diagram would then repre- sent the structure of the adult fiber in longitudinal section. This would also explain the fact that a cross section of the adult tissue, as for example, from a to b, shows cells of widely varying diameter. A similar explanation was offered by MacCallum, 98, in the case of the striated muscle of the pig. Cross sections show an increased number of the smaller meshes of the cyto-reticulum, while the deeply staining deposits which are cross sections of fibril bundles have become greatly enlarged. 270 DANDRIDGE MEMORIAL These heavily staining patches are best developed toward the periphery of the cell. The nucleus is roughly oval in outline. From this structure to that of the adult is but a step. While all the intermediate stages between this and the adult were not examined, sections from stages beyond this up to the eighth day, showed the same structure in various degrees of development. In the adult the sarcoplasmic discs are better developed. The Querscheibe are broader and resemble thick, flat plates. The length and diameter of the cell is greatly increased. SUMMARY. The facts which appear to be of importance as set forth in the foregoing, are as follows : 1. The cytoplasm of the early embryonic heart cell is traversed by an irregular network, the nodes of which are marked by heavily staining deposits. 2. This network tends to become more and more regular, until its strands are longitudinally and transversely disposed. 3. The heavily staining deposits on the primitive network de- velop into the Querscheibe of the adult fibril bundle. 4. The longitudinally disposed lines of the network represent the axes of the fibril bundles of the adult. 5. The sarcoplasmic discs of the adult develop from the inter- reticular cytoplasm of the embryonic cell. GENERAL DISCUSSION ON THE RELATION BETWEEN THE CYTOPLASM AND THE FIBRIL BUNDLES. According to Ranvier, 89, the myocardium of the mammal is composed of rhomboidal branching cells. The nucleus is cen- trally placed and is surrounded by a granular mass stretching out in the axis of the cell. Surrounding this granular mass is the contractile element which shows longitudinal and transverse markings. This element is the fibril and is made up of successive segments having the same structure as voluntary muscle. Koelliker, 02, describes the mammalian heart muscle as com- posed of an interlacing network of cells having centrally placed nuclei. The contractile substance, as in voluntary muscle, consists W I E M A N 271 of fibril bundles, the so-called "Muskelsaulchen," which show a definite transverse striping. Of the later workers, Godlewski's, 02, description is interesting, because of his denial of cell structures in the heart muscle of the rabbit. According to him the heart muscle is a syncytium in which there is no cell demarcation. The contractile substance is the fibril which shows the various markings described by other authors. Thus, in general, in addition to the above, the work of investi- gators goes to show that the contractile substance in the muscle tissue is the fibril. A number of these in turn compose the fibril bundle. Workers are not agreed as to the origin of the fibril bundles. The older hypothesis that they are extra-cellular struc- tures is now refuted, and the generally accepted opinion is that they are intracellular. Two current views exist as to the nature of the fibril bundles. The first is that these structures are coagulation products, and that the living cell contains neither cyto-reticulum nor fibrils (Englemann, 73-81), The second view is that the fibrils are differentiated structures which are formed in the living cell. The latter theory is the one which the results of many workers seem to verify. Of the latest workers Eycleshymer, 04, reports having observed the fibrillse (fibrils) in the living muscle cells of larval necturus. Concerning the origin of the fibrils, there are what is known as the network theory and the fibrillar theory. The upholders of the network theory maintain that the muscle cell contains a con- tractile reticulum, the longitudinal threads of v/hich form the fibrils, the meshes being filled with a more fluid substance. Others consider that the fibrils are produced by the coagulation of the fluid substance, as a result of the action of various reagents. Later work apparently refutes the latter idea. The advocates of the fibrillar theory maintain that the fibrils are the contractile elements, and further, that they arise independently of the cyto- reticulum. Eycleshymer's, 04, work on necturus, supports this idea, and Godlewski, 02, in his work on the striated muscle cell of the rabbit, has been able to find no trace of a cytoplasmic network. 272 DANDRIDGE MEMORIAL In the theory urged by AlacCallum, 98, we have a combination of the network and the fibrillar theories. In this author's words (p. 211), "It simplifies the conception of the structure of striated muscle fiber greatly, to consider the fibril bundles and the mem- branes bounding the compartments in the sarcoplasm as derived from the primitive network found in the muscle cells of very young embryos." (p. 209) "This network tends to become more and more regular until the meshes are of the form of large discs. Some of these break up into smaller ones and in the nodal points of the network there is an accumulation or differentiation of its substance, giving rise to longitudinally disposed masses. These become what in the adult are known as fibril bundles and the discs are the sarcoplasmic discs." Now the question is. How do these theories apply to the con- ditions met with in the heart muscle of the chick? We will consider JMacCallum's theory first. The occurrence of the breaking up of the meshes of the c}^o- reticulum into smaller parts was noticed in the case of the chick. That the fibril bundles arise from the center of the meshes at the nodal points of the network appears, however, to be untrue. Here, in fact, it seems that the nodes of the original network mark the positions of the fibril bundles ; in other words, that the primitive longitudinal threads develop into these structures. To illustrate, the accompanying figure represents a diagrammatic cross-section of the cyto-reticulum. The unbroken lines represent the threads of the original network. The circular masses at the intersections of this network (a-, b, c, etc.) represent the heavily-stained de- posits. The dotted lines divide the large meshes or discs into the "small sarcoplasmic discs" of MacCallum {boc, cod, etc.). Now according to the author just mentioned, a fibril bundle arises in the center of any large disc at the point of intersection of the dotted lines {o, x, etc.). The full lines would then represent boundaries of sarcoplasmic discs. However, in the case of the chick the facts seem to indicate that the fibril bundles arise at the points of intersection of the lines of the original network (a, e, b, etc.). Then the sarcoplasmic disc surrounding any one particular fibril bundle, as, for example, that one the cross section of which is represented by a, would be the area bounded by yboexrzk. W I E M A N 273 The writer's preparations clearly show that the nodal points of the original cyto-reticulum of the embryonic heart cell are marked by more heavily staining deposits, both in longitudinal and in cross section. The deposits can be followed in successive stages, and are always identified with the longitudinal and transverse threads of the network. Eventually they develop into the Quer- scheibe, and the longitudinal threads of the network become the axes of the fibril bundles of the adult tissue. If this be true, the fibril bundles cannot originate from the centers of the meshes seen in cross sections of the cyto-reticulum. Suppose now that fibril bundles were to form at the points a and e of the diagram. Then we would have the two fibril bundles surrounded by one set of sarcoplasmic discs (odtpxrzkyb), a condition sometimes found in the adult ; also mentioned by Mac- Callum, 97, (p. 613), in the human heart muscle. However, were these two sets of sarcoplasmic discs to become separated by a plane of division along a line from o to x, then each fibril bundle would have its ow^i set of sarcoplasmic discs, the structure more generally met with in the adult. If the fibril bundle in its development follows the method sug- gested by the w^riter, another difficulty is encountered with the results of MacCallum's, 98, work. This worker states that the transverse membranes of the cytoplasmic reticulum of the myo- blasts of man and of pig give rise to Krause's membrane in the 274 DAX BRIDGE MEMORIAL adult. Attention is called to the fact that the intersections of these transverse lines with the longitudinal lines of the reticulum mark the positions of the deeply-stainiiig substance which later becomes the Querscheibe. Now, in the adult, Krause's membrane is found as a narrow transverse band across the lightly-staining portions of the fibril bundles, and not at all connected with the Querscheibe. Thus it is readily seen that IMacCallum's explana- tion of the formation of this structure does not apply in the case of the chick, nor could its origin be determined satisfactorily, for, as was remarked in another place, it is not very well differentiated in the heart' muscle of the adult chick. At this point it is interesting to consider the work of Eycle- shymer, 04, on the striated muscle cell of Necturus. This author states that in the study of the striated muscle cells of Necturus, he has been unable to find any evidence of a definite or fixed re- lation between the cytoplasmic network and the fibrillas (fibrils). Further, as serious objection to the existence of such a relation, he says that the fibrillse are unstriated for some time after their appearance. In the case of the chick, however, the above is not true. For if we consider the longitudinal threads of the network as the incipient fibril bundles, then the deposits marking the intersections of the threads would represent the striations, since later these develop into the Querscheibe of the adult tissue. The question is just what is to be understood by "first appearance of fibrillse." If by this we mean the earliest stage in the development of the fibril bundles at which there is any resemblance to the adult structure, we may say that the fibrillse are striated from the start in the chick. With reference to another point in this connection, the writer here quotes a passage from the same author, pp. 298, 299: "A point of capital importance is found in the fact that in Necturus, Amia, Lepidosteus .... as my own observations show, and in other forms as Kaestner, 92, has found, the beginning of fibril- lation is coincident with the first contractions. The movements of the embryo first begin in the anterior of the mid-dorsal myo- tomes and in these the myoblasts are first fibrillated. The above considerations led the writer to support the theory that the fibrillae W I E AI A X 275 are pre-existent structures and represent the principal contractile element." The same argument cannot be applied to the heart muscle of the chick, because the first contractions occur at the time when about 15-17 myotomes have been formed in the embryo. As may be seen from the representation of the heart muscle cell at this stage, no structure which might be truly called a fibril is present. The first appearance of anything that in the faintest way re- sembles the adult is not seen before the 120-130 hours' stage. If the fibrillae are not pre-existent structures, what then are the contractile elements in the very early embryonic stages ? In view of the above facts the explanation offered by MacCallum, 97 (p. 620), seems plausible. The author suggests that the contractile elements in the early embryonic heart would be represented by the irregular network seen at that stage before true fibrils exist. This, it seems, would lend support to the writer's suggestion in regard to the origin of fibrils. For if, as ]\IacCallum says, the cytoplasmic network represents the contractile element in the early stages, it seems reasonable at least to consider the longi- tudinal lines of this network as developing into the fibrils rather than to suppose the latter to arise from accumulations of the network-substance in the cytoplasm contained between the meshes. In conclusion, the results of the work embodied in this paper point to the existence of a definite relationship between the c}lo- plasmic reticulum of the early embryonic cell and the fibril bun- dles of the adult cell. REFERENCES. Engelmann, Th. W., 73-81 : !Mikroskopische Untersuchurigen iiber die quergestreiften IMuskelsubstanz. I u. H Pfliiger's Arch., Bd. vii, 1873. Kontraktilitat und Doppelbrechung. Pfliiger's Arch., Bd. xi. Xeue Unter- suchungen iiber die mikroskopischen Vorgange bei der Muskelkontraktion. Pfliiger's Arch., Bd. xviii, 1878. Alikrometrische Untersuchungen an kon- trahierten Muskelfasern. Pfliiger's Arch., Bd. 26, 1881. Bemerkungen zu einen Aufsatz von Fr. Merkel : Ueber die kontraktion der quergestreiften Muskelfaser. Pfliiger's Arch., Bd. 26, 1881. Ueber den faserigen Ban der kontraktilen Substanz mit besonderer Beriicksichtigung der glatten und doppelt schrag gestreiften Muskelfasern. Pfliiger's Arch., Bd. 25, 1881. Eyclesh>Tner, A. C, '04: The Cytoplasmic and Nuclear Changes in the Striated Muscle Cell of Xecturus. Am. Journ. Anat., Vol. iii, No. 3. Godlewski, E.. '02: Die Entwickelung des Skelet- und Herzmuskelge- •\vebe der Saugethiere. Arch. f. mikr. Anat., Bonn, 1902, Bd. Ix. Koelliker, "02: Handbuch der Gewebelehre des Menschen. 