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HR02305500

ST. LUKE'S HOSPITAL

Medical and Surgical

Reports

Volume III
1911

«BR2AI

COLUMBIA UNIVERSITY
EDWARD G. JANEWAY
MEMORIAL LIBRARY

cot umbra Ulnit>ei'8U|!

DEPARTMENT OF

PRACTICE OF MEDICINE

College of Physicians and Surgeon*

437 W68T 6»TH 8ta*«t, Nt« r««K

Papilloma of Bladder Completely Covering
the Left Ureteral Orifice

Same after One Application of the High
Frequency Current

Same after Second Application of the High
Frequency Current. ( Close vision, pros-
tate not seen in the field)

Final Result, One Month after the first
Application. ( Close vision )

THE TREATMENT OE PAPILLOMA OF THE BLADDER
WITH THE HIGH FREQUENCY CURRENT

ST. LUKE'S HOSPITAL

Medical and Surgical
Reports

Volume III
1911

WILLIAM G. HEWITT
Brooklyn, N. Y.

COMMITTEE ON REPORT OF THE MEDICAL BOARD

Robert Abbe, M.D.
Austin W. Hollis, M.D.
Francis C. Wood, M.D.

Editor of the Report — Francis Rolt-Wheeler, Ph.D.

Managers of St. Luke's Hospital

OFFICERS

PRESIDENT

George Macculloch Miller.

VICE-PRESIDENTS

Waldron P. Brown, J. Van Vechten Olcott.

TREASURER

H. D. Babcock, 32 Liberty Street.

SECRETARY

Hoffman Miller.

MANAGERS

Whose terms of office expire respectively on St. Luke's Day,
October 18th, in the following years :

1912 1913

Francis M. Bacon, Henry D. Babcock,

James May Duane, Stephen Baker,

William Fahnestock, Waldron P. Brown,

Anson W. Hard, George M. Miller,

William M. V. Hoffman, Rev. Henry Mottet, D. D.,

Alvin W. Kreeh, A. Gordon Norrie,

Hoffman Miller, Henry C. Swords,

Charles Howland Russell. J. Howard Van Amringe.

1914
George Blagden,
George F. Crane,
William A. Greer,
J. Van Vechten Olcott,
John B. Pine,
Moses Taylor Pyne,
Herman C. von Post,
Richard H. Williams.

MANAGERS APPOINTED BY ST. GEORGE *S SOCIETY OP NEW YORK

George Gray Ward, Edward F. Darrell.

MANAGERS EX-OFPICIO

The Mayor of the City of The President of the Medi-

New York, cal Board,

The British Consul General, The President of the Board

of Aldermen.

STANDING COMMITTEES

EXECUTIVE COMMITTEE

Waldron P. Brown, Hoffman Miller.

Stephen Baker, William Fahnestock,

John B. Pine, Henry D. Babcoek,

"William A. Greer, George Blagden.

EX -OFFICIO

George M. Miller, President.

FINANCE COMMITTEE

Anson W. Hard, James May Duane,

Stephen Baker, Alvin "W. Krech.

EX-OFFICIO

H. D. Babeock, Treasurer.

AUDITING COMMITTEE

Henry C. Swords, Richard H. Williams.

MEMBERSHIP COMMITTEE

J. Howard Van Amringe, Charles H. Russell,

George Blagden, A. Gordon Norrie.

EX-OFFICIO

Hoffman Miller, Secretary.

COMMITTEE ON LEGACIES AND TRUSTS

George M. Miller, Charles H. Russell,

William M. V. Hoffman, Moses Taylor Pyne,

John B. Pine.

NOMINATING COMMITTEE

J. Howard Van Amringe, Stephen Baker,

Henry D. Babeock, A. Gordon Norrie,

Charles H. Russell,
iv

PASTOR AND SUPERINTENDENT EMERITUS

Rev. George Stuart Baker, D.D.

HOUSE OFFICERS

SUPERINTENDENT

Rev. George Frederick Clover.

PASTOR

Rev. George Frederick Clover.

ASSISTANT TO THE SUPERINTENDENT

Rev. Floyd S. Leach, Ph.D.

ASSISTANT PASTOR CASHIER

Rev. Francis Rolt- Wheeler, Ph.D. Miss P. Graf.

APOTHECARY CURATOR

William V. Byard. Andrew Coats.

CHIEF ENGINEER

P. G. Westerberg.

DIRECTRESS OF NURSES

Mrs. C. E. Bath.

ASSISTANT

Miss F. E. Carling.

HOUSEKEEPER

Miss Jennie L. Roberts.

ASSISTANT

Miss M. E. Savage.

HOUSE STAFF

MEDICAL— FOR THREE MONTHS ENDING APRIL 1st, 1911

DIVISION A.
HOUSE PHYSICIAN

William C. Johnson, M.D.

FIRST ASSISTANT

Edward N. Packard, M.D.

SECOND ASSISTANT

DIVISION B.
HOUSE PHYSICIAN

Edmond R. P. Janvrin, M.D.

FIRST ASSISTANT

Julius S. Weingart, M.D.

SECOND ASSISTANT

Arthur E. Neergaard, M.D. Herman C. Fuhrman, M.D.

SURGICAL— FOR THREE MONTHS ENDING APRIL 1st, 1911

DIVISION B.
HOUSE SURGEON

George H. Humphreys, M.D.

FIRST ASSISTANT

Frederick J. Echeverria, M.D.

SECOND ASSISTANT

DIVISION A.
HOUSE SURGEON

D. R. Perry Heaton, M.D.

FIRST ASSISTANT

Robert B. Kennedy, M.D.

SECOND ASSISTANT

Francis J. McCormick, M.D

T. Brannon Hubbard, M.D.

PATHOLOGICAL— FOR THREE MONTHS ENDING APRIL 1st, 1911
Kenneth R. McAlpin, M.D. Edward C. Perkins, M.D.

William P. St. Lawrence, M.D. Jesse R. Pawling, M.D.

MEDICAL— FOR THREE MONTHS ENDING JULY 1st, 1911

DIVISION A.
HOUSE PHYSICIAN

William C. Johnson, M.D.

FIRST ASSISTANT

Edward N. Packard, M.D.

SECOND ASSISTANT

Francis J. McCormick, M.D.

DIVISION B.
HOUSE PHYSICIAN

Edmond R. P. Janvrin, M.D.

FIRST ASSISTANT

Julius S. Weingart, M.D.

SECOND ASSISTANT

T. Brannon Hubbard, M.D.

SURGICAL— FOR THREE MONTHS ENDING JULY 1st, 1911

DIVISION A.
HOUSE SURGEON

D. R. Perry Heaton, M.D.

FIRST ASSISTANT

Robert B. Kennedy, M.D.

SECOND ASSISTANT

Herman C. Fuhrman, M.D.

DIVISION B.
HOUSE SURGEON

Frederick J. Echeverria, M.D.

FIRST ASSISTANT

Arthur E. Neergaard, M.D.

SECOND ASSISTANT

Kenneth R. McAlpin, M.D.

PATHOLOGICAL— FOR THREE MONTHS ENDING JULY 1st, 1911
William P. St. Lawrence, M.D. Edward C. Perkins, M.D.

Jesse R. Pawling, M.D.
vi

MEDICAL— FOR THREE MONTHS ENDING OCT. 1st, 1911

DIVISION A.
HOUSE PHYSICIAN

Edward N. Packard, M.D.

FIRST ASSISTANT

Arthur E. Neergaard, M.D.

SECOND ASSISTANT

DIVISION B.
HOUSE PHYSICIAN

Julius S. Weingart, M.D.

FIRST ASSISTANT

Herman C. Fuhrman, M.D.

SECOND ASSISTANT

Edward C. Perkins, M.D. Jesse R. Pawling, M.D.

SURGICAL— FOR THREE MONTHS ENDING OCT. 1st, 1911

DIVISION B.

DIVISION A.
HOUSE SURGEON

Robert B. Kennedy, M.D.

FIRST ASSISTANT

Francis J. McCormick, M.D.

SECOND ASSISTANT

William P. St. Lawrence, M.D

HOUSE SURGEON

Frederick J. Echeverria, M.D.

FIRST ASSISTANT

T. Brannon Hubbard, M.D.

SECOND ASSISTANT

Kenneth R. McAlpin, M.D.

PATHOLOGICAL— FOR THREE MONTHS ENDING OCT. 1st, 1911

John R. Ashe, M.D. Kevin D. Lynch, M.D.

George M. Goodwin, M.D. Morris K. Smith, M.D.

MEDICAL— FOR THREE MONTHS ENDING JAN. 1st, 1912

DIVISION A. DIVISION B.

HOUSE PHYSICIAN HOUSE PHYSICIAN

Edward N. Packard, M.D. Julius S. Weingart, M.D.

FIRST ASSISTANT FIRST ASSISTANT

Arthur E. Neergaard, M.D. Herman C. Fuhrman, M.D.

SECOND ASSISTANT SECOND ASSISTANT

William P. St. Lawrence, M.D. Kenneth R. McAlpin, M.D.

SURGICAL— FOR THREE MONTHS ENDING JAN. 1st, 1912

DIVISION B.
HOUSE SURGEON

Frederick J. Echeverria, M.D.

FIRST ASSISTANT

T. Brannon Hubbard, M.D.

DIVISION A.
HOUSE SURGEON

Robert B. Kennedy, M.D.

FIRST ASSISTANT

Francis J. McCormick, M.D.

SECOND ASSISTANT

Edward C. Perkins, M.D.

PATHOLOGICAL— FOR THREE MONTHS ENDING JAN. 1st, 1912

John R, Ashe, M.D. Kevin D. Lynch, M.D.

George M. Goodwin, M.D. Morris K. Smith, M.D.

vii

SECOND ASSISTANT

Jesse R. Pawling, M.D.

MEDICAL STAFF

ATTENDING PHYSICIANS

Van Home Norrie, M.D. Austin W. Hollis, M.D.

Samuel W. Lambert, M.D. Francis C. Wood, M.D.

ASSOCIATE ATTENDING PHYSICIANS

Henry S. Patterson, M.D. Frank S. Meara, M.D.

Lewis F. Frissell, M.D.

ASSISTANT ATTENDING PHYSICIANS

Walter A. Bastedo, M.D. Norman E. Ditman, M.D.

Karl M. Vogel, M.D. Lefferts Hutton, M.D.

PEDIATRIC ATTENDING PHYSICIAN

Charles F. Collins, M.D.

ASSISTANT PEDIATRIC ATTENDING PHYSICIAN

Everett W. Gould, M.D.

CONSULTING PHYSICIANS

Charles W. Packard, M.D. Francis Delafield, M.D.

Henry F. Walker, M.D. Beverly Robinson, M.D.

Francis P. Kinnicutt, M.D.

ATTENDING SURGEONS

Robert Abbe, M.D. Charles L. Gibson, M.D.

ASSOCIATE ATTENDING SURGEONS

Henry Hamilton M. Lyle, M.D. Walton Martin, M.D.

ASSISTANT ATTENDING SURGEONS

W. S. Schley, M.D. John Douglas, M.D.

Nathan W. Green, M.D.

CONSULTING SURGEONS

L. Bolton Bangs, M.D. Charles McBurney, M.D.

Joseph A. Blake, M.D. Francis W. Murray, M.D.

B. Farquhar Curtis, M.D.

ATTENDING ORTHOPEDIC SURGEON CONSULTING ORTHOPEDIC SURGEON

T. Halsted Myers, M.D. Newton M. Shaffer, M.D.

CONSULTING GYNECOLOGIST CONSULTING NEUROLOGIST

William M. Polk, M.D. Pearce Bailey, M.D.

viii

CONSULTING OPHTHALMOLOGIST

Colman W. Cutler, M.D.

ASSISTANT OPHTHALMOLOGIST

Alfred Wiener, M.D.

CONSULTING OTOLOGIST

E. B. Dench, M.D.

CONSULTING DERMATOLOGIST

George T. Elliot, M.D.

CONSULTING LARYNGOLOGIST

D. Bryson Delavan, M.D.

EXAMINING PHYSICIAN

William S. Thomas, M.D.

INSTRUCTOR IN ANESTHETICS

H. Clifton Luke, M.D.

CYSTOSCOPIST

Harry G. Bugbee, M.D.

PATHOLOGICAL DEPARTMENT

DIRECTOR

Francis C. Wood, M.D.

CONSULTING PATHOLOGIST

T. Mitchell Prudden, M.D.

BACTERIOLOGIST CLINICAL PATHOLOGIST

J. Gardner Hopkins, M.D. Karl M. Vogel, M.D.

RESIDENT PATHOLOGIST ASSISTANT

Charles H. Bailey, M.D. George C. Freeborn, M.D.

ASSISTANTS IN CHEMISTRY

N. B. Foster, M.D. E. C. Kendall, Ph.D.

OFFICERS AND STANDING COMMITTEES OF THE
MEDICAL BOARD FOR 1911

OFFICERS

PRESIDENT VICE-PRESIDENT

B. Farquhar Curtis, M.D. Robert Abbe, M.D.

SECRETARY

Henry H. M. Lyle, M.D.

COMMITTEE ON EXAMINATION OP CANDIDATES
FOR THE HOUSE STAFF

Robert Abbe, M.D. Austin W. Hollis, M.D.

COMMITTEE ON EXAMINATION OF PUPIL NURSES
EN SURGICAL SURJECTS IN MEDICAL SUBJECTS

Charles L. Gibson, M.D. Samuel W. Lambert, M.D.

Henry H. M. Lyle, M.D. Henry S. Patterson, M.D.

IN MEDICINES

William V. Byard, Apothecary.

OUT-PATIENT DEPARTMENT

PHYSICIAN IN CHIEF TO
MEDICAL DIVISION

Austin W. Hollis, M.D.

ASSISTANTS

W. C. Calhoun, M.D.
Everett W. Gould, M.D.
J. Preston Miller, M.D.
Henry C. Williamson, M.D.
Thomas Flynn, M.D.
H. Merriman, M.D.
A. Vander Veer, M.D.

SURGEON IN CHIEF TO
SURGICAL DIVISION

William S. Thomas, M.D.

ASSISTANTS

Winfield Seott Schley. M.D.
T. A. Kenyon, M.D
F. 0. Virgin, M.D.
H. E. Plummer, M.D.
R. F. Longacre, M.D.
J. Preston Miller, M.D.
Frank C. Keil, M.D.
Lefferts Hutton, M.D.
A. L. Malabre, M.D.
Otto H. Leber, M.D.

SURGEON IN CHIEF TO OPHTHALMIC DIVISION

Colman W. Cutler, M.D.

ASSISTANT

Alfred Wiener, M.D.

SURGEON IN CHIEF TO GYNECOLOGICAL DIVISION

John V. D. Young, M.D.

ASSISTANTS

F. 0. Virgin, M.D. H. E. Gardinor, M.D.

Henry Christie Williamson, M.D.

SURGEON IN CHIEF TO OTOLOGIC AL DIVISION

E. B. Dench, M.D.

ASSISTANTS

F. T. Hopkins, M.D. Chas. E. Perkins, M.D.

Abbott T. Hutchinson, M.D. Wesley C. Bowers, M.D.

SURGEON IN CHIEF TO ORTHOPEDIC DIVISION

T. Halsted Myers, M.D.

ASSISTANTS

Deas Murphy, M.D. H. D. Urquhart, M.D.

List of Contents

Managers of St. Luke's Hospital Hi

Standing Committees of Board of Managers iv

House Officers v

House Staff vi

Medical Staff viii

Pathological Department ix

Officers and Standing Committees of the Medical Board ix

Out-Patient Department x

Surgical Service Statistics for 1911 3

Surgical Operations Performed in 1911 16

Esophageal Strictures. By Robert Abbe, M.D 19

Papilloma of the Vocal Cords. By Robert Abbe, M.D 22

Rupture of the Kidney in Children. By Charles L. Gibson, M.D 25

The Surgical Treatment of Colitis. By Charles L. Gibson, M.D 33

Fecal Concretion in the Fallopian Tube. By Walton Martin, M.D 37

Extensive Epithelioma of the Cheek with Secondary Involvement of the

Genial Glands. By H. H. M. Lyle, M.D 39

The Bottle Operation for Hydrocele of the Tunica Vaginalis: Ten cases.

Three failures. By H. H. M. Lyle, M.D 42

Intradural Section of the Sixth, Seventh, Eighth and First Dorsal Posterior

Nerve Roots for Intractable Brachial Neuralgia : Failure to relieve the

Pain. Later Section of the Corresponding Anterior Roots with no Relief.

By H. H. M. Lyle, M.D 44

Gumma of the Liver as a Sequel to Yaws. By H. H. M. Lyle. M.D 46

Chronic Perisigmoiditis with Partial Volvulus. By H. H. M. Lyle, M.D. ... 48
Perforation of a Simple Ulcer of the Colon : Operation. By H. H. M. Lyle,

M.D 49

A Series of Cases of Surgery of the Small Intestine. By W. Scott Schley,

M.D 52

Simplified Equipment and Management for the Operating Room. By W.

Scott Schley, M.D 70

Extrusion of Medullary Bone Splint. By W. Scott Schley, M.D 76

Two Cases of Stone in the Ureter. By W. Scott Schley, M.D 78

Tuberculous Peritonitis Simulating Recurring Attacks of Appendicitis. By

W. Scott Schley, M.D 81

The Gatch Bed in Surgical Work. By W. Scott Schley, M.D 83

Subphrenic Abscess Complicating Appendicitis. By John Douglas, M.D 85

Five Cases of Esophageal Obstruction from Three Different Causes. By

Nathan W. Green, M.D 90

Three Cases of Ileo-Colic Intussusception with Reduction and Anchorage

by means of the Appendix : Two Recoveries. By Nathan W. Green, M.D. 95
Mesenteric Thrombosis with Resection of Six Feet of Small Intestine:

Recovery. By Nathan W. Green, M.D 98

Papilloma of the Bladder Treated by Excision : Recurrence Treated with

Radium and the High Frequency Current. By Henry G. Bugbee, M.D. . .101

Bilateral Stricture of the Ureters. By Henry G. Bugbee, M.D 106

Medical Service Statistics for 1911 Ill

xii LIST OF CONTENTS

Report of Cases of Hodgkin's Disease. By Austin W. Hollis, M.D., Otto

H. Leber, M.D., and F. C. Wood, M.D 123

A Case of Thrombosis of the Vertebral Artery. By Henry S. Patterson,

M.D 133

Report of a Case of Acute Endocarditis with Influx of all the Chorda?

Tendinese of the Anterior Curtain of the Mitral Valves. By Lewis F.

Frissell, M.D 135

A Report of Two Unusual Cases of Sepsis. By Lewis F. Frissell, M.D 153

The Dilatation Test for Chronic Appendicitis. By W. A. Bastedo, M.D 159

The Vaccine Treatment of Typhoid Fever. By Austin W. Hollis, M.D. and

Norman E. Ditman, M.D 164

A Case of Paget's Disease. By Karl M. Vogel, M.D 168

The Purin Content of Foodstuffs. By Karl M. Vogel, M.D 175

Acute Bichloride of Mercury Poisoning: A Report of Two Cases with

Recovery. By Lefferts Hutton, M.D 177

A Case of Latent Dissecting Aneurism of the Aorta and Ruptured Sacciform

Aneurism. By Lefferts Hutton, M.D. and J. Gardner Hopkins, M.D 180

Report of a Case of Chronic Ulcerative Colitis, with Signa and Symptoms

of Addison's Disease. By Edward N. Packard, M.D 188

Pneumococcus Septicemia. By A. E. Neergaard, M.D 192

Children's Service Statistics for 1911 197

Orthopedic Service Statistics for 1911 203

An Operation for Securing Motion in Ankylosis of the Elbow designed to

prevent the Subsequent Occurrence of Flail Joint. By T. Halsted Myers,

M.D 205

The Radical Operation with the Application of the Primary Skin-Graft, for

The Relief of Chronic Middle-Ear Suppuration. With Report of Cases.