6 Anlage, p. 609, Leipz., 1902. 276 DAN DRIDGE MEMORIAL Kolossow, A., '92: Ueber eine neue Methode der Bearbeitung der Ge- webe mit Osmiumsaure. Zeitschr. f. wissenschaftl. ]\likroskopie, Bd. 9, 1892, p. 38. MacCallum, J. B., '97: On the Histology and Histogenesis of the Heart Muscle Cell. Anat. Anz., Jena, 1897, Bd. xiii, S. 609-620. '98: On the Histogenesis of the Striated Muscle Fiber and the Growth of the Human Sartorius Muscle. Johns Hopkins Hosp. Bull., Baltimore, 1898, Vol. ix, pp. 208-215. Ranvier, '89: Traite technique d'histologie. Paris, 1889. A METHOD OF DEMONSTRATING SPIROCPI^T^ AND TRYPANOSOMES BY MEANS OF NIGROSIN.* BY CHARLES GOOSMANN, M.D. BuRRi's India ink method, first applied to the diagnosis of syphilis by Hecht and Wilenko/ has received considerable favor on account of its simplicity. There is, however, some evidence of dissatisfaction because of the granularity of smears made according to this method. Barach- speaks of deceptive, wavy fibres resembling spirochajta forms found by him in India ink. Gins^ insists on thorough sedimentation of the ink, and also ad- vises the use of a specially prepared glass slide to facilitate making thin smears. To overcome the undesirable granularity I have been using a solution of nigrosin (nigrosin No. 699 of the National Aniline and Chemical Co., Chicago), which gives a much smoother background than India ink. This is a blue-black pig- ment, but their black nigrosin No. 15502 can also be used. Grueb- ler's water-soluble nigrosin has been tried, but precipitates too easily, probably on account of its greater purity, as it is well known that impure colloids frequently remain in solution better than the purified. The nigrosin recommended above can be ob- tained through any wholesale druggist. With coarse spiroch?et«, granularit}- of the background is immaterial. With more minute forms, it is a distinct disadvan- tage, as the film cannot be thinner than the average diameter of the granules, and if the film is thicker than the organisms, it will blur the latter's outlines. In the demonstration of bacterial fla- gella, therefore, the India ink method has been unsatisfactory, as Gins,* who has done considerable work on flagella, admits. Attempts to show flagella on Bacillus typhosus, however, have not been successful, probably because the nigrosin particles, though much smaller than India ink, are still too large. Nigrosin * Reprinted from the Journal of Cutaneous Diseases, Including Syph- ilis, for December, 1911. 277 278 DANDRIDGE MEMORIAL is a suspension colloid, and by dark-ground illumination the minute particles of which it is composed can be distinctly seen. It may be that a pigment that actually enters into true solution will be capable of rendering these minute flagella visible. To illustrate my meaning: Burri describes the appearance of India ink preparations as resembling that produced by dropping pieces of glass rods into melted dark-stained agar in a Petri dish, and when the agar has set, holding the dish to the light. I would modify that slightly. The India ink method would be illustrated by coloring the agar with large irregularly shaped carbon particles, as large as the diameter of the thickest piece of glass rod. The nigrosin method would be analogous to using much smaller par- ticles to color the agar, permitting the production of a thinner film, and rendering visible a thinner glass rod. If, now, we stained the agar with a soluble (i.e., non-granular) dye, we might get a still thinner film, and sufficient contrast to render visible a fine thread of glass. The preparation of the nigrosin is very simple. Shake up an excess of the nigrosin with distilled water, and allow it to settle. The upper stratum can then be pipetted, or carefully decanted ; or, as I prefer, the preparation can be used without decanting, but always observing caution in handling, so as not to stir up the sediment. It is well to avoid contamination of all sorts, as there is a tendency for the nigrosin to become more coarsely granular. Rod-shaped pieces of nigrosin occur, but these can cause no con- fusion with bacteria, because bacteria never take up the stain — therefore always appearing uncolored. In preparing a slide, the same technique is used as with India ink. To get a thin smear for small bacteria, a platinum loopful of the material to be examined is mixed on the slide with less than a loopful of nigrosin solution, and spread with the edge of another slide to a pale-blue film. The slide, of course, must be clean. A convenient way to avoid the use of too much nigrosin is to touch the loaded platinum loop to a corner of the slide, depositing all excess and mixing the remainder with the material to be examined. In examining blood or feces, it is better to dilute with normal salt solution or distilled water before adding nigrosin, in order to separate the individual particles. For thick G O O S ^I A N N 279 films, such as are best for large organisms (trypanosomes), it is sometimes well to use an excess of nigrosin solution. After the film is dry the oil immersion objective can be used directly, or balsam and cover glass added. My preparations have shown no deterioration in ten months. The nigrosin fluid should be thick and of an oily consistence. I have kept such a solution for nine months without noticing any change in its usefulness. It would be a distinct advantage if the living and motile trepo- nema could be seen without resorting to the dark-field illumination as generally obtained. Meirowski^^ has stained living spirochsetre with various stains, but the organisms lose their motility in a few minutes. In 1888, Certes^ had obtained a dark background for the study of living infusoria by the addition of aniline black. Faber-Domergue,® in 1889, had used diphenylamin blue for the same purpose. Shortly after Hecht and Wilenko published their results with India ink, I tried to find a method which would have the simplicity of their technique and yet retain the motiHty of the organisms. Neither pure aniline black nor diphenylamin blue were at all suitable for spirochsetse or trypanosomes, however, because the pigments were precipitated by the tissue fluids. The nigrosin mentioned above (nigrosin No. 699) did not precipitate and was an improvement on India ink for dry smears. It was very toxic to spirochsetse, however, possibly due to the presence of arsenic. Further experiments with purified aniline pigments will be necessary before it can be decided whether living and motile spirochastae will be rendered visible by this method. Tryp- anosomes lemain alive twenty-four hours in nigrosin solutions, and bacteria seem to retain their motility for a long time. In fact, the marked susceptibility of spirochaetae, whether from syphilis or the normal mouth, to the toxic action of nigrosin, seemed interesting from a biologic standpoint. The following extracts from various writers show the most important points in differentiating between the S pirochccta den- tium and the Treponema pallidum. Hoffmann^ says that the Spirochceta dentium is thicker in relation to length, therefore more plump appearing, the thin ones being mostly shorter than the Treponema pallidum. The ends of the Spirochccta dentium are more blunt; flagella-like terminations are less common. The 280 DAN DRIDGE MEMORIAL spirals of the Spirochcuta dentium are flatter, less regular and narrower. Plaut^ says that the SplrocJueta dentium is almost always shorter than the organism of syphilis. It is generally straight, and thicker than the Treponema pallidum. The windings are very close in the Spirochcuta dentium. Gurd" says the Spirochceta dentium is always thicker than the Treponema pallidum. The extremities of the former are not drawn out in the manner of the latter. It never has more than five turns to the diameter of a red blood cell, while the organism of syphilis has six or seven. It is also shorter than the treponema. Park and Williams^ say that the SpirodJiccta dentium is some- what shorter and thicker. It does not terminate in flagella-like ends. The spirals are 1.0 micron long and 0.5 micron deep; while the spirals of the Treponema pallidum are 1.0 micron long and 1.0 to 1.5 micron deep. Discussing the preceding differential fea- tures, one at a time, we have : (a) The Spirochceta dentium is shorter and thicker than the Treponema pallidum. ]Many short forms of the latter are found, especially in preparations made from fresh secretions. Greater thickness is hardly confirmed by the photomicrographs or by visual observations. It is not at all unlikely, however, that varia- tions in size do occur in all these forms. Gerber^- makes two *forms out of the Spirochceta dentium^ the large ones, for which he retains the above name, and a smaller form, which he calls the Spirochceta denticola. (b) The ends of the Spirochceta dentium are more blunt; flagella-like ends are less common than in the Treponema palli- dum. This may be true in stained specimens, but India ink or nigrosin preparations do not show any such distinction. (c) The spirals of the Spirochcuta dentium are flatter, less regular and narrower. No difference in regularity could be ob- served in my specimens. The spirals of the Spirochceta dentium seem very slightly flatter. To confirm this point, I used a low- power (two inch) objective and micrometer eyepiece on the specimens prepared for this article, but instead of the ratio of length to height given by Park and Williams (vide supra) the following ratio was found: The length of the turns of the Spiro- GOOS^IAXX 281 cli'. or emulsion colloids, or, as water is the absorbed substance, with the hydrophilic colloids. On a merely superficial examination, therefore, catgut seems to belong in a group with gelatin, fibrin or serum albumin. But it behaves like these protein colloids in various other directions also. When we observe that on immer- sion in a dilute acid the catgut fiber contracts, we note at the same time that it does this by a process of swelling; it becomes thicker and shorter. The same thing is noted in tnc case of gela- tin, fibrin or serum albumin. Gelatin or fibrin swells more in any dilute acid than in pure water, and the viscosity of serum albu- min rises when acid is added to it. If the acid is washed out of these colloids, they resume their original form once more, as does the catgut when water replaces the acid solution. Just as gelatin and fibrin show within certain limits an increase in the amount of swelling with every increase in the concentration of the acid