By Edward Bradford Dench, M.D 211

A New Era in Medicine in New York. By F. C. Wood, M.D 217

Selecting Lenses for Photo-Micrography. By F. C. Wood, M.D 227

Case of Incomplete Rupture of the Heart due to Coronary Hemorrhage.

By J. Gardner Hopkins, M.D 242

Report of the Wassermann Reactions done by the Pathological Department

during the Year 1911. By C. H. Bailey, M.D 246

Complement in Human Serum. By C. H. Bailey, M.D 255

Effects on Titrations of Inequality of Sensitization of Corpuscles. By C.

H. Bailey, M.D 258

The Determination of Copper: A Modification of the Iodide Method. By

E. C. Kendall, Ph.D 265

The Determination of Iodine in the Presence of other Halogens and Organic

Matter. By E, C. Kendall, Ph.D 272

A New Method for the Determination of the Reducing Sugars. By E. C.

Kendall, Ph.D 288

Atropin Therapy in Diabetes Mellitus. By Herman O. Mosenthal, M.D 316

Anatomical Study of a Thoracopagus. By J. R. Pawling, M.D 320

Report of the Pathological Department of St. Luke's Hospital for the Year

1911. By F. C. Wood, M.D 324

Plans of the Roentgen Ray Laboratory, Under Construction on the Third

Floor of the Travers Pavilion, St. Luke's Hospital. By Leon Theodore

Le Wald, M.D 339

Report of a Case of Dilatation of the Stomach. Medical Treatment.

Recorded by Means of the X-ray. By Leon Theodore Le Wald, M.D. . . .340
Practical Notes from the Surgical Division of the Out-Patient Department

By William S. Thomas, M.D 345

Possible Causes of Failure Following the Use of Bacterial Vaccines and

Antisera. By H. E. Plummer, M.D 349

Surgical Service

SURGICAL STATISTICS FOR 1911

ALIMENTARY SYSTEM

INTESTINES

-o

Colitia

Colitis, mucous adhesions

Colitis (ulcerative), hemorrhages.

Diverticulitis

Duodenal ulcer

Duodenal ulcer, peritonitis

Duodenal ulcer, volvulus

Enteritis, gastro-enteritis

Enteroptosis

Ileus

Ileus, band

Ileus, intestinal adhesions

Intestinal indigestion

Intussusception

Perisigmoiditis

Vicious circle

Hernia (femoral)

Hernia (femoral, incarcerated), ing. hernia

Hernia (femoral, strangulated) )

Hernia ( inguinal )

Hernia (inguinal sliding)

Hernia (inguinal strangulated)

Hernia (inguinal), oedema of lungs, broncho-pneu

Hernia (umbilical)

Hernia ( ventral )

Hernia, (ventral strangulated)

Hernia (ventral), ileus, abscess of abdominal wall

general peritonitis

Hernia (umbilical), abscess of scrotum, croup ,

Hernia (inguinal), pleurisy with effusion

Hernia (inguinal), lobar pneumonia ,

Hernia (inguinal), phimosis, undescended testis ,

Hernia ( omental )

LIVER

Abscess of liver

Abscess of liver, diffuse peritonitis

Abscess of liver, miliary tbc

Cirrhosis of liver, oedema of lungs

Cirrhosis of liver, endocarditis, ascites, oedema of lungs
Hepatitis (interstitial), displacem't of transverse colon
Jaundice (obstructive)

BILE PASSAGES

Cholecystitis

Cholecystitis (gangrenous), peritonitis.

Cholecystitis, toxic insanity

Cholecystitis (suppurative)

Cholelithiasis

Cholelithiasis with adhesions

Cholelithiasis, cholangitis

1
1
128
1
4
1
7
23
3

1
1
1
1
1
1

184

143
1
3

193

1
2
1
1
3
3
1
1
3
7
4
1
2
5
1
1

10
1
2
154
1
4
1
7

25
3

1
1

1
1
1

214

5
1
1
1
26
1
1

ST. LUKE'S HOSPITAL REPORTS

ALIMENTARY SYSTEM — Continued

Bile Passages — Cont.

Cholelithiasis, cholecystitis

Cholelithiasis, carcinoma of pancreas.

Cholelithiasis, pleuro-pneumonia

Empyema of gall bladder

Hydrops, stone in common duct

MOUTH, GUMS AND TEETH

Alveolar abscess

Painful alveolar process ,

Suppurating root of tooth

OESOPHAGUS

Stricture of oesophagus

Stricture of oesophagus, gastric adhesions, gangrene
of lung

PANCREAS

Pancreatitis (acute), cholecystitis

Pancreatitis (hemorrhagic), delirium tremens.

PERITONEUM

Abscess of peritoneum

Adhesions

Peritonitis, cause unknown.

PHARYNX, TONSILS AND NASOPHARYNX

Abscess (peritonsillar)

Adenoids

Hypertrophy of tonsils

Hyp. tonsils, facial paralysis.

Hyp. tonsils, adenoids

Tonsillar hemorrhage

Tonsillitis (follicular)

Abscess ( anal )

Atresia of anus

Fissure in ano

Fistula In ano

Fistula in ano, pul. tbc

Fistula (fecal)

Fistula (fecal), old appendicitis, peritonitis.

Hemorrhoids

Hemorrhoids, with enlarged glands, neuritis.

Ischio-rectal abscess

Ischio-rectal abscess, sub-ac. nephritis

Proctitis, ischio-rectal abscess

Prolapse of anus

Prolapse of rectum, erysipelas

Stricture of rectum

STOMACH

Gastritis (atrophic) cirrhosis of liver

Gastritis (chr.)

Gastritis (chr.), morphinism, neurasthenia.

Gastritis (chr.), perforation

Indigestion

Ptosis, dilatation

139

123

140

10
1
2

106

1
1

10
1
2
3
1

7
2

6
10
25

1
97

146

1
1
7

29
2
7
1

63
1

13
1
2
3
1
2

134

SURGICAL STATISTICS FOR 1911

ALIMENTARY SYSTEM— Continued

d
P

"3
0

Stomach — Cont.
Pyloric obstruction

3
2
5
1

2
1
3
1

1
1
2

1
1

VERMIFORM APPENDIX

Appendicitis (acute)

61
24

1
5

1
1
1

27
65

Appendicitis (ac. ), peritoneal abs., pulmonary embolus

Appendicitis (ac. catarrhal)

1
3
190
1
3
7
4
1
16
1
1

1
1
1
1

Appendicitis (chronic catarrhal)

Appendicitis (chr.)

191

203

3
7
6
1
16
1
1

1
1
1

Appendicitis (sub-acute), ac. pneumonia

Appendicitis (sub-acute), thrombosed veins of thigh,

Appendicitis (relapsing), renal calculus

Appendicitis (relapsing), suppurative pneumonia

CARDIOVASCULAR SYSTEM

BLOOD

359

346
1

1
1

379

Anemia (pernicious.)

ARTERIES

1
1

3
1

4
1

1
1

VEINS

2
1

9
1

1
1

"20

1
3

26
1

HEART

1
1
1

32
1

....

ST. LUKE'S HOSPITAL REPORTS

CARDIOVASCULAR SYSTEM— Continued

"3
0

LYMPH GLANDS

5
16

1
6

6
10

1
6
1
1

' ' 6

Lymphadenitis (femoral)

CONNECTIVE TISSUE

29
1

' 'i
l
l

2
1

1
7
6

3
9
4

1
1
2

9
1

1
1
2
1
1
8
8
3
1
3
1
12
4
1
1
2

Abscess of popliteal space

2
3
3

Cellulitis of arm (gangrenous)

Cellulitis of broad ligament

2
7
1

i
i

Cellulitis of hand

Cellulitis of leg

Cellulitis of parotid region

Cellulitis of penis

Cellulitis of scalp

Cellulitis of scalp, necrosis of maxilla

Hematoma of chest wall

Hematoma of scrotum, hydrocele

Perineal inflammation following urethral stricture...

1
3

' i

1
4

DUCTLESS GLANDS
Addison's disease

1
3

75
1

Goitre (simple)

8
3
1
2

3
1

' i

Hyperthyroidism

Parotiditis (acute)

MUSCULAR SYSTEM
Bursitis of popliteal space

15
1

1
1

17
1

Myosotis

2
1

' '2

NERVOUS SYSTEM

BRAIN

Abscess of brain

2
2

Cyst of ventricle

1
1

DISEASES OF THE MIND

....

9
1

NERVES

1
9

SURGICAL STATISTICS FOR 1911

NERVOUS SYSTEM— Continued

Nerves — Cont.

Neuralgia (trifacial), paralysis, eczema.

Neuritis (brachial)

Neuritis (peripheral)

Neuritis (retro-bulbar)

NERVOUS DISEASES OF UNKNOWN ORIGIN

Hysteria

Nervous prostration

Neurasthenia (traumatic)

Spasmodic torticollis

Zoster, gangrenous hystericosus of forearm.

SPINAL CORD

Locomotor ataxia

Syringomyelia, paraplegia.
Tabes dorsalis

OSSEOUS SYSTEM

Athetosis of arm

Coccygodynia

Hypertrophy of turbinate bone

Necrosis of vertebrae

Necrosis of maxilla

Necrosis of femur. Pott's Disease

Osteitis (rarefying)

Osteomyelitis of femur

Osteomyelitis of forehead

Osteomyelitis of humerus

Osteomyelitis of maxilla

Osteomyelitis of metacarpal bones of hand.
Osteomyelitis of metatarsal bones of foot . . .

Osteomyelitis of tibia

Periosteitis of phalanx of hand

Periosteitis of femur

Periosteitis of tibia

Periosteal abscess of maxilla

Rickets

Sequestrum of maxilla

JOINTS

Ankylosis of ankle

Ankylosis of hip and knee

Arthritis (chr.) of knee

Arthritis (suppurative) of ankle

Bunions

Hypertrophy of int. ligament of knee. .
Hypertrophy of synovial folds of knee.

Osteo-arthritis of hip

Osteo-arthritis of knee and vertebra?..
Synovitis of knee

REPRODUCTIVE SYSTEM— FEMALE

OVARY

Atrophy of ovary

Abscess (tubo-ovarian. )

Cystic ovary

Cystic ovary (multilocular)

Cystic ovary, pregnancy

Oophoritis

Oophoritis (atrophic)

1
4
39
2
1
9
1

1
2
2

1
2
1
1
1
1
1
6
2
1
2
2
3
2
3
1
2
1
1
1

1
2

1
1

1
1
1
1
3

1
4

40
2
1

10
1

ST. LUKE'S HOSPITAL REPORTS

REPRODUCTIVE SYSTEM— FEMALE— Continued

Ovary— Cont.

Parovarian cyst. . .
Prolapse of ovary.

UTERINE TUBES

Hematosalpinx

Hematosalpinx with twisted pedicle, pregnancy

Hydrosalpinx

Pyosalpinx

Pyosalpinx with abscess

Pyosalpinx with abscess, thrombosis of broad liga-
ment and iliac veins

Salpingitis (acute)

Salpingitis (chronic)

Salpingitis (chr.) post-op. shock, peritonitis

Salpingitis (chr.), peritonitis

Salpingitis (perforative)

Salpingitis with pelvic abscess

Pyosalpinx, paralytic ileus, peritonitis

Salpingo-oophoritis

UTERUS

Abscess of broad ligament

Anteflexion

Cyst (intra-ligamentous)

Dysmenorrhea

Endocervicitis

Endometritis (chr.)

Endometritis (glandular)

Endometritis (hypertrophic)

Erosion of cervix

Menopause (artificial)

Metrorrhagia

Prolapse of uterus

Prolapse of uterus, rectocele, cystocele

Prolapse of uterus, laceration of cervix and perineum

Retroversion

Retroversion, pregnancy

Retroversion with adhesions

PREGNANCY, ETC.

Abortion (complete)

Abortion (incomplete)

Abortion (threatened)

Abortion (incomplete), pelvic abscess.

Ectopic gestation

Ectopic gestation (ruptured)

Lithopedion

Pelvic abscess

Pelvic abscess, pyometra

Pelvic abscess, ileus

Pregnancy

Retained placenta

Toxemia of pregnancy

Atresia of vagina

Prolapse ant. vaginal wall.
Prolapse post, vaginal wall
Vaginitis

Abscess (vulvo-vaginal).

112

180

6
45

18
104

7
4
4
1
74
1
1

2
18
1
2
53
1
1

172

4
19

1
12

1
14

3
11

1
19

1
9

1
2
2
1
1
19

136

10
4
4
1

86
1
1
1
1
2

22
1
2

53
1
1

792

22
5
1

12
8
1

16
1
1
5

16
2

SURGICAL STATISTICS FOR 1911

REPRODUCTIVE SYSTEM— FEMALE— Continued

a*
P

•a

"3
©

Vulva — Cont.
Abscess (Bartholin's gland)

1
1

l
l

REPRODUCTIVE SYSTEM— MALE

MALE URETHRA

1
9
1

Stricture of urethra

Stricture of urethra, calculus, extravasation of urine

PENIS

24
4

2
15

16
2

25
2

PROSTATE

1
1
2

4
1

9
20

SPERMATIC CORD

9
20

16
9

TESTICLE

29
1

32
1

1
4
1

3
1
2

| 1

MAMMARY GLAND

3
1

RESPIRATORY SYSTEM

LARYNX

LUNGS

1
1

PLEURA

1
1

1
5

Pleurisy (supp.), catarrhal croup, ac. bronchitis

1
1

NASAL CAVITY

1
1

ST. LUKES HOSPITAL REPORTS

RESPIRATORY SYSTEM— Continued

Nasal Cavity — Cont.

Epistaxis

Frontal sinusitis.

SENSE ORGANS

ORGAN OF HEARING

Mastoiditis

Mastoiditis, meningitis, otitis media

Mastoiditis, thrombosis of lateral sinus

Mastoiditis (suppurative), catarrhal jaundice, lobar

pneumonia, septic arthritis of elbow

Otitis media

Otitis media (purulent)

ORGAN OF VISION

Cataract

Chalazion

Conjunctivitis

Exotropion

Glaucoma

Iritis, dacryocystitis

Ophthalmitis

Panophthalmitis

Rupture of cornea '

Strabismus

Traumatic conjunctival hemorrhage.

TEGUMENTARY SYSTEM

Carbuncle of lip

Carbuncle of neck

Cicatrix ( painful )

Furunculosis

Ingrowing toe-nail

Pilonidal cyst

Purpura hemorrhagica

Sebaceous cyst of head. . . .

Ulcer of foot

Ulcer of neck

Ulcer (perforative) of foot.
Ulcers (varicose) of leg. . . .

URINARY SYSTEM

Abscess of kidney

Hydronephrosis

Nephritis (chr. interstitial )

Nephritis (chr. interstitial), ascites.

Nephrolithiasis

Nephroptosis

Movable kidney

Movable kidney, pyelonephritis

Perinephritic cyst

Pyelitis

Pyelonephritis

Pyonephrosis, pregnancy

Renal colic

Renal colic, hemorrhagic cystitis. . . .
Traumatic nephritis

URINARY BLADDER

Calculus in bladder. . . .
Calculus, tabes dorsalis.

2-A

' i

1
1

1
8

11
1

1
1
5
2

1
1
1
1

1
4
2
2

1
2
1
3
1
1
3
7

1
4
3
2
11
5
4
1
1
2
3
1
2
1
1

SURGICAL STATISTICS FOR 1911

URINARY SYSTEM— Continued

a
P

"3
o

Urinary Bladder — Cont.
Cystitis (hemorrhagic)

1
1
1

Cystitis, cystocele

. „

Cystitis, tumor of bladder

l
l

1
1

Ulcer of bladder

1
1

2
1

DISEASES DUE TO ANIMAL PARASITES

15
1

CONGENITAL MALFORMATIONS
Branchial genetic cyst

Contraction of foot

2
1
4

2
1

5
1
2
4
2
2

2
1

Hydrocephalus

3
2
2

DEFORMITIES

18
1

10
1

1
1
1
2
1

2
3
1

1
1

LOCAL INJURIES

7
1

12
1

1
1
1
1
1
2

1
1
1

1
1
4
1
2
1
1
1
1
1
1
2
2
1
1

2
2

1
1
1
1
1
1
2
2
1
1
1
3

2
1

ST. LUKE'S HOSPITAL REPORTS

LOCAL INJURIES — Continued

Local Injuries — Cont.

Fracture of fibula (Potts')

Fracture of humerus

Fracture of jaw

Fracture of neck of femur, pneumonia.

Fracture of os calcis

Fracture of olecranon

Fracture of patella

Fracture of phalanx

Fracture of radius

Fracture of radius (Colles')

Fracture of radius and ulna

Fracture of ribs

Fracture of skull

Fracture of tibia

Fracture of tibia and fibula

Fracture of tibia (ununited)

Fracture of vertebrae

Fracture of vertebrae, alcoholism

Gangrene of foot

Gangrene (diabetic) of foot

Gangrene of foot, arterio-sclerosis

Gangrene of foot, nephritis

Gangrene (dry) of foot, nephritis

Gangrene (wet) of foot

Heat prostration

Laceration of cervix uteri

Laceration of perineum

Perforation of ileum

Rupture erector spinal muscle

Rupture of ligament of knee

Sinus of abdominal wall

Sinus of leg

Sinus of neck

Sinus of sacro-coccygeal region

Sinus of thigh

Sinus, perirectal

Sprain of ankle

Wound (gunshot) of face

Wound (incised) of neck

Wound (lacerated) of neck

Wound (lacerated) of hand

Wound (lacerated) of scalp

Wound (lacerated) of scrotum

Wound (incised) of abdomen

DISEASES DUE TO MICRO-ORGANISMS

Erysipelas

Gonococcus epididymitis

Gonococcus salpingitis

Gonococcus uterus and tubes

Gonococcus urethritis

Malaria

Pertussis

Rheumatism (ac. articular)

Scarlet fever

Syphilis (primary)

Syphilis (secondary)

Syphilis (tertiary)

Syph. adenitis, axillary and inguinal.

Syph. gumma of scalp

Syph. gumma of liver

Syph. osteitis of femur

Syph. osteitis of tibia

Syph. fistula in ano

Tbc. abscess of shoulder

Tbc. of bladder

Tbc. of bladder, nephritis

Tbc. of elbow

Tbc. of eyelid

Tbc. of epididymis, orchitis

154

151

1
15

SURGICAL STATISTICS FOR 1911

DISEASES DUE TO MICRO-ORGANISMS— Continued

I O

Diseases Due to Micro-Organisms — Cont.