surrounding them, so also do we note an increased height of STRIETMANN AND FISCHER 291 contraction in catgut when the acid concentration surrounding this increases. The fact that catgut does not at once return to a previous state when the conditions about it are changed has its analogue in the way in which fibrin, gelatin, etc., only slowly recover from the effects of a previous surrounding, when a new one is substi- tuted for it (hysteresis). With a given concentration of acid, the amount of svv'elling attained by gelatin, fibrin or serum albumin is reduced by the presence of any salt (even neutral salts, and such having no ion in common with the acid), and this reduction in the swelling is the greater, the stronger the concentration of the added salt. The parallel of this is found in the reduction of the height of the contraction of catgut in any acid solution, when any salt is added, the reduction being the greater the higher the concentra- Xo" HCI ^Rin^er-sdie flinuten Fig. 8 tion of the added salt. When fibrin has been allowed to swell to its maximum in a mixture of any acid with a salt, and is then placed in pure water, an initial increased swelling of the fibrin is noted, before the decrease sets in which brings the fibrin back to the degree of swelling characteristic of immersion in pure water. It is as though the acid were united more firmly to the protein colloid than are the salts. In spite of greater diffusion velocity of acids over salts, the salts nevertheless seem to get out of colloidal proteins more rapidly than do the acids, an observa- tion not without biological importance, nor without interest for the theory of the colloidal state. This behavior or fibnu also has its analogue in the already observed characteristics in the contraction of catgut when changed from a salt-acid mixture to pure water. Point for point, therefore, the contraction and relaxation of catgut (absorption and secretion of water by catgut) is identical with the taking up and giving off of the water by various oth^. colloidal proteins. 292 DAXDRIDGE MEMORIAL It is easily seen at the same time how these experiments on cal.yut contractions correlate themselves with the experiments of Engelmann. What happens is identical in both instances, namely, an absorption and secretion of water by the proteins composing the catgut, only while Engelmann used an increase in tempera- ture to make the catgut swell, we used, for purposes that will be- come evident immediately, various acids. III. ON THE ANALOGY BETWEEJST THE DESCRIBED CONTRACTION OF CATGUT, AND THE CONTRACTION OF STRIATED MUSCLE. It is easily seen how similar are many of the curves illustrat- ing this paper with the curves obtained and familiar to every physiologist wdien striated muscle contracts. Fig. 10 could easily be mistaken for the record of an ordinary nuscle twutch. In Fig. 9 we observe a series of successively Xzonici ^ ;go"iiCl < Zo^nCi "■ ;'. This state- ment has only recently been generalized to the extent of saying that whenever a muscle is found to contract evidence of acid production in the muscle exists. The contraction of rigor mortis 294 DANDRIDGE MEMORIAL is associated with the production of acid in the muscle, a fact which made L. Hermann, in calHng attention to the analogies that exist between the contraction of muscle in rigor mortis and the ordinary muscle contraction, venture the suggestion that the or- dinary single muscle twitch was due to a temporary production of acid in the muscle. More recently, particularly through the work of Fletcher, Hopkins and Meigs, it has been shown that in water rigor, heat rigor, chloroform rigor, etc., the contractions noted under these circumstances are also always associated with the production of acid in the muscle. But not only is the production of acid associated with every contraction of muscle, but it is the cause of this, as has been shown particularly well by McDougall and Meigs. McDougall studied the effects of acids and various other conditions on the length of the isolated contractile elements of insect wing muscle. He found these to shorten whenever he brought them in contact with any very dilute acid. With increasing concentration of the acid he found that an optimum was reached, beyond which a lessened contraction vv^as observable. It will be recalled that we described this same phenomenon in catgut. When the muscle elements were removed from the acid solution to pure water, re- laxation set in. The relaxation occurred more rapidly if instead of being placed in distilled water the muscle elements were placed in a sodium chloride solution. The more highly concentrated this was the more rapidly did the relaxation set in. Meigs has greatly amplified these experimental observations and described practically identical findings in frog's muscle. From these few remarks it is clear that the chemical condi- tions which we described above as effective in producing and modifying the contraction of catgut are identical with those which do the same in striated muscle, wherefore we conclude that the phenomenon of contraction in mnscle is entirely a problem in colloid chemistry. If this conclusion is justified, then let us briefly review some of our current theories of muscular contrac- tion with an eye to discovering which of them are most nearly correct. In so doing we will find that the proponents of these theories have erred not so much through a failure to recognize that muscular contraction represented a colloidal problem, but STRIETMAXX AND FISCHER 295 rather in that they did not consider this explanation adequate or capable of accounting for more than a small part of the essential phenomena of contraction. IV. HISTORICAL AND CRITICAL REMARKS. For the first great step toward the formulation of a colloidal theory of contraction we are indebted to Franz Fiofmeister,^ that old master who has done so much to establish the biological importance of the colloidal state Hofmeister built upon the fact that protoplasm consists of a series of bodies that are cap- able of imbibing water, and pointed out how in the processes un- derlying the phenomena of imbibition a migration of water and the approximation of two points (contraction) that are sur- rounded by envelopes of water must occur whenever the imbibi- tion capacity of the one is increased at the cost of the other. In this way he tried to account for all the special types of protoplas- mic contraction as observed in different animal and plant forms. The missing element in Hofmeister's theor}- — which he him- self points out — is that he could not explain why the colloids suffered the changes which make for the contraction; in other words, the nature of the chemical changes that induced the phy- sical. For a first proposition in this direction we are indebted to T. W. Engelmann.* Engelmann started from the w^ell-known fact that during muscular contraction the carbohydrates and fats disappear from the muscle, and that carbon dioxide, water, etc., appear in their place. This chemical change is associated with the liberation of heat, and this fact Engelmann utilized to construct upon it his thermodynamic theory of muscular contraction. Briefly formu- lated, Engelmann believes that the muscular contraction is initi- ated by a chemical change in the carbohydrates (and fats) of the muscle which results in the liberation of heat; this heat acting upon the contractile elements contained in the muscle (the aniso- tropic substance) makes them absorb the isotropic substance and so swell and shorten. The physical half of this theory, it will be noted, is also an inhibition theory of the nature of Hof- meister's. To support his contention, Engelmann devised his now famous catgut experiment, in which he showed how this catgut — 296 DANDRIDGE AIEMORIAL which is also anisotropic — contracts in water when its temperature is raised, to relax again when the temperature falls. If the cat- gut strand is only momentarily heated, a contraction curve is ob- tained which is identical in appearance with a single muscle twitch. Engelmann's theory has been attacked on many sides, to our minds often with scant justice when the substituted theories are weighed in the balance against his. The best argument against it are furnished by two facts. First, the amount of heat produced during an ordinar}^ muscular contraction is not sufficient to make anisotropic substance, of the nature of that found in muscle, shorten enough to explain a muscular contraction. Second, a contraction of muscle occurs under circumstances in which there may be no production of heat whatsoever. But even after all this is granted, the great fact remains that Engelmann was the first to create a satisfactory model of the muscular contraction out of materials which may be subjected to physico-chemical analysis, and so to remove the \/hole problem from a realm of speculation and terminology into one of reason and fact. As will be evident later, even in the matter of making a change in temperature re- sponsible for the physical phenomena of contraction, he was not entirely wrong; he only failed to pick the most powerful explo- sive out of a series lying before him. The work of L. Hermann furnishes a valuable contribution to the establishment of a colloidal theory of muscle contraction in several directions. Hermann emphasized very clearly the many analogies both from a chemical and physical standpoint that exist between the ordinaiy muscular contraction and the various rigors. As "coagulation" is an obvious sign in the rigors, the question of whether the ordinary muscular contraction is a "temporary coagu- lation, or a kind of coagulation," has often been argued since Hermann's writings. Hermann took the signs of coagulation and the contraction of muscle in rigor to represent evidences of one and the same process, and believed both of them to be due to the formation of acid in the muscle which occurs in all the rigors. In such a belief he was in part right, in part wrong. In making the production of acid responsible for both he was right, but to understand properly what happened beyond this point was im- STRIETMANN AND FISCHER 297 possible then, for colloid chemistry had not as yet developed suffi- ciently. We know now that the obvious signs of any "coagulation" such as that which characterizes the rigors to-day can only be associated with a loss of water by the "coagulated" colloid.^ As the muscular contraction consists of an absorption of water, just the reverse of "coagulation," it is clear that the "coagulation" and the contraction observed in muscle in rigor must be entirely separate processes. What happens in muscle is identical with the development of a clouding in the cornea of an eye simultaneously with the swelling of the enucleated eye when this is placed in acid- ulated water,*' or the development of a "cloudy swelling" in any of the parenchymatous organs when these are exposed to the same condition/ Two colloids at least are involved in the process, and luhile the one is behaving like gelatine zvhich szcells in acidulated water, the other behaves like casein which under the same circum- stances is precipitated. In rigor the anisotropic substance szcells under the influence of the acid and leads to the muscular con- traction, while under the same circumstances another colloid is being precipitated {or, to use Herinann's word, "coagulated") and giz'es the muscle an opaque appearance. As we shall see later, the loss of water by the one colloid which is being "coagulated" no doubt yields that necessary for the swelling (contraction) of the other. Whether a rigor is reversible or not depends entirely upon whether the precipitation of the colloid involved is reversible or not ; whether, in other words, removal of the condition which has made the colloid precipitate permits this to go back into solution. Depending upon the means employed to produce the rigor and the length of time it has acted, the colloidal precipitations may or may not be reversible, and so the rigor. This matter of rigor can, in a sense, also be mimicked on cat- gut. If we allow a chromium salt to act upon the catgut along with any acid, then we get not only a shortening of the catgut, but a permanent one. In applying the observation that the acid production in rigor is responsible for the permanent contraction here as in the ordinary muscular contraction, Hermann^ made the further valuable sug- 298 DANDRIDGE MEMORIAL gesticn that a temporary production of acid in muscles might ac- count for the norm.al muscular contraction. But this remained a mere suggestion with Hermann. The idea that the production of acid is responsible for the muscular contraction either under normal circumstances or in rigor has been particularly clearly enunciated by William Mc- Dougall.