Tbc. of finger

Tbc. of foot

Tbc. of glands of neck

Tbc. of hand

Tbc. of kidney

Tbc. of knee

Tbc. of lungs

Tbc. of peritoneum

Tbc. of prostate and bladder

Tbc. of rib

Tbc. of spine

Tbc. of testicle

Tbc. of uterine tubes, pulmonary tbc

Tbc. of uterus and broad ligament

Tbc. costal cartilage pectoralis major

Tbc. fecal fistula

Tbc. lumbar abscess

Tbc. ovarian cyst

Tbc. peritonitis, thrombosis saphenous vein, prolapse

of vagina

Tbc. keratitis

Tbc. salpingitis, peritonitis, fecal fistula

LOCAL INFECTIONS

Infection of hand and arm

Infection of herniotomy wound.
Stitch abscess

NEOPLASMS

Adenoma of breast

Adenoma of endometrium

Adeno-carcinoma of colon

Adeno-carcinoma of rectum

Adeno-carcinoma of uterus

Adeno-fibroma of breast

Adeno-fibroma of uterus

Angioma of neck

Carcinoma of abdominal wall

Carcinoma of antrum

Carcinoma of bile duct

Carcinoma of bladder

Carcinoma of breast

Carcinoma of cervix uteri

Carcinoma of chest wall

Carcinoma of face and cheek

Carcinoma of glands (inguinal)

Carcinoma of intestines

Carcinoma of liver

Carcinoma of lungs and pleura

Carcinoma of neck

Carcinoma of oesophagus

Carcinoma of orbit

Carcinoma of ovary

Carcinoma of parotid gland

Carcinoma of pancreas

Carcinoma of rectum

Carcinoma of rectum, fibroma uteri, pulmonary throm-
bosis

Carcinoma of tonsil

Carcinoma of stomach

Carcinoma of tongue

Carcinoma of thorax, ribs, axillary glands, fracture of
femur

Carcinoma of uterus

Carcinoma of vagina

Carcinoma of vulva

Cyst-adenoma of breast

Cyst-adenoma of ovary

1
31

3
21

1
1
3

1
1

1
17

1
1
38
1
6
6
6
3
1
3
1
2
1
2
1
1
1
1

122

4
1
2
3
1
5
1
1
2
1
2
6

44
4
1
5
1

14
1
1
7
3
2
8
2
2

1
10

1
1

2
3

ST. LUKE'S HOSPITAL REPORTS

NEOPLASMS— Continued

Neoplasms — Cont.

Cyst-adenoma of neck

Dermoid cyst of ovary

Dermoid cyst of chest wall

Epithelioma of face

Epithelioma of forehead

Epithelioma of neck

Epithelioma of nose

Epithelioma of lip

Epithelioma of orbit

Epithelioma of maxilla

Epithelioma of tongue

Epithelioma of tonsil

Epithelioma of toe

Epithelioma of vagina

Epithelioma of vulva

Epulis

Exostosis of hard palate

Exostosis of os calcis

Fibromyoma of uterus

Fibromyoma of uterus, pregnancy

Fibroma of omentum

Fibro-sarcoma of femur

Glioma of ulna nerve

Lipoma of abdominal wall

Lipoma of buttock

Lipoma of chest wall

Lipoma of chest and arms

Lipoma of neck

Lipoma of shoulders

Lipoma of thigh

Lymphangioma of neck

Lympho-sarcoma of neck

Hemangioma of hand

Myxo-sarcoma of thigh

New growth of patella

Neuro-fibroma-lipomata (multiple)

Papilloma of bladder

Papilloma of larynx

Papilloma of toe

Papilloma of ovary, pregnancy

Polyp of rectum

Polyp of uterus

Sarcoma of bladder

Sarcoma of abdominal wall

Sarcoma of leg

Sarcoma of maxilla

Sarcoma of mediastinum, aneurysm of aorta.

Sarcoma of testis

Sarcoma of neck

Sarcoma of sacrum

Sarcoma of sheath of thigh muscle

Sarcoma of tibia

Tumor of abdomen

Tumor of breast

Tumor of face

Tumor of intestines

Tumor of neck

Tumor of parotid

Tumor of prostate

Tumor of rectum

Teratoma of abdomen

Teratoma of testicle

INTOXICATIONS

Auto-intoxication

Diabetes mellitus

Diabetes, ulcers, nephritis.

Gout

Morphinism

2G4

1
194

1
1
1

SURGICAL STATISTICS FOR 1911

MISCELLANEOUS

Donor in transfusion

Diagnosis not made

For observation

No pathological condition

SUMMARY

Alimentary System

Cardiovascular System. . .

Connective Tissue

Ductless Glands

Muscular System

Nervous System

Osseous System

Reproductive System

(Mammary Gland)

Respiratory System

Sense Organs

Tegumentary System

Urinary System

Animal Parasites

Congenital Malformations.

Deformities

Local Injuries

Micro-organic Diseases. . . .

Neoplasms

Intoxications

Miscellaneous

Total 2189 2047

919
57
56
15
2
11
35

533
9
25
37
23
30

154

89
264

872

512

151

194

1
7

9
7
70
46
79
4
10

512

2
' 9

37
6
5

174

48
5
2

2
18

' 2
1
1
6

122 2854

OPERATIONS— 1911

ALIMENTARY SYSTEM

INTESTINES

Cecostomy

Colostomy

Entero-eolostomy

Entero-enterostomy . . .

Enterostomy

Enterorrhaphy

Ileo-colostomy

Ileo-colectomy

Intestinal anastomosis.

Jejunostomy

Proctoscopy

Resection of intestines.

HERNIA

Femoral hernia repair 8

Inguinal hernia repair 107

Omental hernia repair 2

Umbilical hernia repair 8

Ventral hernia repair 20

LIVER AND BILE PASSAGES

Cholecystenterostomy 2

Cholecystectomy 17

Cholecystostomy 12

Cholecystotomy 8

Choledochotomy 1

Cholelithotomy 3

Duodenorrhaphy 1

Duodenostomy 1

Incision for abscess of liver 1

MOUTH, TONGUE AND TEETH

Extraction of tooth

Incision of alveolar abscess

Partial glossectomy

OESOPHAGUS

Dilatation of oesophagus.
CEsophagotomy

PERITONEUM, OMENTUM AND RETHO-PERITO-
NEAL TISSUES

Celiotomy 4

Closure of perforation 1

Division of adhesions 16

Exploratory celiotomy 35

PHARYNX, TONSILS AND NASOPHARYNX

Adenoidectomy 9

Adenoidectomy and tonsillectomy 78

Incision for peritonsillar abscess 3

Tonsillectomy 18

RECTUM, ANUS AND PERI-EECTAL TISSUES

Clamp and cautery 36

Dilatation of sphincter ani 9

Excision of fistula in ano 2

Excision of mucous membrane of rectum 4

Incision of fistula in ano 21

Incision of ischio-rectal abscess 7

Incision of peri-rectal abscess 1

Ligation of hemorrhoids 7

Proctectomy 1

Proctoscopy 2

Dissection of fistulous tract 2

STOMACH

Gastrectomy (partial)

Gastroenterostomy

Gastropexy

VERMIFORM APPENDIX

Appendicectomy 219

Appendicectomy with drain 69

Appendicostomy 2

Appendipexy l

Drainage of appendicular abscess 4

CARDIOVASCULAR SYYSTEM

ARTERIES

Ligation of artery 2

VEINS

Ligation of vein 8

Phlebectomy 32

LYMPH GLANDS

Incision 4

Lymphadenectomy 44

Lymphadenectomy (tbc. cervical) 17

CONNECTIVE TISSUE

Excision of carbuncle 3

Excision of scar 5

Incision for abscess 40

Incision for cellulitis 33

Repair of fistula 6

Repair of scar . . , 5

Repair of sinus 5

DUCTLESS GLANDS

Excision of goitre 1

Formation of fistula from parotid duct 1

Incision of parotid duct 1

Thyroidectomy 8

MUSCULAR SYSTEM

Excision of bursae 2

Excision of ligaments 1

Excision of semi-lunar cartilage of knee 1

Myectomy l

Tendon transplantation 3

Tenoplasty 1

Tenotomy 1

NERVOUS SYSTEM

BRAIN

Decompression ,

Drainage of abscess

Elevation of depressed fragments.

Exploratory craniotomy

Subdural drainage

NERVES

Neurectomy.

SPINAL CORD

Laminectomy.

OSSEOUS SYSTEM

Ostectomy

Osteotomy

Osteotomy with drain

Reduction of fracture (closed)
Reduction (opeb) of fracture.

Resection of knee

Resection of carpal bones

JOINTS

Arthrectomy

Arthrodesis

Arthrotomy

Excision of meniscus

Excision of synovial folds.
Removal of foreign body . .

8
12

1
4
1
1

OPERATIONS PERFORMED— 1911

REPRODUCTIVE SYSTEM

OVARY

Excision of cyst 5

Incision for cyst 2

Oophorectomy 37

Plastic on ovary 3

Shortening ligament of ovary 1

UTERINE TUBE

Salpingectomy 44

Salpingectomy with drain 4

Saipingo-oophorectomy 85

UTERUS

Amputation of cervix uteri 2

Curettage 116

Excision of intraligamentous cyst.... 2

Hysterectomy (complete) 4

Hysterectomy (partial) 4

Hysterectomy (supravaginal) 64

Hysteropexy (round ligament) 25

Hysteropexy (ventral) 32

Myomectomy 6

Tracheoplasty 11

Trachelorrhaphy 12

VAGINA AND PELVIC FLOOR

Colpoplasty 5

Colporrhaphy 15

Oolpotomy 21

Excision of cyst 2

Incision of cyst 1

Perineoplasty 26

Perineorrhaphy 24

Plastic repair of abscess 1

URETHRA

Urethrotomy 9

PENIS

Circumcision 18

Incision of scrotum for abscess 1

Meatotomy 1

PROSTATE

Prostatectomy (perineal) 6

Prostatectomy (suprapubic) 4

TESTICLES

Incision for orchitis 1

Orchidectomy 4

Transplantation of testicle 4

SPERMATIC CORD

Bottle operation for hydrocele 1

Excision of hydrocele sac 6

Eversion for hydrocele 1

Inversion for hydrocele 1

RESPIRATORY SYSTEM

LARYNX, BRONCHI AND TRACHEA

Tracheotomy 2

LUNGS AND PLEURAE

Costatectomy 14

Decortication 1

Thoracotomy 19

Thoracostomy 3

NASAL CAVITY

Opening of lateral sinus 1

Plugging of nares 1

Submucous resection 9

ORGAN OF HEARING

Mastoidectomy (partial) 8

Mastoidectomy (radical) 4

Mastoidotomy 4

Paracentesis 4

ORGAN OF VISION

Curettment for tbc. of eyelid 1

Dilatation for cataract 1

Discission of cataract 2

Enucleation of eyeball 3

Excision of cataract 4

Excision of eyeball 2

Needling for cataract 1

Removal of lens 1

TEGUMENTARY SYSTEM

Excision of carbuncle 1

Excision of sebaceous cyst 3

Incision for furuncle 2

Onychectomy 1

Removal of foreign body 2

Skin graft 7

URINARY SYSTEM

KIDNEYS

Decapsulation 1

Nephrectomy 10

Nephropexy 3

Nephrolithotomy 7

Nephrotomy 4

Ureterectomy 2

Ureterotomy 1

BLADDER

Cystectomy 1

Cystorrhaphy 1

Cystoscopy 11

Cystostomy 1

Cystotomy 4

DEFORMITIES AND CONGENITAL MAL-
FORMATIONS

Division of double uterus 1

Excision of scar 2

Plastic repair on cleft palate 1

Plastic repair on hare lip 3

Plastic repair on nose 1

Pozzi operation for infantile uterus. ... 6

INJURIES

Opening of sinus 2

Removal of foreign body 6

Suture of wound 6

Wiring of jaw and teeth 1

DISEASES DUE TO MICRO-ORGANISMS

Incision of local infection 1

NEOPLASMS

Cauterization 6

Excision 81

Plastic on regions involved 16

AMPUTATIONS

Amputation through mid-forearm 1

Amputation of finger 4

Amputation at hip 1

Amputation through metacarpals 1

Amputation through upper thigh 1

Amputation through lower thigh 3

Amputation at knee 1

Amputation through middle leg 1

Amputation through metatarsus 1

Amputation of toe 11

Disarticulation at knee 1

MISCELLANEOUS

Radium treatment 18

ESOPHAGEAL STRICTURES.
Robert Abbe, M.D.

It is but just to a novel surgical procedure, that after a sufficient
number of years' trial the results should be checked up and a fair
record of its established value should be made.

By a fortunate observation, in 1892, in St. Luke's Hospital, while
endeavoring to dilate a very tight resisting stricture of the lower
esophagus, I found that a Billroth bougie (that is, a gum-elastic
bougie, tipped with a metal conical point, in which a string was
fastened for traction) was wedged so tightly that no reasonably safe
pulling would bring it through the stricture. By accident of the
moment, I happened to have another heavy braided silk thread along-
side of it, passing from the open stomach wound to an opening in
the upper esophagus, which I had made.

When the stricture resistance absolutely prevented the bougie be-
ing pulled through, a simultaneous pull on the parallel string moved
the bougie unexpectedly forward. At once I saw that a back and
forth, or sawing motion, of the independent string, wore away the
resisting fibrous stricture while it was put on the stretch by the di-
lating end of the bougie. Larger and larger bougies at once followed
as the string completed the rasping or safe cutting of the stricture,
and the esophagus was enlarged to its full caliber in a practically
bloodless manner.

An entirely new procedure was thus added to the armentarium
of the surgeon in dealing with this hitherto inoperable disease of the
esophagus. I say inoperable because, although numerous cutting in-
struments had been devised to divide these tough strictures, they
were uniformly condemned by surgical authorities as dangerous to
use, because the thin-walled esophagus lies parallel to, and in contact
with the aorta and vena cava.

This happy experience, first published in the Medical Record,
February 25, 1893, was accepted and adopted by surgeons generally,
and has been incorporated in most surgical works as safe and efficient.

20 ST. LUKE'S HOSPITAL REPORTS

"Without reviewing the large number of published and unpublished
cases, I will speak only of my subsequent experience in our hospital.

The good results are lasting if properly followed.

The first case was of a young woman who had swallowed pure am-
monia, with consequent inflamed esophagus and stricture. She was
reduced to a desperate state when I did the above successful operation.

During the subsequent year a full-sized bougie was passed to the
stomach; at first, twice a week, then once a week, then monthly.
During the years following, she passed it herself, several times yearly,
until, after 10 years, she gave it up, as there was no tendency to
recurrence. When I saw her, more than 15 years later, she was in
perfect health, and I could detect no stricture even with a bougie
a boule. That particular patient had a stricture of no great length,
perhaps a half inch, though very tight, admitting merely a thread,
following a whalebone filliform passed up from the opened stomach.

Many cases which I have since operated on have uniformly shown
long stretches of the esophagus (often one-third or one-half), showing
tight, fibrous, solid remnants with the canal almost closed.

Two of these are beautifully shown in the pictures, Figs 1 and 2.

Another case, of which either of these pictures would be repre-
sentative, was brought to me from Philadelphia, 6 or 7 years ago,
and furnishes a fair illustration of what we may expect in the
final outcome of such bad cases. The child was emaciated to a skeleton,
and the best that could be offered to the parents by two of our most
eminent surgeons, by other surgical methods, was, to create a gas-
trostomy opening and thus feed the child for the rest of its life.
I first created such an opening and fed the child until it was strong
and hearty. Eight weeks later I did the string cutting esophagotomy.

Dilatation was kept up for many weeks at first with anaesthesia
for safety. Then, as the child bore it well, by easy passage of bougie.

The family physician persisted, for 2 or 3 years, patiently and
conscientiously, to pass the bougie, and the child ate everything, as
other children. He writes me now that she has grown to be a fine,
robust girl, and has a normal acting esophagus.

It may be said of all these cases that they are caused by swal-
lowing caustic or burning fluids. I have never seen or heard of
a stricture following the long retention of foreign bodies in the
esophagus, such as tooth-plates, toys, coins, etc., which necessarily
make an ulcerated area after a few weeks. I judge nature is com-
petent to dilate such narrowings by the ordinary bolus of food in

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ESOPHAGEAL STRICTURES 21

deglutition. It is the destructive type of inflammation similar to the
urethral infective type, which destroys the epithelial lining and re-
places the mucous and muscular coats by fibrous tissue, which we
have to deal with.

It may be asked — how can one expect ever to restore su .h a tube ?
It is a fair question, and can only be answered by saying it is never
restored to normal. That is, the muscular coat cannot be replaced.

Nevertheless, a perfectly competent and practically useful tube
is created by carving a channel through the fibrous mass — and keep-
ing it open — until it has been lined by flat epithelium, through Na-
ture's kindly and wonderful laws of repair, and until the contractile
tendency of the formed tissue has ceased, as it does after months or
years, according to the amount present.

The same law of stenosis goes on precisely as in urethral strictures,
unless dilatation is kept up at longer and longer intervals. The oc-
casional passage of a bougie is a very small penalty to pay for a
perfectly restored swallowing apparatus.

Taken altogether, we can truly say that the annals of St. Luke's
Hospital may be credited with the demonstration of a successful, safe
and bloodless method of dealing with a bad surgical condition for
which no other method is adapted. One may say that some strictures
can be dilated, without cutting. That is true. And those should al-
ways be dilated. But the majority are absolutely undilatable after
they have become indurated by time, and to these, fortunately, this
method offers complete cure. The surgeon, however, must be sure to
follow up his patient if the result is to be permanent. That happy
issue is now demonstrated by this report of 20 years' use.

PAPILLOMA OF THE VOCAL CORDS.

Robert Abbe, M.D.

Warty vegetations on the vocal cords are the most obstinate of all
surgical conditions in recurrence after removal — and most destructive
to voice and breathing. It is said they sometimes change to cancer
by irritation of the basal cells — but many do not.

One of the most extraordinary illustrations of this persistence of
type is shown in a woman of 60, who was first treated by intralaryn-
geal excision by Dr. Elsberg, the pioneer laryngologist of America —
who, more than 45 years ago, began to excise masses of these growths,
and continued to do so 2 or 3 times yearly, during his life. He was
succeeded by Dr. Lincoln, and later by Dr. Culbert, all experts, who,
in order to give her breathing space, cleared away all visible growth
every 6 months. Dr. Elsberg published her case (Trans. Am. Med.
Assn., 1865) and Dr. Culbert reported upon it 40 years afterward
(see ''The Laryngoscope," St. Louis, September, 1904), giving pic-
tures of the original masses as illustrated by Elsberg.

This case is one of four in which I have been called upon to use
radium, and with the same effect, as shown by each case.

Dr. Culbert held a device between the cords containing 20 mg.
radium, for one-half hour. Three months later he reported almost
all growth had gone from one side — quicker than by any removal
with instruments which he had ever done. One year later he examined
and reports it "to be the cleanest he had ever seen it. One-third of
the inside of the larynx is entirely free from papilloma." One year
later she was breathing even better, without further treatment, and
growths were smaller.

She then showed senile spinal paresis, and died.

Two other cases, presenting great difficulties, but with fair demon-
stration of the specific action in curing them that radium always
shows in curing warts elsewhere, will be briefly mentioned before nar-
rating the most brilliant result of a fourth case, herewith illustrated.

The first is that of a woman, voiceless and with stridulous breath-

Fig. 1.

Fig. 2.

Fig. 3.

Fie. 4.

Fig. 5.

Fig. G.

PAPILLOMA OF THE VOCAL CORDS 23

ing, from whom Dr. Josiah L. Barton had many times excised the
papillomatous mass. To give her relief at first, I did a laryngotomy,
and after excising the growths, applied monochloracetic acid to the
base. Eecurrence took place. Radium was then intra-laryngeally
applied.

The result has been disappearance, and, later, small recurrence.
The patient regained her voice well. The slight recurrence has given
her no annoyance for a year past, and she has not come to the city,
as she is entirely satisfied with her present condition — without fur-
ther treatment.

The second case is of a young child, whose recurrences filled the
larynx, and the laryngologist had made a permanent tracheotomy not
only with no relief, but an extension had followed downward in the
trachea itself, so that a mass had grown on the posterior face of the
trachea, opposite the opening.

The child was so intolerant of laryngeal application of radium
that I placed her in St. Luke's, and under ether, made a thorough
use of strong radium, held in place one-half hour. The result was a
diminution in the disease, but it required a second application, after
6 months, to further control its growth. At the present time, there
is still a visible mass, about one-third of the original, hidden below
the vocal cords, and a very small remnant in the tracheal wound.
There may be one additional treatment required to cure it, but it
seems at present that the final cure by radium will be accomplished.
An interval of many months is usually the best manner of admin-
istration, inasmuch as the good effect always progresses that long be-
fore one can judge whether a sufficient dosage has been given.

The fourth case is a delightful demonstration of the cure of papil-
loma laryngis by radium:

A girl of 17 years had an unusually sweet singing voice, which she
noticed became hoarse in July, 1910. She applied to Dr. Culbert in
September following, who successfully removed a small tumor of the
left vocal cord — which Dr. Ewing pronounced "fibroma" (Fig. 1).
A rapid recurrence (Fig. 2), looking now like papilloma, was re-
moved, but not examined. Again a rapid recurrence, looking now
larger and more dusky, rather like a sarcoma than either papilloma
or carcinoma. It occupied the central half of the cord, and overflowed
into the ventricle. It was difficult to control the anaesthesia of this
patient's larynx so as to make an adequate radium application, though
it was carefully tried. The growth progressed and now seemed typi-

24 ST. LUKE'S HOSPITAL REPORTS

cally papillomatous — obstructing respiration (the voice was gone en-
tirely) (Fig. 3). By the following June it occupied most of the left
and much of the right vocal cord. The pictures accompanying show
its varied stages, the condition immediately before operation being
shown in Fig. 4.

On June 14th, I decided to make a thorough radium application
under anaesthesia. Through a tracheotomy wound, I passed a wire up
to the mouth and drew into the trachea a tube containing 100 milli-
grammes of pure radium, which I was able to suspend with accuracy
between the vocal cords.

This I kept in situ half an hour, while ether was given through
the tracheal tube. Nothing else was done except to allow the tube
to remain a few days in the trachea, for safety. The wound healed
at once on its removal.

Three months afterward (Fig. 5) the patient talked and sang
perfectly.

Examination of the larynx showed and continues to show an appar-
ently normal condition (Fig. 6), with clean, white vocal cord. The
singing voice is restored completely, and is as sweet as ever.

This perfect condition remains after one year.

RUPTURE OF THE KIDNEY IN CHILDREN *

Charles L. Gibson, M.D.

Ruptures or other subcutaneous injuries are very uncommon in
children, only 22 cases being reported in Watson's1 tables. My ex-
perience comprises 4 cases of complete rupture in children from 8 to
12 years old, and a consideration of the conditions found furnishes
some interesting features.

Case 1.— Barbara S., age 10. Admitted to St. Luke's Hospital Aug. 25, 1902.
Two weeks ago was kicked by a horse on the right side of the body ; unconscious
for a while. Next morning urine contained some blood ; none seen since. Some
swelling of the right side developed, with a considerable amount of pain.
Has had no chills, but there have been fever and sweating.

Physical examination showed a bright, healthy child, with a visible swell-
ing of the right lumbar region. No superficial discoloration. The swelling
was elastic, insensitive to pressure, flat on percussion.

Urine. — Acid 1018, no albumen.

Operation. — Right lumbar incision showed the swelling to be a large
retroperitoneal accumulation of normal appearing urine. The kidney was
ruptured in two, the lower pole entirely separated from the upper three-
fourths of the viscus. Nephrectomy ; good recovery. Discharged Oct. 3.

Case 2. — These details are as exact as I can furnish them from memory,
the record being lost.

Boy, about 10, admitted to the Hudson Street Hospital, probably in the
summer of 1907 ; run-over injury ; abdominal symptoms ; median laparotomy
by a colleague; negative findings. Seen by me several days later; diagnosis
of rupture of left kidney. Lumbar incision revealed complete tear of left
kidney. Nephrectomy ; good recovery.

Case 3.— James L., 12. Admitted November, 1909, to the Hudson Street
Hospital. While running across the street, an automobile struck him in the
left side, knocking him d6wn. Scalp wound, requiring two stitches. Brought
to the hospital by the guilty automobile. Soon began to complain of great
pain and tenderness over the left kidney region.

Physical Examination: Tenderness and rigidity in left hypochondrium,

*Read before the Section of Surgery of the New York State Medical
Society, April 17, 1912.

'Watson and Cunningham, Genito Urinary Diseases, vol. ii.

26 ST. LUKE'S HOSPITAL REPORTS

also some slight discoloration. Skin and mucous membranes of good color.
Shortly after admission passed blood-tinged urine. Hemoglobin color index
70 per cent.

Operation : About eight hours after injury ; left lumbar incision. Com-
plete rupture of kidney in two pieces. Nephrectomy ; drain ; good recovery.
Highest temperature, 100%° F. Discharged in three weeks.

Case 4.— M. S., girl, aged 8, admitted to St. Luke's Hospital July 26, 1910,
complaining of pain in the "stomach." Two days before she had fallen a
distance of four and a half feet, landing on the ground on the right side.
Went home ; complained of pain in her stomach, which has continued ever
since. Bowels regular. No trouble with urination ; no blood in the urine ;
has vomited twice.

Physical Examination : Negative, except for the abdomen, which shows
general rigidity, with tenderness on the lower right side. Temperature, 102° F.
Blood count : Leucocytoses, 2,500 ; polynuclears, 88 per cent. No urine record.
Probable diagnosis, appendicitis. Immediate operation. Intermuscular in-
cision. On separating the muscles a considerable amount of fluid blood evacu-
ated. On opening the peritoneum a similar fluid escaped from the pelvis;
the ccecal wall was the site of a considerable ecchymosis. Appendix normal
(removed). The wound was dilated retroperitoneally to aliow of a sponge
being pushed up into the lumbar region ; it returned bloody,- but without evacu-
ating any fluid. Injury to the kidney seemed probable; it could be palpated
quite readily, but no obvious abnormality being detected (intra-capsular
rupture), it was decided to await further developments.

The child recovered well, and seemed relieved. The urine the next day
(17th) was: Neutral 1,034, very faint trace albumen, a few hyaline casts;
July 20, acid 1,014, very faint trace albumen, a few leucocytes ; July 21, acid
1,020, albumen 10 per cent, many red blood cells. In view of this last urine
report, exploration was undertaken. Right lumbar incision. The true capsule
was found intact, but distended with blood, and raised from the kidney.
On opening it, the kidney was found broken completely in two, the lower
smaller fragment showing beginning necrosis. Nephrectomy ; drain. Perfect
recovery. Discharged Aug. 9.

The case is interesting, showing a complete rupture resulting from
a relatively slight trauma, leaving no mark on the body and producing
absolutely no shock, the masking of kidney symptoms by the bruising
of the lower abdominal muscles and the colon, the absence of any
urinary symptoms till five days after injury, and also that the
kidney may be divided completely in two without appreciable solution
of continuity of its capsule. Four complete ruptures of the kidney
in children under 12, occurring in the practice of one surgeon, seems
unusual, in view of the small number of such cases on record. It is
possible that these cases are really not so rare and may be overlooked,
with disastrous results, by those who hesitate to interfere in dubious
cases. The similarity of the lesions is interesting, being exactly alike

-.1}

RUPTURE OF THE KIDNEY IN CHILDREN 27

in all 4 cases — complete division of the viscus in 2 parts, the lower
one being the lesser. In one instance the capsule remained untorn.

The fact that the kidney lesions were the same with the different
kinds of violence seems to confirm the theory of "bursting" by hy-
draulic pressure. Also the line of rupture — vertical to the long axis
at about the junction of the two lower thirds would seem to indicate
that we had here an instance of a definite line of least resistance
such as I have not seen indicated in any of the treatises on the sub-
ject.

Although the lesion in all these cases was severe, the symptoms, on
the whole, were mild, and in several ways deficient. Nephrectomy
was necessary in every instance, and successful; no other operation
would have been permissible. Three of the children have been under
observation and remained well.

As regards the etiology of such severe injuries, it is obvious that
children are relatively little exposed to the various forms of trauma
commonly encountered by active men (96 per cent of all cases). Most
modern observations seem to corroborate Kuttner's view, that the
kidney being a semi-fluid body, bursts along the line of least resistance
according to the law of hydraulics. Direct pressure from the lower
ribs can also explain it. It is less easy, however, to understand the
effects of indirect violence as from a fall on the feet. A point, how-
ever, to be borne in mind, illustrated in two of my cases, is that the
severest form of damage may result from an injury unaccompanied
by marks of external violence on the surface of the body in the kidney
region or anywhere else. Possibly in some children a persistence of
the infantile ptosis2 may persist, leaving more of the surface unpro-
tected by the thoracic bulwark. The particular vulnerability in child-
hood has also been ascribed to the minimum deposit of perinephric
fat and the greater tension of the overlying peritoneum.

The extent of the lesion naturally runs the gamut from the mildest
of superficial bruises to the complete rupture observed in my 4 cases —
to the tearing away of the kidney from its vascular pedicle or the
ureter or complete pulpifying from extraordinary crushes. In the
less extensive injuries it is of practical importance whether the tear
involves or extends into the pelvis — whether larger vascular trunks
are destroyed, with resulting dangerous hemorrhage or jeopardizing
the future vitality of portions of the organ — whether the injury is

sAglave, Bulletin de la Soc. d'Anatomie de Paris, 1910, p. 595.

28 ST. LUKE'S HOSPITAL REPORTS

subcapsular, and finally, whether there is a coexistent tear of the
peritoneum or injury of the contiguous viscera. Unfortunately, few
if any of these lesions can be diagnosticated with certainty as regards
their extent, particularly at a period when early interference may be
all-important. A consideration of the nature of the violence is help-
ful. Injuries resulting from direct violence will probably produce a
rupture of the kidney alone by "bursting" violence. Gross, direct
violence, such as "run over" accidents, are more likely to result in
complex lesions. The intensity of the violence is, however, not a
trustworthy guide, as shown by Case I, where a complete rupture re-
sulted from the kick of a horse that left no mark on the skin. It
must also be borne in mind that a pathological kidney may rupture
from the most trivial accident (Watson's case of the woman whose
hydronephrotic kidney ruptured from muscular action — washing
windows).

The loss of blood resulting from any of these injuries naturally
varies. Generally speaking, it is rarely sufficient to endanger life
quickly; it is, rather, the constant and recurring hemorrhage that is
most to be dreaded. Even with extensive rents of the kidney, the
integrity of the capsule tends, by tension, to check extraordinary
bleeding.

As regards diagnosis, it may be stated broadly that a diagnosis
of some degree of injury to the kidney presents little difficulty. Sta-
tistics give a history of hematuria in 80 per cent of the cases, and
certainly, with painstaking microscopic urinary examinations, this
figure would be increased. It will not ordinarily be difficult to ex-
clude lesions of other portions of the urinary tract, e.g., of the blad-
der, practically always complicated by a fracture of the pelvis. The
history or evidence of an injury which may implicate the kidney will
generally be elicited, pain, tenderness and eventually more or less
pronounced signs of the extravasation of blood or urine, or both, in the
marked cases, will accentuate the diagnosis and also indicate the side
involved. For unusual cases and conditions, the cystoscope or ureter
catheter may be used; but as a routine, these are uncalled for, as
well as unwise, and in children can scarcely ever be used, and if re-
quiring anesthesia, had better be replaced by a harmless and more
satisfying exploratory and therapeutic lumbar incision.

What is most difficult is to determine the extent of the lesion, and
particularly as regards the conditions which most urgently call for
interference. The initial symptoms, with the exception of the degree

RUPTURE OF THE KIDNEY IN CHILDREN 29

of shock and hemorrhage, do not present any features which sharply
indicate the severity of the damage — it is rather on the development
and sequence of secondary manifestation that we have to rely, or,
perhaps, waste valuable time.

Very severe injuries or very mild ones may be usually diagnosed
with readiness, especially with a definite knowledge and appreciation
of the nature of the causative violence. For instance, a child is run
over by a heavy wagon, as reported by a competent witness — there
are extensive marks on the body, there is abundant and early, perhaps
immediate, hematuria, there is marked shock. Given these conditions,
there should be a severe laceration of the kidney and perhaps of other
contiguous organs, possibly entailing a laceration of the peritoneum
overlying the kidney. These complicating conditions may not always
be obvious at the outset, although these marked and dangerous symp-
toms will manifest themselves later — too late, probably, to remedy
them.

On the other hand, a lad may be hit a severe blow in boxing — the
so-called "kidney blow" — feels a good deal of pain, may be tem-
porarily dizzy or sick at his stomach, sooner or later the urine is
tinged with blood. Such a history and such findings indicate a tri-
fling condition requiring no active treatment.

It is, however, the cases of moderate severity or of incomplete
symptoms that are the most difficult to judge. The degree of initial
shock is alone no criterion; it may be intense, certainly, for a short
time, with only a trifling injury ; it may be insignificant or wanting,
with the severest damage. The degree of hemorrhage is also mis-
leading; a small vessel may bleed savagely for a while, and if the
bulk of the hemorrhage finds a ready escape down the ureter we shall
have an alarming picture for a perhaps trifling condition. On the
other hand, mechanical obstacles — rupture of the pelvis or ureter (or
blocking), clotting or absence of considerable hemorrhage from the
kidney, may result in little hematuria even in the presence of the
severest damage.

Absence of visible marks of external violence is no criterion, for
complete rupture may occur despite this negative evidence (Cases I
and IV).

The significance of a swelling in the flank varies a good deal. If
considerable and early, it usually means extensive damage. Some
of it may be due to the trauma to the abdominal wall, some to the bulk
of the extravasated blood, some to the reaction of irritated intestines

30 ST. LUKE'S HOSPITAL REPORTS

inhibiting peristalsis, or to an actual lesion of the gut, or later, to a
peritonitis due to extravasation of urine, or an infection of the
retroperitoneal tissues or from associated injuries.

The amount of urine collecting in the tissues will depend on
whether the injury involves a rupture of (a) the capsule, (b) pelvis,
(c) ureter, and whether the urine can accumulate in a well-defined
space, or whether opportunity is offered for extravasation into the
tissues or the peritoneum. Tuffier has shown from animal experi-
ments, and clinical observations have corroborated that the lacerated
renal surface per se allows little or no urine to escape.

Later swellings may be due to secondary infections. A consider-
able and increasing, well-defined (colon pushed forward) swelling
with remission of acute symptoms and absence of inflammatory signs
would indicate the retroperitoneal accumulation of a well walled-off
collection of urine whose escape down the ureter is shut off — explora-
tory puncture (if deemed wise) will prove the condition.

It is obvious that we are not able to diagnosticate accurately the
extent of many of these lesions. We know also that many such in-
juries, while not rapidly producing death, may do so eventually on
account of the many complications that may arise. My feeling is that
we should not hesitate in dubious cases to complete our diagnosis by
an early exploratory lumbar incision, which will also fill a useful and
probably necessary therapeutic role. Not many years ago we thought
ourselves competent to differentiate the several forms of appendicitis
— few surgeons to-day care to take such a risk, and prefer to replace
doubt with certainty, and I believe that the varying possibilities for
harm of a kidney lesion furnish a reasonable analogy.

As regards prognosis, statistical data of large series of cases have
been collected to show results both of the condition and the value of
the various forms of treatment, but it is doubtful if the older figures
have much value to-day.

Suter,3 in 1905, found in a study of 701 subcutaneous injuries of

the kidney :

Per cent

Total mortality 18.6

of 131 treated by nephrectomy 16.7

" " " 143 conservative operations 14.6

" 427 treated expectantly 20.6

If these figures are of any value at all, certainly an expectant

'Suter, Beit, zur klin. Chirurgie, Band 47.

RUPTURE OF THE KIDNEY IN CHILDREN 31

treatment which has a mortality of over 20 per cent does not make
a very impressive showing. With modern technique, generalization
of skilled operators, efficient means of combating shock, etc., to refrain
from operation satisfied with a mortality of 20 per cent, cannot be
accepted as progress. Watson showed, in a series of 99 cases of oper-
ation in which the condition of the kidney called only for minor pro-
cedure, there were only 7 deaths, the cause of death being found,
generally, to conditions independent of the operation proper (injury
of the other kidney, peritonitis). Watson has formulated the indica-
tion for treatment as follows:

Cases suitable for expectant treatment :

1. The milder forms of the injury.

2. The cases in which there is reason to believe that both kidneys have

been injured, the signs being external evidence of injury on both
sides, tumor in both loins, and anuria.

3. Cases in which there are injuries of other parts of the body of such

grave character as to make futile any operative treatment of the
renal lesion.
Cases demanding operative treatment :

1. All in which there is evidence of progressive hemorrhage, e.g., increas-

ing pallor, pulse of declining strength and increasing rapidity, sigh-
ing respiration, and, locally, a tumor in the loin which is increasing
in size ; or an increasing amount of free fluid in the peritoneal
cavity in the cases complicated by intra-abdominal injuries.

2. Hematuria which persists for a long time, even though the quantity

of blood is at no one time large ; hematuria in which there is a large
amount of blood, even though it has not lasted long; hematuria
which recurs after having ceased ; sudden cessation of a previously
profuse hematuria, and, if there is no reason to believe that both
kidneys are injured.

4. Cases in which there is evidence of intra- or perirenal suppuration,

or of peritoneal infection.

My own feeling would be that we should refrain from immediate
operation in (a) all milder cases, presenting no one symptom of any
severity, and giving a history of injury wThich is presumably of no
great violence ; (b) cases of generalized injury with a very bad general
condition, and absence of urgent kidney symptoms.

For the latter class I would urge an exploratory operation with
an appreciable increase of any or all symptoms at an early date.
Operation in some form, then, is indicated for all milder cases that
show a tendency to increase their symptoms and for all other cases,
barring those falling in class B. My attitude in the border-line cases
would be, when in doubt operate, believing that by such a routine

32 ST. LUKE'S HOSPITAL REPORTS

measure we will not let some seemingly mild case slip through our
fingers. As regards the time of operation, in general, one should
operate as early as possible, but if the main symptom is not that of
an increasing anemia (repeated examinations of the hemoglobin),
one might well occasionally give the patient a few hours to pull him-
self together, though such a delay should not be entertained if we
have associated intraperitoneal injuries calling for prompt relief.

As a rule, the incision should give an extra-peritoneal approach by
the lumbar route — it is the most direct, avoids infecting the perito-
neum, and does not require handling and blocking off of protruding
intestines. Moreover, it will provide the safe and efficient drainage
demanded in most of these conditions. An anterior incision should be
reserved for injuries which presumably involve the intraperitoneal
organs — even in these cases a supplementary lumbar incision for
drainage may be indicated, particularly if a nephrectomy is not per-
formed.