^ This author holds the anisotropic substance (the sar- comeres or contractile elements of the muscle) to be built up of tubules "having delicate walls and containing a fluid or viscid sub- stance." The contraction he holds to be due to an absorption of fluid by these tubules "determined by the setting free of lactic acid in the fluid contents of the sarcomere, aided perhaps by an in- crease in the osmotic equivalent of these fluid contents through an increase in the number of molecules in solution. Then so long as the acid remains present in the fluid of the sarcomere, the addi- tional fluid absorbed will be retained and the state of contraction will continue. But as soon as the acid escapes from the sarcomere the additional fluid will also escape with it into the sarcoplasm and allow relaxation to take place." With McDougall's description of the histology of striated muscle we are not immediately concerned; in passing we would only point out that much of the discussion as to whether a histo- logical structure is "solid" or "liquid" is purposeless, for animal and plant structures are chiefly colloidal in composition, and the colloids that compose living matter combine in one the prop- erties usually cited as characteristic of both the solid (mainte- nance of form) and the liquid state (surface, tension, dift'usion of dissolved substances). It is clear that ^^JcDougall's ideas readily permit one to see why a single muscle twitch, a tetanus, or a rigor due to death, acid or water, all have the phenomenon of contraction in common, underlying all of them is the production of acid in the muscle; and depending upon whether this acid production is only temp- orary or permanent we have either a temporary or a continued state of contraction. IMcDougall worked with isolated muscle fibrils. If these are placed in a weak solution of any acid (acetic or lactic) they swell and shorten. If now they are placed in distilled water and the ST R I EM AX N AXD FISCHER 299 acid is washed out of them they relax again. When the acid ex- ceeds a certain optimal concentration the shortening becomes less marked. If any salt is present in the dilute solution of the acid, the contraction is lessened, or may not appear at all. If fibrils that have undergone no marked contraction in a solution contain- ing both acid and salt are transferred to pure water, they undergo a rapid shortening. We need not do more than merely indicate the fact that these statements are point for point identical with those we made above regarding the contraction and relaxation of catgut under similar circumstances. The theoretical views of AIcDougall have found excellent ex- perimental support and have won precision through the careful studies of Edward B. Aleigs.^'' This author has not only collected the evidence which shows that an acid production underlies every phenomenon of contraction as observed in striated muscle, but he was the first to recognize and clearly express the fact that we deal in this problem (in part only, according to Meigs) with a colloidal phenomenon, and that the acid owes its action to the fact that it makes certain colloids of the muscles swell. Since Meigs' writings McDougalP^ has also expressed this idea in unequivocal terms. W'ith this colloidal view of the muscular contraction we heart- ily concur. The criticisms we have to make of ]\IcDougall and Meigs' ideas are that on both theoretical and experimental grounds they do not consider the colloidal conception entirely adequate. McDougall believes that in the process of contraction osmotic effects play a part in addition to the colloidal, while Meigs thinks, in his analysis of the problem of water absorption by the muscle, that osmotic phenomena are concerned here. No experi- ments are cited to support ]\IcDougairs osmotic hypothesis, and as Meigs, who is the best champion of McDougall's ideas, agrees that the swelling of the contractile elements in muscle (the es- sence of contraction) is a colloidal phenomenon, we may con- sider it settled that at least so far osmotic phenomena do not play a role. In holding to the view that the "living" muscle is surrounded by osmotic membranes, Meigs supports his position by calling attention to the curve of water absorption exhibited by a muscle 300 DANDRIDGE MEMORIAL immersed in distilled water. Such a muscle rapidly attains a maximal swelling, then for a period loses in weight, gains in weight a second time, and then slowly loses again. ^- The curve representing the second gain in weight comes at the same time and accompanies the contraction of the striated muscle, and this Meigs is willing to accept as a process of colloidal swelling (swelling of the contractile elements under the influence of an acid). But the first swelHng Meigs does not consider as of the same type. He here follows the older belief of E. Overton, that osmotic membranes exist about the "living"' muscle cell. When excised and placed in distilled water, these osmotic membranes are destroyed, in part owing to the accumulation of acid within the muscle,in part due to differences in osmotic concentration in- side and outside of the muscle cell which lead to their rupture. When the membranes are thus destroyed, the fluid behind them is allowed to escape, and so the muscle loses temporarily in weight. But this temporary loss in weight can be interpreted more simply as a phenomenon in colloid chemistry. The muscle contains several colloids, and the maximal swelling and precipita- tion points for any given set of conditions are not the same for all these colloids. Under the influence of an acid, for example, the maximal swelling of the one may therefore be attained and exceeded sooner than that of another, and so a swelling of one colloid in the muscle may have reached and gone beyond its maxi- mum (an increase followed by a decrease in weight) before an- other has attained its maximum. As a matter of fact we know that just such a relationship must exist between the different col- loids in a striated muscle when this contracts normally. There is no free water in the body ; it is all held in combination with the colloids of the tissues." If one colloidal element in an organism swells (say the anisotropic substance), it can do this only as it first robs some other element of its content of water. It would be eminently useful, therefore, if the conditions which on the one hand make for a swelling of the anisotropic substance, make on the other for the shrinkage (giving up of water) of another (isotropic substance). To our mind all that characterizes the phenomena of water absorption and contraction in muscle, together with the various STRIEMANN AND FISCHER 301 phenomena of '"coagulation" observed in the rigors, repres^ent but simple expressions of the effect of various acids and salts on that mixture of the several protein colloids which make up the muscle. We propose shortly to deal further with this subject. Here we would only direct attention once more to Fig. 8 and the apparently complicated series of reactions that may be obtained from a simple catgut fibril when exposed to the action of water, acids and salts. It is reactions of this type in muscle that have given rise to the highly complicated beliefs regarding the exist- ence of membranes, etc., about the individual muscle cells. As a matter of fact, we have no more reason for postulating their existence here than in the case of our catgut. ]\Iuch of the confusion that exists to-day in this whole prob- lem of contraction, water absorption, irritability, etc., as observed in muscle, arises from the fact that various authors have too carelessly passed from observations made on one to conclusions regarding another, instead of studying each phenomenon sepa- rately. Association of phenomena does not make them identical. As we have learned that the signs of coagulation observed in rigor mortis are not identical with the phenomena of contraction in the same condition, so also does water absorption not parallel loss of irritability, or loss of irritability mean a loss of the power of contraction. SUMMARY. This paper attempts to contribute to the establishment of a colloid-chemical theory of contraction in striated muscle. A series of experiments on the swelling and contraction of catgut is described, and it is pointed out how these phenomena are not only identical with the physical phenomena of contraction as observed in striated muscle, but how the chemical conditions de- termining both are also identical. A review is given of the work of those men who have contributed most to the establishment of a colloid-chemical theory of contraction, and to this are appended some critical remarks. REFERENCES. 1 T. W. Engelmann: Pfliiger's Archiv, 7, loo (1873); Uebcr den Ur- sprung der Muskelkraft. Leipzig, 1893. 2 K. Spiro, Wolfgang Ostwald, Martin H. Fischer, and Wolfgang Pauli. 302 DAN BRIDGE MEMORIAL 3 F. Hofmeister : Die Lehre von der Pflanzenzelle. Leipzig, 1867. Not accessible in the original. 4 T. W. Engelmann: Pfliiger's Archiv, 7, 155 (1873) ; Ueber den Ur- sprung der Muskelkraft. Leipzig, 1893. 5 See Wolfgang Pauli : Kolloid Zeitschr., 7, 241 (1910) ; Pauli and H. Handovsky: Biochem. Zeitschr., 18, 340 (1909) ; 24, 239 (1910) : H. Han- dovsky: Kolloid Zeitschr., 7, 183. 267 (1910) ; Fortschritte in der Kolloid- chemie der Eiweisskorper, Dresden, 1911; Karl Schorr: cited by Pauli and Handovsky. 6 Martin H. Fischer: Pfliiger's Archiv, 127, 40 (1909). 7 Martin H. Fischer: Kolloid Zeitschr., 8, 159 (1911). 8 L. Hermann: Hermann's Handbuch der Physiologic, 1, 255 (1879). 9 William McDougall : Journal of Anatomy and Physiology, 32, 187 (1898). 10 E. B. Meigs: Zeitschr. f. allg. Physiol., 8, 81 (1908): Am. Jour. Physiol., 22, 477 (1908); Ibid., 26, 191 (1910); Jour. Physiol., 39, 385 (1909). 11 McDougall: Quarterly Jour. Exp. Physiol., 3, S3 (1910). 12 Martin H. Fischer: Pfliiger's Archiv, 124, 69 (1908); E. B. Meigs: American Journal of Physiology, 26. 191 (1910). 13 Martin H. Fischer: Das Oedem, 192, Dresden, 1910; KoUoidchem- 13 Martin H. Fischer: Oedea, 192, New York, 1910; Kolloidchem- ische Beihefte, 2, 304 (1911). AN ANO^IALOUS DUCT BELONGING TO THE URINARY TRACT.* BY PAUL G. WOOLLEY, M.D., AND HERBERT A. BROWX, M.D. The specimen we wish to describe is of unusual interest because of its extreme rarity, for, in spite of a somewhat painstaking search of the Hterature we have found no account of any similar condition. It was found during the post-mortem on a patient in the Cincinnati Hospital (No. 153426) who had been admitted for cutaneous blastomycosis, and who died of the generalized form of that disease. Because none of the symptoms of the patient could be referred in any way to the condition of the genito-urinary tract we shall omit the history and report of the autopsy, and confine ourselves to an account of the condition only as it referred to the specimens. We believe that this case has been discussed from the dermato logical standpoint by Dr. Ravogli. The left kidney weighed 200 gms. The capsule stripped witlr slight difficulty and left a moderately roughened, almost nodula surface. The cut section was rather pale, and the line of de- markation between cortex and m.edulla v.'as indistinct. The cortex was of about normal thickness. The blood vessels were sclerotic. The right kidney showed the same general appearance. The left adrenal showed a somewhat evident hyperplasia of th'" medulla. The right adrenal was apparently absent. Extending from the antero-mesial aspect of the upper pole of the right kidney, that is, from the normal site of the right adrenal, appeared a distended, tortuous, saculated tube, wdiich ran paralle\ with the right ureter which it finally passed to enter the posterior surface of the prostate gland. The average diameter of this sac was about 2 cm. In its wider parts it was distended to about 4-5 cm. At its lower end it was rapidly constricted, almost to * Reprinted from The Johns Hopkins Hospital Bulletin, Vol. XXII, No. 244, July, 1911. 