Nephrectomy should be reserved for the cases in which the integ-
rity of the kidney cannot be preserved, and it is obvious that hemor-
rhage cannot be effectually stopped or prevented otherwise, or the
outflow of the urine into the ureter cannot be efficiently restored. In
the event of doubt arising, regarding the integrity of the other kid-
ney, nephrectomy may be deferred until sufficient information is ob-
tained. Meanwhile, the injured kidney should be attended to, per-
itoneum if torn, sutured or packed, laceration sewn if advisable, the
pelvis drained and the whole or part of the wound packed and drained
efficiently. Where nephrectomy is not required suture or packing
with drainage will suffice. How much more efficient suture rather
than packing a lacerated area will prove, is to me an open question.
I think not much time should be lost in performing it and it should
perhaps be reserved for cases in which packing may less efficiently
check bleeding. The main indication is to provide free drainage,
which will minimize the disastrous secondary effects of injury and
extravasation.

This paper is written to call attention to the fact that rupture of
the kidney in children is probably commoner than generally esti-
mated. That the lesion is frequently severe, consisting of a complete
division of the kidney into unequal halves. That shock and other
symptoms may be slight and out of proportion to the gravity of the
lesion. That operative interference should be more freely employed
and gives good results.

THE SURGICAL TREATMENT OF COLITIS.*

Charles L. Gibson, M.D.

My interest in the surgical treatment of colitis dates back to 1900,
when I devised a line of treatment intended to replace the only means
recognized then as efficient, namely, artificial anus. This method of
mine is the one most generally used to-day ; but its origin and useful-
ness has been considerably obscured by the introduction of a modifica-
tion in the technique of my original operation by Weir, substituting
for my valvular caecostomy appendicostomy. I hope to be pardoned if
I make this paper the subject of a review of the development of the
more modern treatment.

As regards the value of the artificial anus, I had been very skeptical,
in the brief years it flourished, whether the cure was not worse than
the disease. Moreover, the evidence advanced of its curative value
was oftentimes unconvincing, and it was natural that the relief ob-
tained should only be partial unless a complete artificial anus was
made, absolutely eliminating the fecal current from reacting the colon.
If a complete artificial anus were made, its eventual repair required
a severe operation with a high mortality.

I set out deliberately to devise a form of operative treatment that
should be the antithesis of the artificial anus, allowing of no escape
of fecal contents.

I felt that if the principles of ordinary surgical drainage and clean-
liness could be applied to the large intestine, we would have gained
considerably in facilitating the healing of the ulcerated surfaces. That
result I thought could be brought about by devising a means of fre-
quently flushing the large intestine, greatly diluting its irritating
contents and removing them from prolonged contact with the ulcer-
ations. So if we could give the patient an opening in the bowel for
access to its contents and yet prevent their egress, the problem would
be solved.

The Kader form of gastrostomy had then come to be considerably

♦Read before the International Surgical Association at Brussels, September,

1911.

34 ST. LUKE'S HOSPITAL REPORTS

employed, and all I had to do was to use the same technique in the
caecum which I did. At the outset I believed that by making a suitable
incision (intermuscular) we should have a small and easily controlled
wound, confinement to bed for its healing 10 days or less, the patient
could then receive ambulant treatment or administer it himself by
introducing the tube several times a day and flushing out the bowel
with various appropriate solutions. During the intervals neither tube
nor dressing need be worn, and the closure of the wound would be
automatic as the discontinuance of the passage of the tube for a few
days would allow of the valve action to become permanent.

All these theoretical requirements were found in general to be
feasible in practice ; but owing to the introduction of appendicostomy
two years later, the origin of the method was lost sight of. I was a
long time in getting an opportunity to perform this operation myself ;
but two of my kind friends, to whom I described this procedure, were
good enough to make a trial of it at my suggestion.

Dr. P. R. Bolton performed it in 1900, reporting the case in the
Medical Record for March 16, 1901, and in November, 1901, Dr. F. H.
Markoe also performed it at my suggestion. My first case was per-
formed later in 1901. The method was described in a paper1 read by
me March 5, 1902, in Boston, but publication was delayed till Sep-
tember.

Dr. Weir, in April, 1902, did my operation at my suggestion. The
same day he had a second ease, and having had some difficulty with
my technique (tube was pulled out after being put in place), decided
to use the lumen of the appendix as the channel. He lost no time in
getting into print, so that, when my article appeared, appendicostomy
had already been claimed as the proper treatment for colitis, and is
generally so used. I think, whatever its merits from the technical
standpoint, that the modern treatment owes its origin distinctly to me.
That is, if I had not shown Dr. Weir how to do a valvular colostomy,
he never would have thought of treating colitis except by the forma-
tion of an artificial anus.

I cheerfully recognize the merits of appendicostomy. It is a little
simpler for a person without much surgical skill to perform, and there-
fore safer. The appendix may, however, not be of a suitable size or
position (retrocecal) to lend itself properly to the procedure, and the

'The Creation of an Artificial Valvular Fistula for the Treatment of Chronic
Colitis (Boston Medical and Surgical Journal, Sept. 25, 1902).

THE SURGICAL TREATMENT OF COLITIS 35

patient has to wear constantly a dressing, which is not the case with
my technique.

So there still remains some sphere of usefulness to the original
operation, and I repeat its original description, as given in the Boston
Medical and Surgical Journal, September 25, 1902.

The technique is as follows: A small incision — preferably the
McBurney intermuscular — is made over the caput coli. If desirable,
the anaesthetic can be discontinued as soon as the peritoneum is
opened. Nitrous oxide gas anaesthesia might be used. With an in-
telligent and self-controlled patient local anaesthesia might suffice.
Should there be any difficulty in bringing the colon to the surface, I
see no positive disadvantage in utilizing the lower ileum. Two Lem-
bert sutures, half an inch apart, are inserted, and the caecum opened
between them. A soft catheter, about 30° F., is introduced so that
it projects well into the bowel, and the original sutures tightly tied.
The wall of the gut is further infolded around the tube in two super-
imposed layers. The ends of the superficial layer are used to suture
and hold the caecum to the musculo-aponeurotic structures. The tube
may also be secured in place by passing a finer catgut stitch through
its wall. The abdominal wound is closed at the angles, or packed. It
will be safer not to begin irrigation before 3 or 4 days. The tube
may be withdrawn in a week or 10 days, being introduced only when
necessary for the irrigation, and withdrawn so soon as it has served
its purpose. If our ideal has been attained, there will be no leakage,
even when the colon is visibly distended. Treatment should be per-
sisted in till a cure is obtained. Closure of the fistula occurs spon-
taneously with the discontinuance of the daily passage of the catheter.

It seems to me unwise, if not impossible, to attempt at present to
formulate any indications for the employment of this measure. From
what has been related, it is fair to say that certain forms of colitis can
be cured by it. It may be objected that such cases and the ones here
described are of the milder variety that would yield to the orthodox
treatment. Personally, it seems that the results have been more di-
rect, progressive and prompt than are attained by the non-operative
measures.

On the other hand, I do not cherish any illusions regarding certain
forms of ulceration, such as the tubercular, that may be properly con-
sidered as incurable, especially when accompanied with similar or
more extensive changes in the small intestine. Actual experience
only can determine whether by frequent cleansing of these ulcerating

36 ST. LUKE'S HOSPITAL REPORTS

surfaces and by neutralization of the products of decomposition we
can somewhat ameliorate the symptoms, and if to an extent that war-
rants actual interference.

With regard to the therapeutic agents that may prove of value
when so locally applied, I can only indicate those ordinarily employed.
For the present I shall rely principally on the mechanical cleansing by
flushing the bowel with an appropriate bland solution, such as the
normal saline. It may either be used as a continued irrigation, escap-
ing through the rectal tube, or the colon may be filled to moderate
distention, say 3 quarts, and subsequently evacuated. The frequency
should be established by the tolerance of the bowel and the urgency
of the symptoms. At the beginning, if well borne, I should prefer to
repeat the irrigation at regular intervals of 8 or 12 hours, possibly
oftener. Agents destined to exert a direct influence on the ulcerating
surfaces will naturally act better after the preliminary cleansing.
They should be introduced separately from the saline, or after it has
been evacuated. The bowel should be flushed with plain water prior
to the use of substances such as AgN03, which combine with the
saline.

The required therapeutic agents will also vary somewhat with the
nature of the colitis. Gradually increasing strengths of quinin and
methylene-blue have been recommended for the amoebic form. Nitrate
of silver in strengths increased from 1-20,000 will, I think, prove the
best single remedial and stimulating agent. The whole gamut of the
milder non-poisonous antiseptics, especially of the naphthol group,
may be tried, as well as the ordinary astringents. Small doses of iodo-
form in emulsion might be tentatively tried in the tubercular form.
Glutol, a non-irritating derivative of formalin, which acts so admir-
ably in ordinary suppurations, might also be employed. The patient
should be on an appropriate, chiefly proteid, diet.

My own experience is very small, but gratifying. Six cases. One
tubercular case (unsuitable) was not improved. Four cases were
cured. In one subsequently operated upon by another surgeon for
another condition, marked healing of many of the ulcerated areas
was found. One patient almost moribund was operated upon with
local anaesthesia very satisfactorily and was completely restored to
health.

None of these cases was of the amoebic variety, which I believe is
hard to cure by this or any other means, and are liable to undergo
relapse sometimes after long intervals of freedom from symptoms.

:f.

FECAL CONCRETION IN THE FALLOPIAN TUBE.
Walton Martin, M.D.

On March 8, 1911, a Swedish girl, 20 years old, unmarried, was
admitted to the hospital. She had been ill for 2 weeks. During that
time she had had severe sharp pain in the lower right quadrant of the
abdomen. The pain had not been constant, but had occurred at in-
tervals. She had felt ill, and had had fever. There had been no
disturbance with bowel or bladder.

On examination, there was well marked rigidity on both sides of
the lower abdomen, but it was more marked on the right side. The
patient looked ill. The temperature was 101°, the pulse 142.

The diagnosis of appendicitis was made, and operation was done
as soon as the patient could be prepared. On opening the peritoneum,
there was a gush of foul-smelling pus. The appendix had partly
sloughed away and only the proximal end could be found. This was
removed and a drainage tube introduced.

The patient made a slow but satisfactory recovery and left the hos-
pital 5 weeks later, with a normal temperature. There was still,
however, a discharging sinus at the site of the incision. The dis-
charge was purulent and foul-smelling, but not fecal. A probe could
readily be passed for several inches along a fistulous tract.

The patient returned to her work, but reported at the hospital
from time to time, and on August 7, 1911, 4 months after her first
operation, she was again admitted, as she still had the discharging
abdominal sinus. This sinus seemed to have changed little since she
had left the hospital. From time to time it had discharged small
amounts of very foul pus, and she had had, at times, considerable
pain in her side. It was evidently not a fecal fistula, and the per-
sistence of the sinus was supposed to be due to the failure to remove
the distal portion of the appendix. It was supposed that the presence
of this distal portion was causing the trouble. An operation was
advised.

On August 8, 1911, an incision, circumscribing the old scar, was

38 ST. LUKE'S HOSPITAL REPORTS

made, and the fistulous tract carefully dissected out. The tract led
downward and inward between loops of intestine, until it reached
a dark purple, tubular mass about the size of the index finger; from
the end of this structure pus was exuding through a pin-point open-
ing. Followed mesially this structure became narrower and finally
joined the uterus. It was obviously the uterine tube. It was re-
moved, and the abdominal wall closed. The wound healed satisfac-
torily, and the patient left the hospital at the end of 3 weeks.

The specimen removed was tubular and 8 cm. long. It measured
0.5 cm. at the uterine end, and 2 cm. at the distal end. On cutting it
open, a fecal concretion, about 1 cm. in length, was seen in the lumen of
the thickened distal portion. It was identical in appearance with a
fecal concretion such as is usually seen in the appendix. There was
pus in this portion of the tube ; it had a foul, fecal odor. The fimbriae
at the outer end of the tube were turned in, so that the end of the
tube looked club-shaped, as in the ordinary pyosalpinx. Microscopic
examination snowed the walls of the Fallopian tube thickened and
infiltrated with round cells.

The concretion had evidently been freed during the attack of ap-
pendicitis by the sloughing away of the appendix, and had been taken
up by the Fallopian tube, where it had found lodgment for 4 months.
The irritation of the concretion in the tube caused the constant escape
of pus through the end of the tube into the abdominal sinus.

I have been unable to find the record of a similar case.

EXTENSIVE EPITHELIOMA OF THE CHEEK WITH SEC-
ONDARY INVOLVEMENT OF THE GENIAL GLANDS.

H. H. M. Lyle, M.D.

Although the genial or facial glands were not mentioned by the
majority of the older writers (Richet, Bouchard, Sappey, etc.), Mas-
cagni described them in 1787, distinguishing the supra-maxillary and
buccinator groups. Boyer, Jacob and Cruveilhier also mention them.
In 1887, Poncet called attention to the clinical significance of these
glands; his work was further extended by his pupils, Vigier (1892),
Albertin (1895). This clinical work stimulated an interest in the
subject and brought out researches by Princetau (1899), Cappette-
Laplene (1899), Buchbinder (1899), Kiittner, Trendel, Thevenot
(1900).

The glands are found in 65 per cent of the cases. According to
Cuneo and Poirer, they can be divided into three sets. An inferior or
supra-maxillary group, situated on the external surface of the inferior
maxilla, close to the facial vessels. The middle or buccinator group
(Molar of Testut and Jacob) are situated on the external surface of
the buccinator, in front of the anterior border of the masseter; they
are in close relation to Stenson's duct. The superior or molar group
when present, are found along the ascending branches of the facial,
one in the supra-orbital region, a second in naso-genial fold, and a
third on the malar bone.

Trendel has collected 25 cases of secondary cancerous involvement
of these glands; cases are also reported by V. Bruns, Kiittner and
others.

In the light of these facts the following case occurring on the ser-
vice of Dr. Gibson, is of interest :

The patient, a man, 52 years old, was admitted to St. Luke's Hospital
September, 1910. He had a tumor of the left cheek, of 11 weeks' duration.
Ten days previously his physician had incised the tumor, but no pus was
found.

On examination, there was a large, indurated swelling occupying the left

ST. LUKE'S HOSPITAL REPORTS

cheek and involving the angle of the mouth. In the center of the mass
there was a discharging sinus. The buccal surface showed a cauliflower-
like growth, which was not attached to the jaw. The sub-maxillary lym-
phatics were enlarged and hard. A section of the growth removed for ex-
amination showed it to be a squamous-celled carcinoma.

Operation.— A wide excision of the growth, including the angle of the
mouth, was made, and the defect closed by a modification of the Dowd
operation, plus a flap taken from the neck. Primary union resulted. Ten
days previously a block dissection of the neck and sub-maxillary and sub-
mental regions had been done.

Fig. 1. — A, original growth. B, recurrence in Buccinator group of genial
glands. C, recurrence in the inferior group. The dotted outline indicates the
amount of skin removed.

Four months later, when the patient returned for observation, an
examination showed that the mucoperiosteum of the jaw had been in-
volved, and there were two distinct hard nodules on the cheek, one
just below the center of the malar bone; the second an inch lower
down and posterior to the angle of the mouth. There was no cervical
involvement.

At a second operation, virtually the whole cheek below the malar
bone was removed, along with the fascia and fat covering the masseter.
In this fascia, the buccinator and supra-maxillary groups of the genial

Fit:. 2. — The result, after the removal of a large
portion of left cheek, the angle and floor of the
mouth, and half the body of the lower jaw.

EPITHELIOMA OF THE CHEEK

glands were found to be involved. The left half of the body of the
jaw, with the involved mucous membrane of the floor of the mouth,
was removed. Cutaneous flaps were obtained from the neck and the
right side of the chin. Considerable difficulty was experienced, ow-
ing to the cicatricial tissue left from the previous operation. The
buccal lining of these flaps was obtained by splitting the mucous
membrane of the tongue and turning it upward, after the method
suggested by Sonnenburg.

Fig. 3. — Sagittal section through the mouth, after removal of a large por-
tion of the cheek and half the lower jaw, showing the method of closing the
defect by flap from the tongue.

Three months later a secondary plastic operation was performed
to widen the cavity of the mouth.

The points of interest in the case are: (1) the involvement of
the genial glands, failure to recognize and remove these at the time
of the primary operation having been one of the causes of the recur-
rence; (2) the use of a flap of mucous membrane from the tongue
to line the cheek.

THE BOTTLE OPERATION FOR HYDROCELE OF THE
TUNICA VAGINALIS— TEN CASES— THREE FAILURES.

H. H. M. Lyle, M.D.

In order to get the true value of any surgical procedure it is
necessary to report the failures as well as the successes. In Keen's
Surgery, volume IV, page 607, in describing the "Bottle Operation,"
Bevan quotes E. Wyllys Andrews as follows: "I recommend it with-
out reserve and do not hesitate to urge that it supersede the older
operations. ' '

The following is a brief account of our experience with the "Bottle
Operation." In a series of 10 cases we have had 3 failures. The
first of these failures could not be justly charged to the operation.
The patient had a chronic cardiac condition, which might have been
a factor in the passive congestion of the reversed sac. In the second
case, the surgical indications for this operation were apparently per-
fect. The failure was a complete surprise, and led us to think that it
was due to some error in technic. As the patient refused further
operative treatment, the cause of the increased size of the sac and
testicle remained problematic. In the third case, with the previous
failures freshly in mind, the operation was carefully and deliberately
carried out. The hydrocele tumor disappeared, but its place was
gradually taken by a tumor composed of thickened sac and testis,
This secondary condition was little or no better than the primary.
Two months later the reversed sac was excised by Dr. Douglas. The
sac wall, which measured one-half inch thick, was composed of ede-
matous connective tissue.

The patient was shown before the New York Surgical Society,
November 8, 1911. The discussion of the case brought out the fact
that this operation had failed in the hands of other surgeons. Dr.
A. V. Moschcowitz said that he had abandoned the operation on ac-
count of failures, and said there was also a good theoretical reason
why this operation should not be done. In some cases the testis are
fastened to the bottom of the scrotum by the remains of Hunter's

FAILURES IN BOTTLE OPERATION FOR HYDROCELE 43

ligament. To perform this operation properly, in such cases, the
ligament has to be cut. If this has to be done, it is just as easy, or
easier to cut the sac away, that is, to perform Von Bergmann's oper-
ation.

The object in reporting these failures is to emphasize the fact that
even in selected cases, "the bottle operation" may give as unreliable
operative results as the allied operations of Doyen, Jaboulay and
Winklemann.

INTRADURAL SECTION OF THE SIXTH, SEVENTH, EIGHTH

AND FIRST DORSAL POSTERIOR NERVE ROOTS FOR

INTRACTABLE BRACHIAL NEURALGIA— FAILURE

TO RELIEVE THE PAIN— LATER SECTION OF

THE CORRESPONDING ANTERIOR ROOTS

WITH NO RELIEF.

H. H. M. Lyle, M.D.

The patient, an engineer, 43 years old, was referred to the service
of Dr. C. L. Gibson by Dr. W. Bastedo, with a diagnosis of Intractable
Brachial Neuralgia. Three months previously to admission he was
violently injured by a lever striking him on left side of his neck at
the level of his jaw. He was unconscious for 24 hours. The left arm
was completely paralyzed, and he suffered intense pain in the neck
and arm. An exploratory incision showed that the roots of the cervi/
eal plexus were torn. The arm was amputated. At the present time
he complains of an intense neuralgic pain in his missing hand and
arm.

Physical Examination.— Spare man, aged 43, looks haggard and worn.
Heart, lungs and abdomen normal. Left pupil contracted and undilatable.
There is a vertical scar, 2% inches long, at the anterior border of the left
sterno-mastoid. The left arm has been disarticulated at the shoulder. The
resultant scar is freely movable and the stump is not sensitive to pressure.
The bony parts appear to be normal except foi a slight prominence of the
left clavicle and upper ribs; there is slight lateral curvature of the spine.
As the arm was missing, no notes regarding anaesthesia are available. The
patient was examined by Dr. Pierce Bailey, who recommended an unilateral
intraspinal division of the left 7th and 8th cervical and 1st dorsal posterior
nerve roots. X-ray examination of spine is negative.

Operation, December 1, 1910 — Unilateral laminectomy with seetion
of 6th, 7th, 8th cervical and 1st dorsal posterior nerve roots, by
Dr. Lyle.

With the patient in the ventral position, an incision 414 inches
long was made in the cervical region, the muscles separated and a

SECTION OF NERVE ROOTS FOR BRACHIAL NEURALGIA 45

hemisection of the laminae made, according to Taylor's method. The
dura was then opened, the posterior roots of the last three cervical and
the first dorsal were identified, hooked up and cut. The posterior root
of the sixth cervical had been torn away from the cord. The dura was
sutured with a fine catgut and the wound closed.

There was a moderate post-operative reaction. The patient re-
mained free from pain for 5 days, then he began to complain of pain
in the thumb, hand and arm ; this pain gradually increased, and at the
end of two months was, if anything, more intense than before the
operation.

As an explanation of the failure of posterior root section to cure
certain cases, it has been stated that there are additional sensory
paths in the anterior roots, and in such cases, these possible sensory
paths must be cut in order to obtain a cure. With this point in view,
Dr. Taylor decided to section the anterior roots. As the arm was
already gone, this appeared to be an ideal case to try it in. Six
months after the original operation, Dr. Taylor cut the anterior roots.
This operation has failed to relieve the pain.

The points of interest in this case are the tearing away from
the cord of the posterior root of the sixth cervical, and the persistence
of the intense pain in the hand and arm after a complete section of
both the posterior and anterior nerve roots of the 6th, 7th, 8th cervi-
cal and 1st dorsal.

GUMMA OF THE LIVEE AS A SEQUEL TO YAWS.

H. H. M. Lyle, M.D.

Patient, male, age 49 years, native of West Indies (Grenada).

Family History.— Father and one uncle died of carcinoma of the stomach.

Past History.— The patient had had gonorrhoea 15 years ago, and yaws
(frambesia), 39 years ago. No history of syphilis. Has complained of
gastric trouble for 30 years, at various times has been treated for gastritis,
ulcer and carcinoma.

Present History.— Patient complains of a constant pain in stomach; this
comes on an hour after eating, and persists until the following meal, or un-
til relief is obtained by vomiting. The constant pain has kept him awake
at night. Lately he has noticed a fulness in the upper epigastrium. Is
weak, and has lost 40 pounds in weight. The blood examination is negative;
the analysis of the stomach contents shows a hyperacidity.

Physical Examination. — The patient is greatly emaciated. No glandular
involvement can be made out. There are several old scars on the arms and
legs; these are said to be results of yaws. In the midline of the abdomen,
1 inch below the ensiform cartilage, there is a smooth, hard mass, which
apparently lies below the edge of the liver. The spleen is not enlarged.
A preoperative diagnosis of carcinoma of the stomach, starting from an old
ulcer, was made.

Operation by Dr. Lyle.

A smooth, round tumor, the size of a mandarin orange, was found
on the anterior surface of the left lobe of the liver. The liver was en-
larged and congested. The stomach, pancreas, and spleen normal, the
mesenteric glands are not enlarged. As an extended search failed to
reveal any other lesion, a diagnosis of gumma of the liver was made
and the abdomen closed.

Two Wassermann tests were made, the first was negative, the sec-
ond doubtful. After an intravenous injection of salvarsan, a third
Wassermann test was made, which was positive. Under specific treat-
ment, the tumor has disappeared and the liver has grown smaller.

The interest in this case rests largely on the possible relationship
between yaws and syphilis. The patient and two other members of

GUMMA AS A SEQUEL TO TAWS 47

his family were isolated in a hospital given over to the treatment of
yaws. Under these circumstances, it is reasonable to assume that
the diagnosis of yaws was correct.

It has been said that an attack of yaws gives an immunity to
syphilis. If this is the case, the patient must have had syphilis before
yaws.

CHRONIC PERISIGMOIDITIS WITH PARTIAL VOLVULUS.

H. H. M. Lyle, M.D.

The patient, male, 50 years old, has for a considerable time suf-
fered from attacks of pain and distention in the left iliac region.
These symptoms have been distinctly localized. The attacks have
been preceded by severe frontal headaches, and no relief could be
obtained until the distention was reduced by free bowel movements.
Two days prior to his admission to the hospital, he had a severe head-
ache, which compelled him to give up his work. He took a cathartic,
which set up violent peristalsis, resulting in 10 or 12 movements of
the bowels. These were at first fecal, but soon became mucoid and
bloody. Following this, the patient was seized with a violent pain in
the iliac region, and he vomited several times. With the onset of
the pain, the movements of the bowels ceased abruptly. No gas was
passed.

Physical examination : The patient presents the picture of an acute intes-
tinal obstruction. There is moderate general distention of the abdomen, with
marked local distention and tenderness in the left iliac region. The patient's
temperature is 100, pulse 120. There is moderate leucocytosis, with no relative
increase in the polymorphonuclears. After lavage and repeated enemata, the
distention was greatly reduced, and some gas passed per rectum. As the
symptoms were apparently improving, the operation was deferred, the patient
meanwhile being kept under close observation. With the reduction of the
distention a distinct mass was made out, which gave the impression of a thick-
ened intestine. The most probable diagnosis seemed to be an obstruction from
a new growth.

Operation by Dr. Lyle.

The sigmoid was found to be covered with broad, veil-like adhe-
sions; the lower edge of this veil was tough and fibrous, and it ex-
tended from the parietal peritoneum across the sigmoid. Around
this, as an axis, the sigmoid had partially revolved. The band was
freed, and the sigmoid straightened out. The presence of the veil-
like adhesions showed an attempt on the part of Nature to limit
the greatly dilated and movable sigmoid.

PERFORATION OP A SIMPLE ULCER OF THE COLON-
OPERATION.

H. H. M. Lyle, M.D.

The caput eoli and the lower portion of the ascending colon can
be looked upon as the stomach of the large intestine. The functions
of this segment correspond both embryologically and anatomically to
those of the true stomach. With these facts in mind, it is not strange
that similar pathological conditions may occur in this region.

The occurrence of a simple ulcer of the colon has been known for
a long time. Cruveilhier (1830-32), in speaking of gastric ulcer,
wrote, "these considerations apply perfectly to the small and large
intestine." Unfortunately, Cruveilhier 's clinical examples were not
well chosen. The discussion aroused by Cruveilhier led to the re-
porting of a case by Marchesseaux (in 1837) and a second by Roger
(1838). Lebert (1855-61) stated that simple chronic ulcers are
analogous in all points to those of the stomach; the latter occurring
the more frequently, had received the most attention. In 1897,
Combes reported 2 cases.

In all these observations not much attention was paid to the clin-
ical aspect of the subject until 1902, when Quenu and Duval published
a paper entitled "L 'Ulcere Simple du Gros Intestin." In this mono-
graph the authors attempted to rescue the simple ulcer from the
pathological chaos of the large intestine. The paper is a clinical
study of the pathogenesis, the symptoms, diagnosis, etc., of this little-
known affection. It is based on personal observations and a study of
the 31 cases reported in the literature. They state that the simple
ulcer of the colon has all the pathological characteristics which dis-
tinguish a "round ulcer" of the stomach from other gastric ulcers;
it is a simple ulcer in the group of colon ulcerations. Of the 31 re-
ported cases, 13 occurred in the caecum and ascending colon; in 20
cases the ulcers were multiple ; 23 cases perforated.

The following case occurred in the service of Dr. C. L. Gibson,
and was operated on by Dr. Lyle, October, 1909.

50 ST. LUKE'S HOSPITAL REPORTS

Surgical Number 79,130. — The patient, a married woman, 26 years old,
was admitted to the hospital with a diagnosis of acute gangrenous appendici-
tis. The patient has been a sufferer from indigestion and chronic constipa-
tion for years. In her search for relief she has made the rounds of the
clinics. The obscurity of her symptoms has led to the different diagnoses
of gall stones, kidney stones, ulcer of the stomach, appendicitis, etc. Lately
she has complained of a dull, aching pain in the region of McBurney's point ;
this pain is worse after a full meal and after exercise. Occasionally she has
had attacks of alternating constipation and diarrhoea. No blood has been
passed. There is no history of jaundice, typhoid, tuberculosis, or lues. She
has lost considerable weight and strength.

Two weeks ago she was seized with a sharp, rumbling, colicky pain
in right iliac fossa. There was considerable tenderness and distention on
the right side. The patient was nauseated, but did not vomit. The pain was
accompanied by a chill and a severe headache. After an hour the pain sub-
sided, and became intermittent in character, lasting for an hour or so and
then disappearing. This condition persisted for three days. Just before ad-
mission she was seized with violent cramplike pain in the right iliac fossa ;
she was nauseated, and vomited. The pain was accompanied by a severe chill,
a sense of weakness, and intense tenderness just above the crest of the ileum.
After an hour the pain subsided somewhat and became intermittent in char-
acter. Her bowels are constipated. There is an increased frequency of urina-
tion, but no burning.

Surgical condition : Woman, small frame, poorly nourished ; heart and
lungs normal, abdomen slightly distended, no general rigidity, no cutaneous
hyperesthesia. In the right iliac fossa there is a tender mass about the size
of a lemon. Vaginal and rectal examinations negative. On admission, patient
had a subnormal temperature, but just before going to the operating room it
rose to 100, pulse 92, respiration 26.

Blood examination : Leucocytes 25,000, polynuclear 86, lymphocytes 14.
A diagnosis of acute appendicitis, with abscess, was made, and patient sent
to the operating room.

Operation by Dr. Lyle, October 23, 1909.

The abdomen was opened by an intermuscular incision over the
mass ; on reaching the peritoneum a large abscess containing fecal
matter was encountered, the cavity was evacuated and a search for
the appendix was instituted. The appendix was found without the
mass and apparently had nothing to do with it. On the inner wall
of abscess cavity there was a moderate-sized perforation of the as-
cending colon ; the immediate edges of the perforation were formed of
necrotic mucous membrane. The perforation was found to be in the
center of an oval, indurated ulcer of the external wall of the ascend-
ing colon. The greatest length of the ulcer (2y2) lay in the long
axis of the gut. There was marked involvement of the surrounding
lymphatic glands. The immediate edges of the ulcer were trimmed

PERFORATED SIMPLE ULCER OF THE COLON ul

away and saved for microscopical examination. The ulcer was then
closed with a double Lembert suture as the induration precluded the
use of an exulcerating purse-string suture. Contrary to expectation,
the indurated fibrous tissue offered an excellent hold for the suture
material and made the closure very simple. As the possibility of a
lymphatic infection from the appendix could not be excluded, the
appendix was removed. After inserting a rubber dam drain, the
wound was closed. The patient made an uninterrupted recovery and
was discharged from the hospital in 21 days. There was no fecal
leakage at any time after the operation. The microscopical exami-
nation showed an edematous mucous membrane with ulceration, no
evidences of carcinoma or tuberculosis, the appendix was normal.

The resemblance between this condition and that of a perforating
gastric ulcer was so striking that one could almost have believed that
one was dealing with a typical round ulcer. The condition in no way
resembled the usual ulcerative processes encountered in this region ;
there were no diverticula of" fecal concretions.

The patient disappeared from view until March, 1912, when she
returned with a ventral hernia in the scar of the former operation.
The hernial repair was performed by Dr. Gibson; and at this oper-
ation an excellent opportunity was offered to study the condition of
the colon.

The second operation for a ventral hernia occurring in the scar
of the above operation was performed by Dr. Gibson, in March, 1912.
The colon appeared to be perfectly normal in all respects, and the
only means of identifying the site of the old ulcer was the presence
of a few membranous adhesions.

A SERIES OF CASES OF SURGERY OF THE SMALL
INTESTINE.

"W. Scott Schley, M.D.

The following cases of resection of the intestine, and of obstruction
without resection, occurred upon the 1st Surgical Division in the
service of Dr. Abbe. They are a part only of the small intestine
work, and represent chiefly emergency conditions operated by the
writer. There are several interesting types of obstructive conditions.
The fairly numerous cases of strangulated hernias, inguinal, femoral
and umbilical, have not been included. All of these patients have
recovered, all have been seen at intervals since leaving the hospital
(but one), and all remain in good condition. The conditions cited
below illustrate a variety of troubles, and the operative findings have
been shown by schematic drawings.

Case 1. — M. F., a small boy of 12 years, was admitted March 11, 1908.
Two and one-half hours before entrance, while attempting to climb a wall,
he pulled down a large stone, and falling backward the rock came down
upon his abdomen. He was carried home and suffered severe pain from
the moment of being struck. He vomited brownish fluid resembling "blood
and dirt" Urination normal after accident ; no blood in urine.

On admission he was greatly shocked, pale and with cold extremities.
There were contusions and abrasions of the face, but none of the abdomen,
which was flat, not distended, but generally rigid, especially the upper half.
Maximum point of tenderness in epigastrium just to right of median line.
There was dulness in the flanks, which seemed distinctly to change with
change of position. The house surgeon noted that the area of dulness
seemed to have increased in the short time the patient was in the ward be-
fore operation. It was considered a case of ruptured liver or intestine.
Operation : Straight incision through right rectus muscle. Abdomen found
to contain a large amount of bile with considerable blood. Liver and gall-
bladder and bile-passages found undamaged. Jejunum found torn com-
pletely across three inches from duodenojejunal junction. Ends of gut
trimmed and immediately united with small Murphy button, reinforced with
peritoneal stitch. Recovery uneventful ; button passed before leaving hospital.

Case 2. — S. McO, a woman of 37 years, was admitted to the hospital, May
20, 1910. Fifteen years before she had had the ovaries removed, and two
years later the uterus. Ten years later, following a year of constipation

SURGERY OF THE SMALL INTESTINE

Fig. 1 (Case 1). — Rupture of jejunum at transverse double lines. SecoDd
dotted lines show continuity restored with button.

ST. LUKES HOSPITAL REPORTS

with periods of vomiting and difficult micturition, she was operated upon
again and adhesions were said to be the cause of the trouble. After this
operation a "lump" api>eared in the scar, and grew for six months, when it
was excised. It recurred, and was again removed, a year and a half ago. For
the third time it has appeared and gradually increased in size. Posture,
she declares, has some effect upon the size. At times it is painful.

Fig. 2 (Case 2). — Point 1 shows mass in abdominal scar adherent to gut.
Dotted lines, limit of resection. Point 2, lateral anastomosis.

SURGERY OF THE SMALL INTESTINE 05

She presented a mass the size of a golf ball in the abdominal wall near
lower margin of previous laparotomy scar. The skin was involved and the
center had an ulcerated area. Probe passed down the center an inch. No
discharge. The mass did not appear to be tender and was attached to the
tissues of the abdominal wall. Examined vaginally, no added information
could be obtained.

Operation: Old scar, including growth, excised. The mass was found
densely adherent to a loop of small gut. Malignancy was suggested from the
history of recurrences, and it was thought wiser to resect the adherent por-
tion of gut. Four inches of gut were excised and the ends brought together
by lateral anastomosis (Fig. 2).

Microscopic examination of the tissue showed chronic inflammation only.
There was no history of a fecal fistula, wound suppuration, nor was there an
old stitch. The muscular tissues were not invaded.

Case 3. — F. F., a woman of 40 years, was admitted to the hospital Novem-
ber 9. 1910. This patient came seeking relief for a large ventral hernia re-
sulting from an operation performed two years before for ovarian tumor.

She presented a long scar to the right side of the mid-line, broad and
very thin. Skin and thinned-out scar tissue, to which the gut was densely
adherent and through which the convolutions were visible and palpable,
alone formed the abdominal wall at that point.

Operation: Old scar excised. Even with the greatest care a loop of the
very thin-walled gut, densely adherent to the cicatrix, was opened. The re-
mainder of the adherent intestine was separated with difficulty, often leaving
a mass of scar tissue on the bowel wall. The opened knuckle of gut was
excised and the ends brought together by lateral anastomosis. Recovery
was uneventful ; highest temperature following operation, 100 1-5°.

Case 4.— E. H., a woman 42 years of age, entered the hospital April, 1910.
She had a discharging small intestine fistula in a scar in the mid-line of the
abdomen. In November, 1909, I had operated in the country upon this pa-
tient for intestinal obstruction of the most urgent sort. She was then seven
months pregnant and had been taken six days before with the acute pain,
vomiting and abdominal cramps of that condition. When seen, her condition
was desperate, and a hasty operation resulted in freeing a loop of ileum
from a band just below the pelvic brim on the right side. From the length
of time the gut had been shut off, it was gangrenous at the point of con-
striction. Three inches were excised and the ends joined with Murphy but-
ton reinforced with peritoneal stitch. During convalescence, two weeks later,
the wound opened and discharge from the small gut took place. The button
could be felt in the gut and was removed by the attending physician through
the wound. Several months later she came to the city for the closure of
the intestinal fistula. At this operation it was found that the button had
passed down several feet from the original site of resection and had lodged
in an angle of bowel that had become attached to the median incision. It
had then ulcerated its way through. The intestine was freed, again resected
and the ends closed by end to end suture. This patient has been seen re-
cently and is in perfect health.

ST. LUKE'S HOSPITAL REPORTS

Case 5. — M. D., a small girl of six years, was admitted December 7, 1909.
She bad been taken sick one week before with abdominal pain and vomiting.
From the onset of pain, the vomiting had been frequent and irrespective of
attempts to take nourishment. Bowels said to have moved well day after
beginning of attack and two days before entrance. No blood or unusual

Fig. 3 (Case 3). — Intestine densely adherent along whole extent of
abdominal cicatrix. Portion of gut resected with cicatrix and united by
lateral anastomosis.

SURGERY OF THE SMALL INTESTINE

conditions were noted by the parents. The abdomen was not rigid, mod-
erately distended and with general tenderness. Signs of fluid within the
peritoneum. Right rectus more rigid than left. Rather more tenderness
over right lower quadrant and with greater muscular spasm. A mass occu-

Fig. 4 (Case 4).— Point 1, site of original obstruction. Point 2 (should
have been descending colon), where button ulcerated through gut and estab-
lished a fistula. Point 3, where colon was resected and joined by end-to-end
anastomosis with suture.

58 ST. LUKE'S HOSPITAL REPORTS

pied the region of the caput and extended for four or five inches along the
line of the ascending colon. Rectal examination revealed nothing.

Operation: Intermuscular incision over caput extended by opening the
rectus sheath. Condition found to be ileo-colic intussusception with gangrene
of the small gut. It was so rotten that it was difficult to reduce. The mes-
entery was black with thrombosed vessels. Over 22 inches of intestine were
excised and the small gut anastomosed with the caput at the ileo-csecal
junction by button reinforced with peritoneal stitch. Button passed on 7th
day. Convalescence stormy and prolonged. Child now in excellent health.

Case 6.— G. K., a man, 42 years of age, was admitted first to the Medical
Service of Dr. Janeway, Dec. 23d, 1910. An abdominal condition of gravity was
certain, but an exact diagnosis could not be made. He had been taken sick 24
hours before entrance and several hours after a meal, with a sudden sharp pain
across the upper abdomen. This pain was continuous and frequently radi-
ated to the lower abdomen in a stab-like manner. He vomited once several
hours after the beginning of the attack. Bowels have not moved since the
attack, nor has he passed flatus. Blood count and differential count both
high. Examination revealed only a moderately distended abdomen with
general rigidity. Tenderness to pressure was not marked and seemed some-
what greater over the upper half. Some fluid accumulation. He had the
appearance of suffering and of one acutely ill. Transferred to Surgical
Division.