303 304 DAN DRIDGE MEMORIAL the immediate vicinity of the prostatic part was a blastomycotic abscess which involved, to a minimal extent, the wall of the duct. The upper part of this distended duct ended in a mass of tissue of about 2x1x1 cm. in size, which was taken to be the remains of an atrophic adrenal and which later proved to contain only one small area which in any way resembled adrenal tissue. This mass also contained abscesses. There was no connection whatever be- tween the tube and the kidney, ureter or bladder. The pelvis of the kidney was not dilated. Both testicles were present and had undergone descensus. In the expectation that sections of the specimen would be of some assistance, bits of tissue were taken from the nodule of tissue at the renal extremit}^, from the sac at its origin near this renal nodule and from the prostatic portion of the tube. The blocks of tissue taken from the uppermost part included the nodule itself and the kidney so that comparison could be made in the same section. The sections made from these blocks can, for the purposes of description, be divided into three parts ; one, representing the mass of the nodule ; a second representing the kidney ; and a third, the boundary zone betv/een nodule and kidney. The tissue of the first part was for the most part well-formed fibrous tissue enclosing large and small cystic spaces, large and small blood vessels, nerves, collections of epithelial cells (colum- nar, as a rule, occasionally cubical), which seem to represent cross sections of ducts, and the blastomycotic abscesses. The larger cystic spaces were lined with a single row of cuboidal epi- thelium and filled with a granular albuminous material in which masses of desquamated epithelium, polymorphonuclear leucocytes, giant cells, and blastomyces, were imbedded. The smaller cystic spaces were of two particular forms. One form was lined with one or more rows of cylindrical or high columnar epithelium and filled with desquamated cells, cellular detritus, leucocytes, and extra- and intra-cellular blastomyces ; the other vvas lined with one or more layers — usually a single layer — of cuboidal epithelium and contained a material that greatly resembled thyroid colloid. Occasionally this colloid showed concentric lines and in some cases it was so changed that it stained with basic dyes and ap- Fk;. 1. Ii.Lu.STRATioxs. — 1. ii pliotojjrapli of tlie jrross specimen: 2. the atl renal (?) rest: i. same as 2. enlarged: 4. cystic spaces showing colloid: 5. cystic space showing corpus amylaceuni: 6. ducts in the nodule above the kidney: 7. wall of the larsj-e duct. All of the illustrations except 1 and .i were drawn with a c;iniera liicida at table lieiy:ht usinsi a I.citz ocular IV anil obj. .?. Fitrure .^ was drawn with a I.eitz ocular IV and a Spen- cer -I mm. A ii.Sii olijeotive. V 't ji. .<• *, S '••■'■u' J,' 'l- t**V Fk.. 4. ;vx^^/^ Fig. 6. Fig. WOOLLEY AND BROWN 305 pearcd quite similar in appearance to the corpora amylacea of the prostate gland. As a rule, however, they were rather more irregular than the ordinary prostatic corpora amylacea, and had a striking resemblance to other similar bodies that are occasionally present in the ovary and other organs. The blood vessels had, as a rule, thickened walls and in the majority of instances showed endothelial proliferation, even, in some cases, to the point of ob- literation. The nerves showed no abnormalities, either in cross or longitudinal sections. No ganglion cells were observed. The tissue of the second part represented merely a narrow zone of kidney tissue in which there were general changes that taken collectively indicated a chronic diffuse nephritis of mod- erate severity. The boundary zone between the two parts already described was composed of f brous tissue that firmly united the kidney and the nodule. This zone was of some little width, but the line of demarcation was narrow, and was represented by a narrow line of renal capsule. In but a few sections, close to the kidney, and yet separated distinctly from it were small localized masses of tissue, glandular in structure, and quite similar to the tissue that is seen in adrenal and renal adenomas, and in which was no sign of ganglion or chromaffin cells. The general impression given by these sections was that one was dealing with a possible combination of renal, adrenal, and ovarian tissue indifferently arranged. Drs. Knower and Wieman have suggested the occasional resemblance to a Wolffian body. The sections from the sac itself at the upper and lower ends >show that the walls of the sac were composed of fibrous tissue with a minimal number of smooth muscle fibers and were lined with low columnar or cuboidal epithelium. There are, under more or less normal circumstances, possi- bilities of but three openings into the prostatic urethra — two, the openings of the ejaculatory ducts, which were present in this case, and one, the opening of the united Miillerian ducts. There is also the theoretic possibility that as a result of em- bryonic developmental variations as suggested by Pohlman the ureter might open into the prostatic urethra. Pohlman says that in changing its position on the A\''olffian duct from dorsal to lat- 306 D A NDR I DGE MEMORIAL eral, at which time the ureter comes to open distinct from the Wolffian duct and would naturally open in common with it or into parts developed from its lower end, or "the ureter might open laterally to the Wolffian duct and on a level with it. The opening in this case would be found in the prostatic urethra." If this be a true explanation, then the mass of tissue above the kidney is the remnant of an atrophic or h^-poplastic kidney, or it is the remains of the Wolffian body. In the former case we should be dealing with a unilateral multiplicity of kidneys, each with its ureter, one of which opens into the prostate ; in the latter we should have to consider that the duct was the result of per- sistence of the united Wolffian duct and ureter. There is the other possibility that in this case we are merely idealing with an abnormal course of a complete ureter without any participation of a Wolffian duct, as occasionally happens in cases with accessory ureters. It is to be noted that in such cases one of the ureters, usually the one which has the superior origin, lies deeper and may open into the colliculus seminalis, the vas 'deferens or the seminal vesicle. In any case we cannot account for absence of the adrenal except on the basis of aplasia, or per- haps — if the nodule mentioned above be adrenal — hyperplasia. Either of these results, it might be suggested, may be the result of the development oi' accessory renal tissue at the expense of ad- renal. The embryonic relationships of the urogenital organs are so close that the possibilities of variations are very numerous. Marchand emphasized this from the side of the genito-adrenal organs when he suggested that variations in the sizes of adrenals and ovaries cannot be considered as purely fortuitous. It is our misfortune that the anatomic evidence at our disposal is not sufficient to permit us to come to any decision as to whether ?we are dealing with the result of one or the other of the possi- bilities mentioned. LITERATURE. Pohlman : Amer. Med., 1904, 987. Marchand: Intern. Beitraege z. Wissensch. Med., Virchow's Festschrift, Bd. 1. Aschoff: Pathologische Anatomie, Jena, 1909, Bd. 11, S. 506. Kaufmann : Specielle Pathologische Anatomie, Berlin, 1907, S. IIZ. THE GER^IICIDAL ACTIOX OF BASIC FUCHSIN.* EUGENE S. MAY, M.D. "Fucpisix (rubin is obtained by the oxidation of a mixture of aniline, ortho- and paratoluidin, by means of arsenious acid or nitrobenzol in the presence of iron chloride, which acts as the means of carrying over the acid. It is soluble in water, alcohol and aniyl alcohol. Rubin is 'basic dye-stuff' and serves for the staining of cell nuclei, fuchsinophile granulations and bacteria."^ A convenient classification of the aniline dyes, that of Krieger,- places the three salts of fuchsin in the rosaniline group. The members of this group are : Methyl violet, 6 B. C^, H30 N., CI. ^lalachite green, C23 H25 No CI. Rosaniline acetate, Qo H20 ^'3 CL H3 O.. Rosaniline hydrocliloride, C20 Hgo N3 CI. Rosaniline sulphate, (C20H20N32) SO4. It is only with the last three members of this group, rosaniline acetate, hydrochloride and sulphate, that Ave shall be concerned. These three salts are generally known as the fuchsins. The acetate is the most basic, and the sulphate most acid in reaction, and it is the acetate which is furnished us as basic fuchsin, and the hydrochloride and sulphate as acid, or ordinary fuchsin. This difference of chemical reaction in these salts is of importance, since Krieger- has shown that the greater the degree of basicity of the dye the greater is its germicidal action. Our experiments confirm these findings, with the exception, that our results, when testing the germicidal action of the acid salts upon bacteria, have been uniformly negative. METHODS. There are many technical difficulties in the handling of the problem and many observers have attempted to work out a tech- nique which will not be open to criticism. Ainley Walker and :^Iurry2 added such dye-stuffs as Grubler's methyl violet, fuchsin 307 308 DAN BRIDGE MEMORIAL and methylene blue, in (0.2 per cent.) solution, to culture media (principally plain agar-agar), sterilizing the media in the ordinary way. They often noted the precipitation out of the coloring matters to the bottom of the tubes. They then inoculated the tubes with the bacterium under investigation and their experi- ments prove that very interesting morphological and biological changes occur in bacteria which are grown upon culture media so prepared. They found that the motility of the bacillus typhosus was lost, that the bacillus was replaced by a thread-like organism, twenty to thirty times as long as the original bacillus. No seg- mentation was noted, though branching forms were frequently encountered. With the work of Walker and Murry as a basis many observers accepted the fact as proven that the bacillus were dead. This we believe to be an error, since the tubes were not under observation for a sufficient length of time. We have noted growth in tubes after seven or eight days, where no growth had been observed after forty-eight and seventy-two hour^. This phenomenon is readily explained by an inhibitory rather than a germicidal action of the dye (as proven by Geppert, quoted by Krieger). Further, we have noted a very great difference in the germi- cidal action of the dye, according to whether the inoculations have been made into warm or cold solutions ; cold solutions being for the most part non-germicidal, while warm solutions are uniformly active. Again, we have noted many times that solutions from which all pigment has been precipitated, by careless sterilization, had completely lost their power to kill bacteria. Because of heat applied during the sterilization of solutions of the dye chemical changes occur in the dyestufT itself, perhaps new and entirely different chemical compounds are produced and these are appar- ently more active than the original dyestuff itself. Koch used what is known as the silk thread method. He placed sterile silk threads in emulsions of bacteria, and then al- lowed them to dry for twenty-four hours. They were then intro- duced into sterile solutions of various dyes and tested out. Krieger dismisses the technique of Koch as open to error and bases his technique upon the work of Walker and Murry. Briefly, Krieger's^ own method of investigation is this : Bacterial sus- M A Y 309 pensions were prepared from cultures and emulsified in sterile physiological salt solution, then filtered, and drops of the filtrate carried over with platinum loops to the sterile cover slips ; the cover slips were then placed in the incubator for one hour (till dry) ; then the cover slips were transferred to the various dye solutions for variable periods of time, washed in water, and after- wards dropped into broth tubes. If no growth resulted (length of time of observation not stated), it was taken for granted that the micro-organism was dead. Many sources of error arose, as he himself notes ; too long drying may weaken or kill the bacteria, or they may be mechanically washed off. Our own technique is about as follows and we believe that we have obviated nearly all source of error : Carefully weighed quantities of basic fuchsin (Grubler's) was made up into a stock solution of 1.00 per cent, with double dis- tilled water and placed in sterile bottles and kept away from the action of light. From this stock 1.00 per cent, solution higher dilutions were made, as 0.75 per cent., 0.5 per cent., 0.25 per cent., 0.1 per cent., 0.075 per cent., 0.025 per cent., 0.01 per cent., and 0.001 per cent. ; 5.00 c.c. of these solutions were run into thor- oughly cleansed, sterile test tubes, and then sterilized in flowing steam in the Arnold sterilizer for fifteen minutes on three suc- cessive days. This we determined after many trials to be about the limit of sterilization. Greater heat or more prolonged heating brought about a precipitation of the dye. The germicidal action of these stock fuchsin solutions was tested in the following manner: Three loops-full of the water of condensation from twenty-four hour agar slant cultures was car- ried over to the standard basic fuchsin solution and thoroughly mixed. The bacteria-fuchsin solution thus prepared was then constantly kept at a temperature of about 40° during the whole of the experiment. Immediately, and at intervals of one, five, fifteen, thirty, forty and sixty minutes, three loop-fulls of the w^arm bacteria-fuchsin mixture was inoculated upon a culture medium known to be favorable for the growth of the micro-or- ganism under investigation. Controls were made and the tubes incubated at 37° for from seven to fourteen days. Careful note was made of the presence of growth from day to day, in order to 310 DANDRIDGE MEMORIAL ascertain that the resuUs were not due to an inhibitive action of the dye upon the bacteria. In several instances the original bacteria-fuchsin solution was also incubated with the other tubes, and, at the end of two weeks, centrifugalized and the bacteria thoroughh- washed with sterile physiological salt solution and new sub-cultures made. In all instances no growth was noted. Also the dye was first added to the culture media and then the inoculations were made. These served as controls for any in- hibitory action of the dye. As a routine all bacteria-fuchsin mix- tures were incubated, and at the end of fourteen days sub-cultures were made with negative results. The germicidal action of the fuchsin solutions was tested upon B. coll, B. typhosus, B. paratyphosus, B. enterifidis (Gaertner), B. dyscntericc, staphylococcus pyogenes aureus, a saprophytic strain of B. tuberculosis, Oidiuni albicans from the human throat and Oidia from a case of generalized blastomycosis. The culture of B. coli was isolated from a case of chronic cystitis with per- sistent colonuria. It was with a view of combating this latter condition that this research was originally undertaken. All of these stock cultures were furnished me by Dr. W. B. Wherry, to whom I am much indebted for advice and assistance. The following table summarizes our bacteriological investiga- tions. In this table results as given are constant. We have shown repeatedly that fuchsin is germicidal in much higher dilutions than here shown (1-10000 to 1-100000), and it should be remem- bered that the action of these higher dilutions is variable. It will be noted that a warm 0.1. per cent. (1-1000) solution was lethal in five minutes to B. coli, B. typhosus, B. paratyphosus, B. enteritidis, B. dysentericc, and the staphylococcus pyogenes aureus, while the blaslomxyces was not killed in less than fifteen minutes. In the case of B. tuberculosis and Oidium albicans lethal action was not manifested by higher dilutions than warm 1.0 per cent. (1-100) solution acting for five minutes. We have made several animal experiments to show the non- toxicity of the dye. With warm 1 per cent, solutions we have made repeated irrigations of the urinary bladders of rabbits. Repeated and careful examination of the urine and sections of the bladders showed no irritation or inflammatory changes. Basic MAY 111 Micro-organisms *B. typhosus B. paratyphosus B. coli com. B. enteritides B. dysenteriss tB. tuberculosis ♦Staphylococcus Time of con- Over Strength of tact neces- Warm Cold sterilized Con- solution 1-1000 or 0.1 per ct. Less than 0.1 per ct. or 1-1000 1-100 or 1 per ci. Less than 1 per ct. or 1-100 1-1000 orO.l per ct. Less than 0.1 per ct. or 1-1000 sary to kill sol. sol. bacteria. 5-60 min. 5-60 min. 5-60 min. — -for: sols, trols -fort -r -f -f-or+ -fort -f - -fort +ort -f + +ort -fort -f — -fort -fort -f -f -fort -fort -f fBlastomyces tOidium albicans 1-1000 or 0.1 per ct. Less than 0.1 per ct. or 1-1000 1-100 or 1 per ct. Less than 1 per ct. or 1-100 15-60 min. 5-60 min. — -1-ort -fort 4- + -fort 4-ort - -fort +ort -f + ■ or J ort 4- -f = growth. — = no growth, t = variable * Subcultures made into -f 1 broth, t Subcultures made onto cose agar slants, (-f 1 = 1 per cent, acid to phenolphthalein.) -1 du- fuchsin has also been injected into the lumbar subdural space of dogs in 1 per cent, and 0.1 per cent, solutions with like effect. In the last two experiments the great diffnsibility of the dye is es- pecially well shown. This we believe to be of cordial importance in the use of the dye as a general surgical antiseptic, since a very 312 D ANDR I DGE MEMORIAL recent work of A. von Wassermann, dealing with the treatment of cancer, is based upon the great diffusibihty of a dye carrying the therapeutic agent to poorly vascularized cancer cells. It is of interest to note that in 1870 Stilling advocated the use of aniline dye solutions in surgical dressings because of its great diffusi- bility, harmlessness, activity, and that it coagulates no albumen. CONCLUSIONS. 1. Based upon the results of our investigations with basic fuchsin we conclude that we have a germicidal agent which is more powerful than carbolic acid and one which has a greater diffusibihty and is less toxic. 2. Based upon our clinical observations we conclude that we have a germicidal agent which has a marked stimulative action on epithelial and granulation tissue growth. We have had as yet no experience with the dye in the treat- ment of lupus and blastomycosis. We hope to soon be able to try basic fuchsin out on these cases and in a later report give the results of our investigations. REFERENCES. 1 Rohrman : Biochemie, berlin, 1908, p. 482. 2 Krieger: Centralblatt f. Bact., etc., 1911, Bd. 59, Heft 4, p. 481. 3 Walker (E. W. Quinley) and Murry: Brit. Med. Jour., vol. 11, p. 16. 4 Geppert : Berliner Klin. Wochenschr., 1889, Nov. 36, p. 37. 5 Wassermann, A. von: Deut. Med. Woch., 1911, No. 24, p. 531. 6 Stilling, J. : Berl. Klin. Wochenschr., 1870, No. 24, p. 531. NOTES OX TWEXTV-TWO SPONTANEOUS TUMORS IX WILD RATS (M. NORVEGICUS).* ];V PAUL G. WOOLLEV^ M.U., AND \VM. 1!. WIIERRV, M.U. We must express our regret that the following report does not deal with the inoculability of spontaneous tumors in wild rats. This apparent lack of energy is due to the fact that the tumors were found during the systematic examinations of rats captured or killed in San Francisco during the campaign for the eradication of plague (1907-08). The routine of bacteriological examinations left no time for the experiments on implantation that we should have carried out under other circumstances. In the literature that we have had at our disposal we have been able to glean but little information as to the incidence of tumors in wild rats. The general fact has been elicited, however, that sarcomas have been most frequently reported, and Opolant makes the statement that whereas in mice 95 per cent, of the tumors are adenocarcinomas of mammary origin, in rats 95 per cent, are sarcomas — a statement that does not correspond with Tyzzer's results in the case of mice nor with ^IcCoy's or ours in the case of rats. It is true, however, that except for McCoy's statistics, few epithelial tumors have been reported, and this is at the bottom of the current belief in the predominance of the con- nective tissue group of tumors. In ]\IcCoy's series of ninety-nine there were forty-eight epithelial tumors, a percentage of 48.4 per cent. In our series of twenty-two there were fourteen or 63.64 per cent. In jMcCoy's series there were thirty sarcomas and eighteen libromas ; a total of forty-eight tumors of fibroblastic origin. The other tumors were one lipoma, one endothelioma, and one angioma. In our series there were seven sarcomas and one fibroma. Our cases, like those of ]\IcCoy, were all in ]\Ius norvegicus * Reprinted from the Journal of Medical Rcscarcli. Volume XXV, Xo. 1. 313 314 DAXDRIDGE MEMORIAL (decumanus), a fact that is undoubtedly explained by the rela- tively small numbers of AIus rattus and Mus alexandrinus in the rat population of San Francisco. The twenty-two tumors which we report were found in the course of the examination of about twenty-three thousand rats, and since but one cf our rats exhibited more than one growth it is apparent that our results compare well with those of AlcCoy, who found that, on an average, one rat in a thousand was affected with a tumor of one sort or another. Of McCoy's ninety-nine reported cases, thi -ty were sarcomas, twelve carcinomas, and one endothelioma, a total of forty-three malignant growths. In our series were seven sarcomas, one epithelioma, one adenoma, and three renal adenomas, a total of eleven malignant growths. In McCoy's series sixteen tumors showed metastasis; in ours but four. The tumors that gave rise to metastasis in both series were with one exception (McCoy's case of renal carcinoma) sarcomas. The cases were as follows : Case No. 1 (3837). Adult. Sex? — A tumor about the size of a walnut was observed in the right axilla. It was not adherent to the skin and was not closely bound to the surrounding tissues. It was rather soft and on section appeared whitish and had a lobulated appearance. It was thought that it had a definite re- lation to the mammary gland. Sections showed that it \x3.s a typical fibro-adenoma with no evidence of malignancy. The sections showed a grossly lobulated appearance. The various lobules were composed of central col- lections of parenchymatous cells surrounding, in a single row or occasionally several rows, central duct-like spaces which were filled with coagulated proteid material. In some instances the coagulated material had an inspissated appearance. Occasionally no lumen w-as present in the centers of the parenchymatous masses so that the lobules were composed of solid masses of cells. The connective tissue was abundant and w^ell formed and contained considerable numbers of mast cells. Case No. 2 (5386). Adult female. — The tumor in this case was in the left groin and measvired 3.5 x 8.5 centimeters. Upon its surface was an ulcerated, punched-out area five millim.eters in diameter. The tumor was not adherent, was soft, and on section white and lobulated. Sections showe.l that this tunior was similar to the preceding (3837), but dift'ered in that the parenchyma was somewhat better developed, and that the connective tissue was more mature, and WOOLLEY AND WHERRY 315 showed a tendency to become hyaline. The epithelial cells showed