Operation: Median incision below umbilicus. Large amount of blood-
stained serum. No odor. Intestine moderately distended and with slight
vascular engorgement. Twenty-two inches of bowel were found black red
from occlusion of mesenteric veins. On section, the arteries of the mesentery
bled freely, but the veins were thrombosed. The diseased gut and liberal
healthy margins were removed. Ends joined by button reinforced with peri-
toneal stitch.

This patient did well, but failed to pass the button before leaving the
hospital. He returned a month ago for another condition, and the radiograph
showed that he had passed it in the meantime.

Case 7.— E. S., a man of 27 years, was admitted April 11, 1911. He had
been operated upon five months before at the hospital for an acute appendi-
citis with abscess. He was drained for some time and made a good recovery.
After being home for some weeks, he began to have occasional attacks of
colicky pain associated with a sluggish condition of the bowels. The morning
of his admission to the hospital, for the second time he bad been taken with
a sudden and very severe pain about the umbilical region accompanied with
nausea and vomiting. On entrance his appearance was typical of intestinal
obstruction, and the demand for interference immediate.

Operation: The abdomen was opened in the median line.

The adhesions in the right iliac region were very dense and also on the
right side of the pelvis. In the greatly distended condition of the small gut
and the mass of adhesions, the particular point of obstruction could not be
found. An enterostomy was done, taking as low a point in the ileum as
possible. After drainage of the bowel for several weeks, his condition was

SURGERY OF THE SMALL INTESTINE

so greatly improved that the operation for relief of the cause of the obstruc-
tion could be undertaken with more leisure and deliberation. The area of
the colostomy wound containing- the gut was excised and the intestine lightly
clamped off. With considerable difficulty, the small gut was freed from ad-
hesions and bands throughout and traced down to the caecum and the large
gut from that point to the rectum. On account of the damaged condition of
the peritoneal coat from the old inflammatory process, the anastomosis was
done by invagination (see Fig. 8), after the method described last year by

Fig. 5 (Case 5). — Gangrenous intussusception. Twenty-two inches of ileum

resected.

ST. LUKE'S HOSPITAL REPORTS

Dr. Gibson in the report, rather than by the more usual one of end to end
or lateral anastomosis. This man has been seen within a fortnight and is
well.

Case 8.— M. H.( a woman 22 years of age, was admitted January 6, 1911.
She had been operated upon a year before for an appendicitis with abscess

Fig. 6 (Case 6). — Mesenteric thrombosis, veuous closure. Resection of nearly

two feet of gut.

SURGERY OF THE SMALL INTESTINE 61

and peritonitis at another hospital. Since that time she has been troubled
greatly with constipation, getting worse. She has had severe abdominal
pains accompanied with marked constipation at fairly frequent intervals.
For a week before entrance her bowels had not moved. Three days before
admission she was taken with unusually severe pain accompanied with per-
sistent vomiting. Her distention was great, the vomitus foul and geueral
condition bad.

Operation: A dense mass of adhesions occupied the pelvis and the right
lower quadrant of the abdomen. The exact site of occlusion could not be
determined in the time allowed for a safe conclusion of the operation. As
in the former case, an enterostomy was considered preferable to an imme-
diate anastomosis. A loop of ileum two feet from the caput was brought
into the median wound, and as in the last case, a rubber drain tube inserted
proximally. After several weeks of clearing out and drainage, an attempt
was made to separate adhesions and find the point of occlusion. The density
and extent of the matting together of the bowel made separation impossible,
and the only recourse left, to empty the small gut into the large, was ac-
complished by a direct implantation of the proximal end into the transverse
colon, the nearest available large gut free from adhesions. The distal end
was likewise implanted that there might be no excluded or occluded intes-
tine. It was impossible to resect this distal part on account of the iron-
clad nature of the adhesions, and at the time no other disposition seemed
possible. This patient was seen four months after her operation and de-
clared herself well and comfortable. She had gained greatly in weight and
appeared in perfect health.

Case 9.— Intestinal Obstruction from Enterolith: J. K., a man 72 years
of age, was admitted March 2, 1908. Four days before entering the hospital,
he was attacked with a dull grinding pain across the upper part of the
abdomen. He took cathartics without result, nor would enemas relieve him.
Vomiting occurred two days later, and on admission was of distinctly fecu-
lent character. It is of interest to note that the patient, a physician and an
intelligent man, asserts that he had no trouble of any sort with his bowels
prior to this attack. Two years before he had passed a number of gall-
stones, the size of distal joint of index finger, and which had facets. Before
their passage he had attacks of gall-stone colic.

Operation: Incision through the right rectus disclosed a collapsed large
gut with a distended small gut. On working back from the ileo-ca?cai junc-
tion a large, smooth, dark mass was found distending the lower part of
the jejunum. It could not be moved up or down. An incision opposite the
mesentery released a stone the size of a small hen's egg. There was no ul-
ceration of the mucosa of the intestine; there were no diverticula in which
the stone could have pocketed. The convalescence of this elderly patient was
uninterrupted.

ST. LUKE'S HOSPITAL REPORTS

Fig. 7 (Case 7).— Intestinal obstruction following suppurative appendi-
citis. Numerous and deqse adhesions. Enterostomy followed later by freeing
adhesions, use of sterile oil and anastomosis by invagination (see Fig. 8).

SURGERY OF THE SMALL INTESTINE

Fig. 8. — Anastomosis in case 7, by invagination.

ST. LUKE'S HOSPITAL REPORTS

Fig. 9 (Case 8). — Intestinal obstruction following suppurative appendicitis.
Dense adhesions, enterostomy, later implantation into colon (see Fig. 10).

SURGERY OF THE SMALL INTESTINE

Fig. 10 (Case 8). — Impossible to separate adhesions. Both distal end and
proximal implanted into nearest free colon (transverse).

ST. LUKE'S HOSPITAL REPORTS

Fig. 11 (Case 9).— Buterolith impacted in lower ileum. Complete obstruction.

SURGERY OF THE SMALL INTESTINE

Fig. 12 (Case 10). — Enterolith impacted in lower ileum. Complete obstruction.

ST. LUKE'S HOSPITAL REPORTS

Fig. 13 (Case 11). — Acute obstruction caused by augulated ileum adherent to
caseous mesenteric gland.

SURGERY OF THE SMALL INTESTINE GO

Case 10.— Intestinal Obstruction from Enterolith: A. H., a woman of 60
years, was admitted to the hospital April 5, 1908. She had been taken with
nausea and vomiting five days prior to her entrance. The vomiting was
continuous, and she could not retain food or medicine on her stomach. First
food, then bile, then feculent material came up. Vomiting gave relief. This pa-
tient says that she has never been jaundiced and that her bowels have
always been regular. Her general health has always been good. She has
had no serious illnesses in the past. She was very ill on entrance with
greatly distended abdomen and dry tongue.

Operation: Median incision. Large intestine collapsed and small dis-
tended. On working back from the caput cob, a dark mass the size of a
pullet's egg was found distending the gut about 18 inches from the ileo-caeeal
valve. The intestinal wall was very thin and distended, but it was possible
to push the stone up to a higher level where the thinning was not so marked,
and remove it through an enterotomy at that point where repair by suture
would be easier. As in the former case, there was no ulceration of the
intestinal mucosa, nor were there diverticula to be seen. Convalescence here
also was most happy. Both of these cases have been followed, and they
are apparently in excellent health to-day.

Case 11.— I. T., a small boy in his 9th year, was admitted April 24, 1907.
He had been well the earlier years of his life, but for some time before
present illness had had occasional abdominal cramps. He was taken three
days before admission with severe cramps in the abdomen and vomiting.
Bowels moved slightly during the interval before admission. The boy ap-
peared to be a well-nourished child. The abdomen was greatly distended
and very tender over the whole surface. Peristalsis could be easily seen.

Operation: Median Incision, umbilicus to pubes. Large gut collapsed.
Small gut distended and deeply injected. The cause of the obstruction wag
found to be an adhesion about one-quarter of an inch in diameter, extend-
ing from an enlarged old lymphatic gland, near the foot of the mesentery,
to the ileum two inches from the caput coll. The obstruction had been
caused by the angulation and constriction. The gut was viable and its re-
lease was accomplished by cutting the band. This patient made a rapid
recovery and has been seen several times since leaving the hospital.

SIMPLIFIED EQUIPMENT AND MANAGEMENT FOR THE
OPERATING ROOM.*

W. Scott Schley, M.D.

The natural tendency in matters relating to surgical operative
equipment is rather towards elaboration and addition, as new facts are
discovered and newer requirements develop in the steady, march of
progress. The endeavor to have every added essential and accessory
immediately to hand is the most fruitful source of complication and
elaboration, requiring a very constant attention and study to elimi-
nate and simplify, as the burden of paraphernalia becomes unneces-
sarily irksome, time-consuming and possibly wasteful.

In operative work a proper economy of time and labor should not
be lost sight of, especially when it results in greater good to the pa-
tient, greater surety and ease, and a greater saving of materials.
These things can best be accomplished by a safe and quick method
of handling gauzes, instruments and solutions, the ready accessibility
of everything needed, and excellent lighting, making it possible for
sterile individuals to conduct the entire work rapidly and without
danger of rendering themselves or the material unsterile at any
stage.

There is nearly always something in other plants and equipments
of actual or suggestive value that well repays time spent in study
and observation, for comparison with and often the elucidation of
problems at home. From time to time additions and changes in the
operative equipment at St. Luke's Hospital, New York City, have
been made whenever greater ease and surety of work and a greater
saving of time, materials and general labor to all could be gained.
These objects have never been lost sight of, and to-day the equip-
ment stands, I believe, second to none in simplicity and working ef-
ficiency. The constant endeavor of those interested in these things
has been towards elimination and simplification of existing material
and its concentration, rather than the addition of more: the perfection
of essentials and rejection of unessentials.

*Previoii8ly published.

Fig. 1. — Showing instrument sterilizer open. High-pres-
sure steam pipes under the flooring, and entering the sterilizer
from helow.

SIMPLIFIED EQUIPMENT FOR OPERATING ROOM 71

The general requirements, which have become recognized through
study, observation and experience, will first be mentioned, and then
spoken of more in detail.

The operating room should be of fair size and self-contained, the
necessary equipment being within the room itself or in its walls, to
the saving of many steps and the unnecessary passing of assistants
and nurses in and out during the progress of operative work. The
furniture can be so reduced and simplified that nothing but the oper-
ating table, instrument table, canisters for holding gauzes and dra-
peries and an electric towel heater occupy the free floor space ; hot
and cold water sterilizer or its taps, instrument and utensil sterilizers
and the few solution bottles being arranged along or even within re-
cesses in the walls. Instrument cases are best built in the walls with
glass doors flush with the wall, eliminating movable and obstructing
furniture and dust accumulations. If two operating rooms adjoin,
they can be accessible from either side. An excellent example of this
was seen at Sonnenburg's Clinic at the Moabit Hospital, Berlin.
Special solutions, anesthetics, hypodermatic solutions, etc., are best
arranged similarly. Instrument and utensil sterilizers should be
actuated by high pressure steam coil and should be opened by foot
pedal, enabling sterile assistants or nurses to operate them without
hand contamination or the necessity of calling others to aid. Stock
solution bottles (saline, alcohol and sublimate), and the hot and cold
sterile water taps should be also arranged for foot release. It is
possible by such means to cut down the personnel of the operating
staff, and especially to avoid the intermediary handling and exposure
of gauzes, drapery and instruments in transit from the sterilizer to
the operating table.

Natural lighting, as long recognized, should be from one side of
the room as well as from above. Artificial lighting is best accom-
plished by means of the newer indoor enclosed electric arc, both for
general illumination and for direct lighting above the table.

A means that will provide perfect protection for gauzes and
drapery and yet allow of instant accessibility was found in Europe
and brought to a high state of perfection by von Biselsburg, of Vienna,
in the canister container system. Gauzes are sterilized in closed metal
canisters and their air ports closed. They are then ready at any time
to be brought in and placed on the stands where the cover in a few
seconds is connected with the cover-elevating device worked by foot
lever. They are always handy, their contents are instantly accessible

72 ST. LUKE'S HOSPITAL REPORTS

and entirely protected and they can be renewed on their stands, when
empty, in a few seconds as cartridges in a gun. Experience has shown
to date no quicker and safer way of handling gauzes, towels and
drapery. Gauzes may be taken out in small amounts at a time in
anticipation of their need, by a nurse or assistant, and with the
gloved sterile hand or forceps. These containers were introduced in
St. Luke's Hospital in 1905 by Dr. H. H. M. Lyle, have amply proven
their worth and are used upon both surgical divisions.

The instrument sterilizer, in addition to being placed in the oper-
ating room, should not be too far from the instrument passer's table.
It should be a semi-automatic affair, opening by foot lever and clos-
ing noiselessly when the pressure of the foot is released. A high pres-
sure steam coil in the bottom will boil water more quickly than will
gas. The instruments should be placed in and sterilized in trays,
and passed from them to the operating table. The present instrument
was worked out by the author while abroad, and later made in this
country by one of the large manufacturing firms. This apparatus has
been placed in the amphitheater of the hospital and has worked with
efficiency for over three years. It is heated by steam coil from the high
pressure service of the operating and sterilizing rooms, and will boil
warm water in 3 minutes. It is placed upon the instrument passer's
side and but 8 feet from his table, so that he is enabled, unassisted,
to boil instruments between and during operations, without crossing
the path of any one, quickly and without contamination of hands or
instruments. This sterilizer is placed against the wall and does
not occupy the free floor space. The steam is under complete control
and the inlet valve can be turned by foot.

The instruments are placed in shallow copper trays that fit the
sterilizer and are put in one over the other. A slightly inturned
edge prevents telescoping and perforated bottoms allow the water to
drain off on lifting them out.

Through forethought in construction the amphitheater was pro-
vided with hot and cold sterile running water, the tanks being be-
hind the scenes, out of the way, and the taps leading through the
partition to within a few feet of the operating table. A utensil
sterilizer also actuated by high pressure steam and operated by foot
pedal, has been added and placed to the rear, where it is accessible
and allows the few basins and irrigators used to be boiled between or
during operations as necessary.

The operating table is simple and provides the different positions

Fig. 4. — Copper canisters t'<»r gauzes and draperies. Canister stand with mov-
able balance weight for cover.

Difriia"aiiMi,fi'y

■Sllll

liiiMi

-. T ;.- gg g._ -r5 k, - } £ ■ ■ 81 ■ ■ ■ M

wsvKssav
« a! m m m m m mm

Fig. 5. — Instrument trays. The larger ones have perforated bottoms, and the

smaller, for finer instruments, are perforated at the edges.

mmmmmmmui
•■■mill
■iiiiaiii

■■■••■laiBi wng

■■lUtii!

Fig. G. — A battery of canister containers, with towel heater and instrument

table.

SIMPLIFIED EQUIPMENT FOR OPERATING ROOM TS

quickly. The instrument table is a simple glass or metal top affair
with one shelf below and with a basin bracket on one leg. A table 40
x 20 inches and 4 feet in height is sufficiently large for general work.
These two articles of furniture need no elaboration beyond the pos-
sible addition of a removable stout wire bracket attached to one leg
to hold a basin of saline solution.

All solutions except the 10 per cent saline, 70 per cent alcohol and
1-8 bichlorid of mercury, have been banished from the operating
room, and these are contained in large stock bottles whose outpour is
regulated by foot pedal release, and which are placed against the
wall upon the nurse's side, about 8 feet from the operating table and
instantly accessible. The proper amount of saline solution is run
into the small basin or irrigator and sterile water of the desired tem-
perature is added from the wall taps. Saline or other solutions can
be made up in this way and reach the operating table in 10 seconds
without hand soiling. Irrigating stands and large irrigators are not
used; a 4-quart enameled metal container with 4 feet of tubing an-
swers all purposes, can be easily sterilized and is held by hand when
needed.

For artificial illumination the superiority of the electric arc over
the incandescent bulb, both for general and direct light, I believe
is fully apparent when once tried. It gives infinitely more and better
quality of light. Some of the better equipped European clinics have
adopted the system with excellent results. Abroad the lights are
sometimes arranged with upward reflection, which is the best plan
for general illumination where the walls do not exceed 12 feet in
height. In the amphitheater at the hospital, where greater height had
to be dealt with, it was necessary to find a lamp of suitable down-
ward reflection and diffusion. Such a lamp it was my fortune to find
in the newer indoor enclosed arc with small opalescent globe and
thin white porcelain reflector and diffuser above. This lamp is seen
in Figure 7, where two of these for general illumination take the places
of batteries of incandescent globes. After some experimentation with
the lights and shadows of the arc lamp, I devised the apparatus shown
herewith for 2 lights, with common reflector arranged 4^ feet be-
tween carbons, that will illuminate the whole table at once in addition
to the field of operation.

The small opalescent globe softens and diffuses the 1,200 or more
candle-power and with the superior regulating device of this lamp
upon a good circuit and with soft core carbons it is almost absolutely

74 ST. LUKE'S HOSPITAL REPORTS

without flicker. These arc lights are arranged as in incandescent
lighting, and use the same current (taking the 110 or 220 volt direct
or alternating, and from 3.5 to 5.5 amperes, according to require-
ment). They are best arranged upon different circuits to avoid the
possible chance of simultaneous extinguishment should anything hap-
pen to one circuit.

For miniature lamps, head lights, cystoscopes, motors, etc., several
ordinary wall taps have been placed within a few feet of the operating
table and electrical connection can be instantly made by the ordinary
push plug.

More and more it is found that elaborate equipment for general
operative work, whether of elaborate tables or special instrument
stands, is not required. In addition to the solution bottles upon the
nurse's side, there is only a small glass wall-shelf for the few sterile
basins and the irrigator.

Upon the First Division the patients are fully prepared in the
ward and are given only a light alcohol (70 per cent) rub on the
table as a final preparation after removal of the light sterile protec-
tive dressing. Elaborate and excessive drapery has been abolished
and a maximum of 2 sheets, over rubbers, and 4 towels answer for
the majority of cases.

In preparing such a room for work but one unsterile person is
necessary to bring in the 3 canisters and towel heater, place them on
the stands and connect the covers with the elevating device. The
instrument passer, before washing up, places the instruments in the
trays and puts them in the sterilizer. One nurse, before washing up,
places the few basins and the irrigator in the utensil sterilizer. The
operator, assistants and other nurses are in the meantime washing
up and dressing, and the patient is being anesthetized. Hot and cold
sterile water and the few solutions are always ready. The instrument
passer, after washing up, covers the top and shelf of the instrument
table with a few sterile towels from a canister, and removes his trays
and instruments from boiler to the table. A nurse, upon the nurse's
side, after washing up, covers the nurse's shelf with towels and the
small solution basins and irrigator are placed thereon. The unsterile
orderly or assistant places the suture and ligature containers on the
lower shelf of the instrument table and the instrument passer takes
his suture and ligature material, catgut, silk on spools and any other
material needed for one or two cases and places it in the folds of a
sterile towel or two. Any suture or ligature material left over, even

Fig. 7. — Type of stand for stock solution bottles, having foot
release.

Fig. 8. — Two lamps with common reflector, 4 feet 6 inches between
carbons. Apparatus over operating table. Almost complete elimination of
shadows is produced.