a more constant increase in the number of layers and less coagu- lated proteid in the spaces. There was some tendency to inter- canalicular growth. At a single point there was evidence of in- vasion of the supporting tissue by the epithelial cells. Mitotic figures were few. Occasional direct divisions were observed. Case No. 3 (2). Adult. Sex? — A very large tumor 7.5 x 13 centimeters in the subcutaneous tissue of thorax, not adherent, white, lobulated. It differed from 5386 only in absence of ten- dency to infiltration and in absence of mitosis. Case No. 4 (5755). Adult female. — The tumor was situated beneath the skin on the left side of the thorax. It was soft, lobu- lated, whitish in color and not adherent to the skin or surrounding tissues. Microscopically this growth showed a more pre-eminently adenomatous structure than the foregoing tumors. The whole mass was generally lobulated. It also showed a beautiful alveolar arrangement. The adenomatous parts were divided and sub- divided into large and small masses by well developed, ripe con- nective tissue. The alveoli were composed chiefl}' of solid masses of cells, with only occasional evidence of lumens which were filled with inspissated coagulated proteid material. In the preceding tumors the cells had vesicular nuclei, and a homogeneous granular protoplasm that frequently showed a basophilic tendency ; in this the nuclei were small, though still vesicular, while the protoplasm was spongy and clear. There was no evidence of reaction on the part of the supporting tissue ; no sign of infiltration of the epi- thelial parts ; no evidence of rapid growth at any place. Case No. 5 (16646). Adult female. — In this case there were two tumors, one the size of a hen's egg under the skin on the left side of the thorax ; one — a. smaller one — in the right groin. Neither was adherent. Both showed the same structure as the growth in Case No. 5755. Case No. 6 (5298). Adult female. — The tumor was situated on the left side of the thorax and measured 5 x 2.5 x 2.5 centi- meters. It was hard, cut with difficulty, and was not adherent., This tum.or was an example of fibro-adenoma in which the cell masses showed, as a general rule, central lumens surrounded by but a single row of cells. The whole grcv/th was formed of alveoli each of which was divided and subdivided into small acini by a scanty fibrous tissue. The gross masses were limited by a well-formed — in some places hyaline — connective tissue. The lumens were filled with coagulated material. There was no evi- dence of malignancy. Case No. 7 (17142). Adult female. — The animal was preg- nant. In the right inguinal region there was a globular, soft, 316 DANDRIDGE MEMORIAL lobulated, vv-hile tr.mor measuring about 2.5 centimeters in di- ameter. It was not adherent. The tissue of this growth was composed chietly of long, free and interlacing processes, which were constructed of a narrow, central, vascular, connective tissue covered with from one to several layers of epithelial cells. These papillary processes originated from the thin hbrous capsule that surrounded the whole mass. In this capsule a few eosino- philic cells were observed. No mitotic figures were found. Remarks. — The eight tumors described in the preceding para- graphs represent growths of an adenomatous type, the variations within the group being determined by the relative development of the glandular tissue and the stroma. In all but one case (5) the tumors W'Cre single. In the one case tv.'o similar tumors were present in different parts of the body. All the animals in which the sex Was recorded were females, a fact that indicates the greater tendency of females in rats, as in human beings, to ex- hibit mammary growths. This sexual difference is shown in Mc- Coy's figures in which thirty out of thirty-four mammary tumors v/ere found in female rats. In none of the seven animals from which these growths were taken was there any evidence of a causative factor. Case No. 8 (6712). Adult female. — In this animal a slightly adherent, soft ovoid tumor the size of a hazel nut w^as discovered in the right inguinal region, and upon the upper lip among the large whisker hairs was a small epithelial growth. The mass in the inguinal region proved to be a typical, pure, soft fibroma. The growth on the lip was due to a localized hyperplasia of the epi- thelium — a hyperkeratosis — with no evidence of down growth and no sign of malignant change. It was not apparently due to Sar- coptes alepsis. Case 8 furnishes the only example of a pure fibroma in our series. In McCoy's series there were sixteen subcutaneous fibro- mata. Case No. 9 (13487). Adult. Sex? — The tumor in this case was a papilloma of the bladder associated with calculi. The calculi were sent to Prof. H. B. Ward for examination for ova of parasitic worms. Up to the present time no ova have been demonstrated. The growth was composed of elongated branching and inter- lacing papillar}^ projections, each with a central connective tissue framework carrying blood vessels, and covered with approxi- mately normal, though occasionally hyperplastic, epithelium. The WOOLLEY AXD WHERRY 317 spaces between the interlacing columns were sometimes cystic, sometimes completely filled with cells of a polygonal squamous type, but without evidence of keratinization. In such cellular masses the central cells not infrequently showed degenerative changes. There was no evidence of malignant change. Interspersed between the cells at various places in the growth were ovoid bodies composed of a central round protoplasmic mass with one or two rounded chromatin masses. These central structures were surrounded by a clear space limited externally by a thin sharply demarcated capsule. These structures are appar- ently the result of retrogressive metamorphosis of epithelial cells, though at first it was suggested, because of the fact that the blad- der contained calculi, and that in M. norvegicus bladder worms (Trichosoma Sp?) were not infrequently found, that they might be ova. Reinarks.^Case Xo. 9 represents the only example of bladder tumor which we have seen. Among McCoy's cases there was no example of such a tumor, which indicates that, in spite of the frequency of bladder worms and calculi, new growths of the bladder are very uncommon. Case Xo. 10. Adult female. — Above the labia was an ulcer- ated surface 2.5 millimeters in diameter, where the skin was thick- ened, hard, and ulcerated. Attached to the border of this area was a nodular mass 10x5x6 millimeters, which was firm in con- sistence and pinkish on section. The labial growth showed hyperplasia of the epithelium with distinct invasion of the subjacent tissues. The surface of this hyperplastic growth was ulcerated, and the tumor itself was infil- trated with considerable numbers of polymorphonuclear leuco- cytes. The epithelial cells in the invading columns shov^'ed nu- merous mitotic figures, symmetrical and asymmetrical, and some epithelial giant cells. The nodular mass connected with the tumor was composed entirely of granulation tissue. Remarks. — Epitheliomatous growths are not frequent in rats so far as our records show, and in ^McCoy's series there is no example. Borrel, Gastinel and Gorescu^' believe that acarids, particu- larly Demodex folliculorum, play an important role in the pro- duction of epitheliomas in man. While the analog}' is not com- plete, it may be worth mentioning that whereas hyperkeratosis of the ears, lips, and nose, due to Sarcoptes alepsis, was extremely 318 D A NDRIDGE MEMORIAL common among the Norway rats on the Pacific Coast, yet no tumors were found at these sites. Case No. 11 (8741). Adult female. — A flattened ovoid tumor 3 X 2.5 centimeters was found in the right groin. It was not ad- herent, w'as readily peeled out, was soft and had a lobulated ap- pearance. An emulsion of this tumor was made in physiological saline and injected subcutaneously into a small white rat. No growth of parasitic or tumor origin appeared, and two months later the rat was chloroformed and examined. Nothing abnormal was discovered. The bulk of the tumor was composed of groups of cells of squamous epithelial character limited by a well developed, par- tially hyaline, connective tissue. The minor portion was a gland- ular tissue with delicate supporting connective tissue structure. The epithelial islands of the major part varied in size and shape. The small islands, those which showed for the most part little or no keratinization, v/ere generally round. The larger ones, those fonned of an external zone of more or less normal, or flattened epithelial cells and a central area of cells shov/ing extreme kera- tinization, or merely masses of keratohyalin, were polymorphous, lobulated, trefoil-shaped, or round. About the smaller islands there v/as a well marked small round-cell infiltration with occa- sional polymorphonuclear leucocytes. About the larger there was merely a well formed connective tissue. In many instances in both the smaller and the larger islands the epithelial cell boundaries could not be distinguished, so that the central, cellular or keratin masses seemed to be surrounded by a more or less complete syncytial layer. In various places the cells contained "inclusions," usually acidophilic, each surrounded by a clear achromatic zone. At no place could prickle cells be observed. The glandular portion of the tumor showed longitudinal and cross sections of ducts and acini, some with a central lumen; some completely filled with cells. Among the typical epithelial cells were others that had a yellow granular appearance, the result of the presence in the protoplasm of numbers of flne yellow granules of lipoid ( ?). The lining epithelium of the ducts and acini were composed of one or several layers of cells of cjdindrical or cuboid form. In the supporting tissue there was very little evidence of reaction, except for occasional basophilic polymorphous cells, and a few eosinophiles. No mitotic figures v^-xre found. The blood vessels w^ere slightly congested. In a few sections small colonies or clumps of organisms were WOOLLEY AND WHERRY 319 found. The individuals of these colonies were rounded or spin- dle-shaped with granular and vacuolated bodies. These were arranged tip to tip in chains within the clumps. Associated with them there were a few structures resembling mycelial threads. The identity of this organism which was found only in the aden- omatous part of the tumor cannot be more than guessed. Its relation to the tumor can only be conjectured. Remarks. — We believe that there are but four similar tum.ors on record — one reported by Tyzzer, and three by Murray ; all in mice. These tumors are interesting examples of metaplasia due most likely to continued irritation of one sort or another, and are apparently comparable in their metaplastic changes to the inter- esting lung tumors described by Tyzzer in mice. It is difficult, however, to discover what the cause of the irritation w-as in our case. There were microbic parasites present, but only in the purely adenomatous parts. It is possible that the absorbed se- cretions from these organisms was responsible, in part, for the changes in the tumor, but to us this possibility seems remote. Case Xo. 12 (10375). Adult. Sex?— This rat showed a soft tumor the size of a filbert in the submaxillary region, v»"hich was adherent to an adjacent lymph gland. Sections showed that the tumor was composed of small poly- morphous cells with relatively large vesicular nuclei and a slightly- granular protoplasm, and with no evidence of orderly arrange- ment, except that they are more compact!)^ related to the blood vessels. Mitotic figures were nmnerous and in some instances asymmetrical. It was a small polymorphous cell sarcoma. Case Xo. 13 (9). Adult female. — This rat showed a large tumor of the right humerus, ovoid in shape and measuring 4x3 X 3 centimeters. It surrounded the upper part of the humerus and involved the shoulder joint. It was soft and whitish and apparentlv very vascular. It was not adherent to the skin. The humerus itself w-as not involved. It was apparently a periosteal tumor. The sections shov/ed a partially alveolar structure due to the peri-vascular arrangement of the tumor cells which were of a short spindle shape variety. There w^as no evidence of endo- thelial origin of the tumor. Occasional giant cells w-ere present. X^o chondroblasts w-ere found. Mitoses were frequent. Case Xo. 14 (20804). Adult male. — The animal showed rather marked post-mortem changes. Just above and attached 320 DANDRIDGE ME^IORIAL to the right adrenal was a soft tumor mass the size of a small walnut. It was smooth and glistening and the surface was mot- tled with reddish white. Between it and the stomach were similar smaller nodules, and extending anteriorly across the abdominal cavity was a large lobulated mass 3 x 2.5 x 1 centimeter and in the mesentery another measuring 2x2x1.5 centimeters. Be- neath the liver were other smaller rounded masses, and a single one in the left kidney. Throughout the liver were other tumor growths, and the peribronchial lymph glands were fused together into a tumor-like mass. The lungs were nodulated and on section the areas of consolidation had the same appearance as the other tumor masses. This tumor was a typical lympho-sarcoma, the origin of which it was impossible to determine. The character of the growths in all the situations was identical. Case No. 15 (7). Adult. Sex? — In the liver region a tumor measuring 2x3 cubic millimeters, irregularly ovoid, and appar- ently closely associated with the gall-bladder was found. It was adherent to the edge of the right lobe of the liver, and was com- posed of a soft grayish or whitish tissue with areas of congestion. In a cleft in the anterior of the tumor mass was a free Cysticercus fasciolaris. The vesicle or bladder which usually encloses the cysticercus was not found. A cysticercus within its cyst was found projecting from the lower border of the right lobe of the liver. Part of the tumor was fed to a white rat with no result. The tumor proved to be a polymorphous cell sarcoma com- posed of round and spindle cells, with numerous giant cells scat- tered throughout. INIitoses were frequent. Case No. 16 (8). Adult female. — Attached to the under sur- face of the lower lobe of the liver was a pinkish, lobulated tumor face of the lower lobe of the liver was a pinkish, lobulated tumor the size of a large hen's egg. Throughout the omentum and mes- entery were hundreds of metastatic nodules varying in size from that of a large pea to 0.5 millimeters in diameter. As in the previous case free cysticerci fasciolaris were found lying in smooth walled channels within the tumor mass. In the upper part of the duodenum was a small ulcer near which an intestinal worm was attached. In the non-secreting portion of the stomach were two small crater-like elevations of a pale color. The stomach con- tained dipterous larv?s and parasites resembling tricocephalus. The intestine contained tapeworms. In the cecum were some anchylostoma-Iike worms. The tumor in this case was composed of polymorphous and giant cells in close association with thousands ,of ova. It had apparently originated in the liver. The metastatic nodules VV O O L L E Y A N D W H E R R Y 321 were composed of cells similar to those of the primary growth and contained no ova. The gastric lesions were due to the presence of small sub- epithelial cystic spaces containing ova that resemble those of an- chylostoma. About these there is no evidence of malignant change. Case No. 17 (22058). Adult female. — In the gastric omen- tum there was a large lobulated pinkish-white tumor the size of a large hen's egg. Scattered throughout the mesentery v/ere simi- lar, but smaller, rounded and ovoid nodules, 3-6-8 millimeters in diameter. Other similar masses were found in the subperitoneal tissues. Microscopic study showed that the tumor was a large spindle-cell sarcoma with metastases of the same type. Giant cells were present in small numbers and mitoses were scanty. Case No. 18 (4). Adult male. — In the abdomen attached to the diaphragm and to one lobe of the liver was a tumor mass, 4 X 3x 3.5 centimeters, irregularly ovoid in shape and composed of a soft, almost fattv tissue. Attached to the diaphragm were three or four smaller nodules two to six millimeters in diameter ; tiattened, rounded, and apparently composed of the same sort of tissue as the larger growth. Cysticerci were present in the liver substance and two were present in the tumor. The tumor was a very vascular polymorphous cell sarcoma and occasionally pre- sented a p'crfect pt-rivascular, alveclar api^earance. There were no ova present. Remarks. — This group of cases is extremely interesting to us for the reason that several of them (15, 16, and 18) were asso- ciated with parasitic worms, and because several of them (14, 16, 17, 18) produced metastases. In one of them ( 16) the sarcomatous changes were evidently associated with the presence of an enormous number of ova. In another (17) the tumors were present in the mesentery, but in the absence of parasites or ova outside the intestine. In still another (16) merely cystic spaces were present in the stomach walls, and in these spaces ova of another sort of parasite were present. In all the cases directly associated with the presence of immature tapeworms, cysticercus fasciolaris. the malignant tu- mors affected the liver. These facts bring up the questions whether it is the worms themselves or their excretions that are to blame for the tumor, or whether it is the ova that are chiefly to blame, as in bilharziosis of the bladder and intestine ; whether the tenia? alone, either through their presence and secretion and ova 2il2 DAN BRIDGE iM E M O R I A L are active in producing these tumors ; and whether the liver is more prone to undergo malignant change as the result of these various influences. Saul did some implantation experiments using various portions of the cysticercus fasciolaris. Rats inocu- lated with the head end and middle portions died of evident tox- emia. One inoculated with the tail end developed a fibro-sarcoma at the site of implantation. Reimplantation with a portion of his tumor resulted in infection. It is interesting that so many tumors of rats are associated with parasitic worms. In twelve of McCoy's cases parasites were associated with tumors. One of these growths was a fibroma. The other eleven were sarcomas. All were of hepatic origin. Case No. 19 (8994). Adult. Sex?— All of the left kidney except the upper pole was replaced by a tumor mass, ovai \\\ form, the size of a hen's egg, smooth, and encapsulated. On sec- tion it appeared partially fatty and necrotic, partially hemor- rhagic. The tumor mass appeared on microscopic examination to be composed of three parts; one a mass of recent hemorrhage; one a laminated mass of partially organized clotted blood ; one the larger part composed of renal and tumor tissue. The kidney substance itself showed cloudy swelling, edema, and interstitial accumulation of small, round cells. The interstitial changes were more marked in the immediate vicinity of the tumor mass, and in this region there were also occasional giant cells of renal epithelial origin. Though the tumor itself was as a rule well demarcated from the kidney substance, there were points at which an ap- parent transition could be made out, so that it seemed evident that the papillo-adenomatous tumor mass was of renal origin. In oc- casional spots there seemed to be some evidence of malignant re- version in the connective tissue. Case No. 20 (3) Adult male. — In this animal the central part of one of the kidneys was occupied by a grayish-yellow and pinkish-white mass which was bounded by approximately normal renal tissue. Microscopically this tumor resembled the preceding one. There was less hemorrhage in the tumor, and more evidence of chronic interstitial changes in the kidney substance. The tumor showed adenomatous, cystic and intracystic arrangement, with transition from renal substance to tumor. There was also some evidence of sarcomatous change in areas where the cells had a localized tendency to assume a spindle form, especially in those parts of the tumor where, with a rich vascular supply, the cells had a more or less perfect radial perivascular arrangement. WOOLLEY AND WHERRY 323 Case No. 21 (5). Adult female. — The organs seemed generally healthy except the left kidney, which was enlarged, and in its an- terior had had a wdiitish appearance. The left adrenal was imme- diately in juxtaposition with the tumor area but separate from it. The tumor was composed of cells smaller than those of the two preceding cases, of a more solid type and with fewer giant cells. Within the tumor itself were well-preserved glomeruli which had been surrounded in the progressive growth of the neoplasm. In this case as in the others there was evidence of renal origin in the gradual transition of renal cells at the tumor borders. Remarks. — In spite of certain likenesses to adrenal tissue we believe that these tumors have originated in renal tissue and not in misplaced adrenal rests; that they are malignant renal adenomas, therefore, and not hypernephromas, in the sense of Grawitz. This seems reasonable because of the evidences of malignant transformation in the cells immediately about the tumor proper. We realize that this transformation may be explained as being the effect of the presence of the tumor rather than the cause of it, but w^e think that there are greater similarities between the kidney proper and the tumors than between adrenal tissue and the tumors. In McCoy's series of eleven renal tumors, one produced meta- stasis. Of our cases none metastasized. SUMMARY. Total rats examined. 23,000 Total rats with tumiors, 21 Total tumors. 22 Total epithelial tumors. 14 63.64% Total connective tissue. 8 36.36% Tumors oJ breast, Q 40.9 7o (< a kidney, 3 13.64% a (I bladder, 4.54% a li skin. 4.54% ti << connective tissue, 4.54% a a liver, 3 13.64% a .< mesentery. 4.54% t( a submaxillary gland. 4.54% a •< periosteum, 4.54% a ii lymph glands. 4.54% Malignant, 11 50.50% Metastasis, 4 18.18% Associated with parasites. 3 13.64% 324 DA NDRIDGE MEMORIAL BIBLIOGRAPHY. McCoy : The Rat in Its Relation to Public Health. Public Health and Marine Hospital Service, Washington, 1910, 64. Wherry, Walker and Howell: Journal A. M. A., 1908, 1. 1165. Borrel, Gestinel and Gorescu : Ann. d. I'lnst. Past, 1909, xxiii, 97. Saul : Centr. f. Bakt., I. Abth. Orig., 1908, xlvii, 444. A COMPUTING CHART FOR MAKING A DIFFEREN- TIAL LEUCOCYTE COUNT.* BY A. E. OSMOND^ M.D. Any laboratory worker who has had any amount of blood work to do, especially in making differential leucocyte counts, has been more or less troubled with the necessity of having to figure out the percentages of the various types of cells and the liability of error. IcELLS COUNTED ,0 2 kO s s t S 5 to >a « *a s la i 3 rf^ to s i z J> = sss tO 2 g - POLYMORPH Itll ISI M »l HI M »1 Ml I!! Nl IHI f HI IHI tn 1 R K 1 IW H IfJ LARGE-LYMPH INI 1W TSi nil 11 181 SMALL-LYMPH iil M HI tu U HI Ml Vi 1 Ml EOSINOPHILES i 1 TRANSITIONAL II MAST CELLS 1 - MYELOCYTES PERCENTAGE d=> £ la i£> 5 S 2 « s £ S 3 »0 o> A computing cbart to. facilitate making a differential leucocyte estimation. The accompanying chart I have devised for use in the labora- tory of the Cincinnati Hospital, and we have found it quite convenient in simplifying the work and removing sources of error. The chart is inexpensive and can be made out of a piece of ground glass or a slate, suitably ruled and marked in ink so as to be * Reprinted from the Journal of the American Medical Association, January 8, 1910, Vol. LIV, p. 124. 325 002; 1 001 961 i 061 i 58 581 081 08 j 5i[ 1 Oil! S8 391 i 091 1 09 SSI! "'" 1 ! osi! 1 2i 5>I| 1 ofi! OL 581 1 081 1 59 9KIi Obi, 08 511; Oil! 55 SOI •'•^' , go:: 1 05 i «6 1 06 9^ 58 OS 0? 5t 01 98 59 09 08 OS SS 9f oTf OS 98 1 08 91 SS OS 01 51 01 ; 9 9i s a » Q e E I a E 2 to s 2 m •a a e "S E tn 09 § e u O u g P r- 'D r- U ^ Tr = G •— ^ IJ ^ ji; r-; ;_; en a, r>| CI M lA Oh O >> ^ 'H, o g G '