SIMPLIFIED EQUIPMENT FOR OPERATING ROOM 75

if contaminated, including the iodine catgut, can be easily and quickly
resterilized for subsequent days. Anything needed, not anticipated
in advance, is immediately accessible.

A perfect division of labor with simplification of apparatus allows
quicker handling of cases as well as celerity and ease in the prepa-
ration of the room, and a diminished number of helpers, if preferred.
All sterilized and necessary materials are accessible to sterile hands
and but one unsterile assistant is required to handle unsterile material,
to clean up between cases and do the heavier work. Dry sterile rub-
ber gloves are worn by all and are always accessible near the instru-
ment sterilizer in a container opening by foot pedal.

Such are the main features and outline of the scheme it has been
the endeavor to instal and perfect at St. Luke's.

The system works out to include in its personnel the undergraduate
nurses of the hospital, so necessary in the American plan of educating
and preparing them for future surgical usefulness in their private
and institutional work and in rounding out their education. Slight
modification of duties of the different members of the operating staff
are therefore undertaken from time to time.

The suggestions for some of the equipment were gathered at a
number of the clinics of the world, some of the most valuable from
the rooms of Eiselsburg, of Vienna ; Kocher, of Bern ; Sonnenburg, of
Berlin. Thought and experience have added from time to time new
features to a constant betterment, and through the liberal and pro-
gressive spirit of the Board of Managers and Superintendent these
changes have been quickly consummated.

Because many have been interested in this equipment, and have
adopted these ideas, and because of the inquiries received, it has
seemed of sufficient general interest and importance to merit this brief
article which, leaving the description of mechanical details to photo-
graphs, is meant to be suggestive rather than complete and exhaustive.

The canisters were made by one of the larger instrument firms
and have already been adopted in several hospitals, and recently for
naval use. The instrument sterilizer was made by another of the
larger firms and is now manufactured in various forms as regular
equipment.

EXTRUSION OF MEDULLARY BONE SPLINT.
W. Scott Schley, M.D.

J. S.. a man of 45 years of age, was admitted to the 1st Surgical Di-
vision May 27, 1911.

Three years before he had suffered a compound fracture of the left fe-
mur in the middle third. He was taken to a hospital, where an operation
was finally done, and after 7 months, he left with the wound completely
healed. Four months before he entered St Luke's, he noticed a swelling
on the anterior aspect of the left thigh. This broke down, opened, and left
a small, discharging wound. He suffered from the suppurating process and
had temperature and malaise. Two weeks before coming to the hospital,
another swelling appeared on the outer side of the leg in the old scar. This
was incised by his physician. Both sinuses led to bare bone at the same
point on the shaft. The left leg showed 3 inches shortening.

Operation.— Incision through old scar on the outer side of leg down to
the bone showed a hard white object projecting from the shaft (see Fig. 1).
It was thought to be a sequestrum, at first sight. A better view showed that
it was a bone tube, and by cutting about the shaft and rotating the tube, it
could be withdrawn.

The splint had not been absorbed, and had even preserved its surface
polish. It had finally acted as a foreign body and had been partly expelled.
It is of interest in connection with the operative treatment of fractures.

Fig. 1. — Bone splint working
toward surface. Sinus, discharg-
ing pus, leads to site.

TWO CASES OF STONE IN THE URETER.

W. Scott Schley, M.D.

Among the eases of kidney and ureter troubles the past year, upon
the 1st Surgical Division, there have been two of special interest;
one, because of the great severity of the subjective symptoms with
the minimum amount of damage, and the other because of the almost
total absence of subjective symptoms with great and extensive dam-
age to the kidney and ureter.

Case I.— J. O. B., male. Admitted June 21. Discharged July 23 last.
A year prior to entrance he was taken with an exceedingly severe pain in
the left flank. This pain extended down the left side into the testicle and
down the left thigh, and was characteristic in its sharp and cutting char-
acter. This condition was intermittent, hut he was never free enough from
it to return to work for over 2 months. There have been recurring attacks
up to the present time. On entrance, he had been having pain more or less
continuously for 2 weeks. He is said to have passed blood in the urine from
time to time. He was a well-built and nourished young man, with slight
rigidity on the left side of the abdomen and left flank without great tender-
ness.

Cystoscopy and catherization of the ureters, as well as a radiograph,
demonstrated a calculus in the lower part of the left ureter 3% to 4 inches
from the bladder. Little or no urine from affected side. Examination for
blood on entrance, neg.

Operation (Dr. Schley).— Transperitoneal ureterotomy. Abdomen opened
with 6-inch incision through the left rectus. Stone could be felt in the ureter.
Field of operation padded off and the peritoneum incised, when ureter could
be drawn up and opened (See Figs. 1 and 2). Stone removed and small
bougie passed to bladder and pelvis of kidney. Ureter closed with fine in-
terrupted silk stitches. Peritoneum over ureter closed, leaving a very fine
cigarette drain just through. Abdominal wound closed in usual way by
layer suture.

The convalescence in this case was absolutely uneventful and rapid.

Case II.— M. Z., female. Admitted April 4, 1911. Discharged May 10, 1911.
For tbe last 2 years the patient has had a dragging sensation in the right side
of the abdomen, but hardly amounting to pain. It has never been sufficiently
bad to prevent her following her occupation as cook. There is no history
whatever suggestive of attacks of renal colic and none positive of renal
derangement.

Fig. 1. — Peritoneum opened. Ureter, containing calculus, drawn out.

FiS- 2.— Peritoneum and ureter opened. Calculus tightly wedged in place.

STONE IN THE URETER

Fig- 3. — Large hydronephrotic kidney mass. Somewhat lower, and more
across median line than shown.

80 ST. LUKE'S HOSPITAL RBPORT9

She was a fairly well-nourished female of good color to skin and mucous
membranes. There was no rigidity of the abdominal muscles, and but slight
tenderness over the right side of abdomen. There was a large, tense,
elastic mass extending from the free border of the ribs to the pelvic brim
and across the median line (See Fig. 3). This mass was dull on percussion,
slightly movable, and not of especial tenderness on deep palpation. It pro-
duced a very appreciable distention of the abdomen. Vaginal examination
gave the sense of an indefinite mass high up on the right side. Colonic
inflation and the position of the mass left no doubt of the condition as a
kidney tumor. This patient's condition before entrance was diagnosed as
ovarian cyst and her reason for consulting a physician was as much because
of her increase in girth as because of the discomfort in the side.

Operation (Dr. Schley).— Incision through outer border of the right rectus.
Large, dark, elastic mass with colon running over upper part. Extended
from behind lower ribs to pelvis. The ureter was greatly dilated, to quite
an inch in diameter through greater part of its course. Condition plainly
one of hydronephrosis. Passing a bougie through opening in the ureter
demonstrated a stone about 2% inches from the bladder, but so rough and
embedded in the greatly thickened ureter that it could not be dislodged, and
a 2-stage operation was considered wiser and safer. The kidney, of which
but a mere shell of tissue remained, was removed and the ureter excised
to within a few inches of the stone. This patient made so perfect a con-
valescence and felt so well that she preferred to retain the calculus, and
operation for its removal was not insisted upon. She has been followed, and
remains in good health. Microscopic examination of a small remnant of
cortical tissue near the fundus showed swollen glomeruli and marked paren-
chymatous degeneration of the convoluted tubules. Radiograph showed the
calculus near the bladder (Fig. 4). Two photographs show the conditioa of
the kidney (Figs. 5 and 6).

Fig. 4. — Stone in lower part of right ureter.

Fig. 5. — Reduced picture of kidney exterior. Specimen
was put in strong formalin, without previous distention, and
great shrinkage resulted.

**^

Fig. 6. — Thin shell of cortex at upper pole can be seen. Typical
hydronephrosis of extreme degree.

TUBERCULOUS PERITONITIS SIMULATING RECURRING
ATTACKS OF APPENDICITIS.

W. Scott Schley, M.D.

H. Le V., a young man of 19 years, was admitted to the hospital De-
cember 27, 1911. His chief complaint was pain in the right lower quadrant
of the abdomen.

Family History.— Both parents alive and well.

Two years ago he had some cough and expectoration and was told that
he had trouble at the left apex. He left work, lived in the country, and
apparently recovered. About 8 months ago he began to be troubled with
stomach disturbances, gas and gurgling, but did not lose weight. Three
months before coming to the hospital, and while working, he was taken with
a severe epigastric pain, but managed to finish his work, and the pain had
gone by night. There was no nausea with the attack. Six weeks later
had a similar seizure, the pain lasting some 8 hours and extending from
epigastrium to right lower quadrant. He felt uneasy and tired before the
pain began. Two weeks before entrance he had his last attack, with pain
chiefly of the right lower quadrant. There was nausea and vomiting and
the duration 12 hours. He had been constipated prior to the attack. He
was seen by a physician at this time, and the diagnosis of appendicitis
made. He has had some soreness in the right lower quadrant since his
first attack, and said that he had occasional twinges of pain in the right side.

His general appearance was that of a well-nourished, well-muscled and
healthy-looking young man. In the chest a few suberepitant rales could be
heard at the right apex behind. Thorax expanded well and equally on both
sides, resonance good. Heart somewhat irregular, 56 per minute on exami-
nation. Sounds clear and strong. Slight blowing systolic murmur heard
all over chest, and loudest at apex. There was no rigidity to the abdomen
or mass felt. Slight tenderness existed in a small area just to right and
below umbilicus. Superficial glands were not appreciably enlarged, with the
possible exception of the right epitrochlear. His temperature on admission
was 973a, and on discharge 98. Beyond a slight reaction to 1004/5 following
operation, he -had no temperature at all. His pulse ran a fairly regular rate,
averaging in the seventies.

Operation.— Intermuscular appendix incision. Scattered over the peri-
toneal surfaces were numerous discrete pearly nodules varying in size from
a pin point to a pin head. They were more numerous in the mesentery of
the appendix than elsewhere, and became much more scattered as one left
that region. All the loops of ileum drawn down into the wound showed

8*2 ST. LUKE'S HOSPITAL REPORTS

tubercles. They were more numerous upou the visceral than upon the
parietal peritoneum. No adhesions could be demonstrated. The serous
surfaces were moist, but there was no fluid. The appendix lay below caput,
towards pelvic brim. It was but moderately congested, and had but a mod-
erate number of tubercles on the surface, (See Fig. 1.) The presence of so
many in the mesentery was thought to possibly indicate ulceration of the
mucosa, and it was removed. It lay free and there were no adhesions. Grossly,
the appendix showed only moderate thickening of its coats. The internal cali-
ber was even throughout, and there were no constrictions. It was empty. Sev-
eral hemorrhagic spots in the mucosa, without apparent ulceration, appeared.
They were on the side of the mesenteric attachment. The pathological re-
port shows: Chronic appendicitis. Tuberculous peri-appendicitis invading
the meso-appendir.

Fig. 1. — Tuberculous periappendicitis. Numerous tubercles in peritoneal,
investment of appendix and in its mesentery.

THE GATCH BED IN SURGICAL WORK.

W. Scott Schley, M.D.

For nearly a year, in the male surgical ward of the 1st Division,
we have been trying a bed that has proved a great success. In ad-
dition to the usual spring bed, it is intended to provide for an easy,
comfortable and secure sitting or semi-recumbent position. It has
served especially well in those abdominal cases for which elevated
posture is necessary to facilitate drainage, prevent dissemination of
exudates, or for other reasons. Its great advantage over the back-

Fig. 1. — Gatch bed in profile. Ratchet ou frame provides for a variety of
angles of elevation, both for back aud legs.

rests of various forms lies not only in the fact of the inclined planes
being integral with the bed itself, but in its taking care of the lower
extremity as well. This bed was devised by Dr. Gatch, of the Johns
Hopkins Hospital, and the first one was made up in that institution
about 2 years ago. The adjustable spring is now made up to fit any
single bed, and its usefulness is thereby greatly extended, as it can be

ST. LUKE'S HOSPITAL REPORTS

adapted to beds in a ward without changing their uniformity. The
uprights of the regular bed have also recently been fitted with sockets
for securing two levels for the mattress; a high surgical bed or a
lower convalescent bed. The ordinary ward mattress takes the angles
made by the elevation of the spring planes, and a comfortable curve
is the result that can be borne for long periods. (Figs. 1 and 2.)

Fig. 2. — Gatch bed, with dimensions in inches.

SUBPHRENIC ABSCESS COMPLICATING APPENDICITIS.*
John Douglas, M.D.

Subphrenic abscess occurs as a complication of acute appendicitis
in between .5 and 1 per cent of the cases, according to Ross (Journal
A. M. A., August 12, 1911), who has analyzed the reports of a large
number of statistics by Treves, Kelly and Hurdon, by Lance, and
also 3,891 cases of acute appendicitis occurring in the German Hos-
pital and Mary J. Drexel Home, Philadelphia, Pa. In the 31 cases
reported by him, there were 22 deaths. Of the 31 cases, from brief
history reports, it would appear that in 15 the abscess was situated
below the liver. In the remaining 16, where the pus was between the
liver and the diaphragm, or above the lower surface of the liver, there
were only 4 recoveries.

The following two quotations from Ross' article prompt the report
of this case with the X-ray photograph, illustrating its value as a means
of diagnosis : " It is to my mind a refinement of diagnosis at present
impracticable of accomplishment for any one to determine definitely
the variety of subphrenic abscess before operation. As will be seen
later, we are fortunate, indeed, always to diagnose even the existence
of a subphrenic abscess." Later on, he states: "Only the most care-
ful study of individual cases will give even an approach to correct
diagnosis. ' '

Grace S., aged 13. Seen in consultation, July 31, 1911. Her illness began
11 days before, witb an attack of severe vomiting, which lasted iy2 days, when
she began to have severe pain in the right side of the abdomen. The pain
was severe, and aching in character, continuous, not localized, and radiated
to the back and right shoulder. It was increased by respiration. The pain
had been gradually decreasing, and was now most marked over the lower
right chest, in the axillary line. She had fever (103° to 104° F.) every eve-
ning, but no chills. Has had some cough, but no expectoration. Was slightly
jaundiced for three or four days, but jaundice had disappeared when she
was seen by the writer. The bowels had moved every day.

♦Reprinted from "Surgery, Gynecology and Obstetrics."

86 ST. LUKE'S HOSPITAL REPORTS

Physical examination of the chest showed slightly diminished expansion
and breath sounds, slight dulness, and a few large, moist rales over the right
base.

There was no general abdominal rigidity or tenderness, but over the upper
right quadrant of the abdomen rigidity and tenderness were marked. A mass,
apparently the lower border of the liver, could be felt 2 inches below the
costal arch. This area, and just below it, were very tender. Percussion in
the right mammary line was flat from the fifth intercostal space down to the
edge of the mass. There was some tenderness in the right costo-vertebral
angle. The temperature was 103° F., pulse 140, respiration 30. The leucocyte
count was 25,000, with S8 per cent of polynuclear cells.

A diagnosis of high appendicular abscess was made, and she was referred
to St. Luke's Hospital for operation.

Operation. — An incision 3% inches long was made along the border of the
right rectus muscle, with its lower end about on a level with the umbilicus.
The appendix was found with its outer extremity almost sloughed away,
behind a high, undescended caecum, just underneath the liver. There was a
small amount of pus, with the characteristic odor of colon infection, well
walled off from the rest of the peritoneal cavity by adhesions and the omen-
tum, and limited above by the under surface of the liver. The appendix was
removed. The liver had been apparently displaced downward, and examina-
tion demonstrated adhesions between the diaphragm and the upper surface
of the right lobe. On separating these adhesions a considerable quantity
of bloody pus, smelling of colon infection, was discharged. A thick rubber
dam drain was passed up a distance of 12 cm. between the liver and dia-
phragm, and a counter drainage opening made in the loin. The final incision
was partly closed, and drained with a rubber dam drain.

For a week following the operation there was a profuse discharge of
bloody, purulent material, which gradually became less, but the patient con-
tinued to have an irregular temperature — up to 101° to 102° in the after-
noon— the cough became more troublesome, while the physical signs persisted.
It was believed that the subphrenic abscess was not draining, so to determine
this fact the X-ray shown in the illustration (Fig. 1) was taken. This
demonstrated very plainly that the diaphragm, above the liver, was pushed
upward almost to a point to the level of the eighth rib behind. So an anaes-
thetic was administered on August 11th, the eleventh day after operation, and a

'long, soft rubber tube, 1 cm. in diameter, was inserted, to replace the rubber

.dam, with a further evacuation of pus. The cavity was irrigated through this
rubber tube, and drainage was again profuse. On August 21st a second X-ray

•was taken, showing the diaphragm considerably lower; the tube was removed,
and again replaced by rubber dam. The temperature stayed down for four

•days, but on August 27th rose to 103° again.

Under light chloroform anaesthesia, the adhesion between the right lobe
of the liver and the diaphragm were broken up by the finger, inserted through
the incision in the loin, with the resulting escape of considerable pus. A
11 cm. rubber tube was introduced a distance of 12 cm., and the cavity, wbich
was well walled off, irrigated.

As the adhesions were quite dense, the question arose whether the dia-

Fig. 1. — Showing diaphragm displaced upward by abscess.

SUBPHRENIC ABSCESS COMPLICATING APPENDICITIS 87

pbragm had been perforated, with involvement of the pleural cavity, and a
third plate (Fig. 2) was taken, which demonstrated that the end of the tube
was below the diaphragm. The following day the temperature was normal,
and further recovery was uneventful.

It is also of interest in this case to note the presence of jaundice as
Besredka (quoted by Ross) states, as a means of differential diag-
nosis ''there is never jaundice in uncomplicated subphrenic ab-
scesses. ' '

The mortality of subphrenic abscess is about 33 per cent. It is
lower in children than in adults, probably because the large majority
of eases are due to appendicitis, while in adults a considerable num-
ber of cases are caused by perforation of the stomach or duodenum.
Intrathoracic complications have been estimated to be present in 66
per cent of the cases. This is probably too high, as Ross states that of
21 cases coming to autopsy, only 5 showed purulent pleurisy and 1 a
pleurisy with exudate not purulent. Intraperitoneal abscesses, which
are more frequent, are more apt to perforate the diaphragm than
extraperitoneal.

The diagnosis is difficult. In addition to the quotation from Ross
given above, Reeve (American Practice of Surgery, Vol. 7, 1910, p.
487) says: "There are no certain physical signs by which in all cases
collections of fluids above the diaphragm can be distinguished from
those situated below this structure. ' ' Also, " It is not possible to make
a differential diagnosis between a subphrenic abscess and an encap-
sulated basal empyema." He advises, however, the use of the Roent-
gen rays, and mentions a case in which Monro demonstrated the
presence of subphrenic abscess by the X-ray after rib resection and
several punctures had failed. Although writers on the subject allude
to the unreliability of the physical signs, this case of Monro's was
the only one found by the writer in which the X-ray as a means of
diagnosis was made use of.

The physical signs usually found are dulness or flatness, dimin-
ished breath and voice sounds and vocal fremitus, with the presence
of rales over the base of the lung, the area of dulness being char-
acterized by being convex upward and not changing its area with a
change in the position of the patient. In those cases where gas is
present in the abscess cavity there are 3 zones of different resonance
on percussion. The normal pulmonary resonance above, a zone of
tympanic resonance caused by the gas, below this, and the area of
flatness caused by the pus, which is continuous on the right side with

88 ST. LUKE'S HOSPITAL REPORTS

the liver flatness. When there is also fluid in the pleural cavity there
will be 4 percussion zones, an area of flatness intervening between
the normal pulmonary tympany and the tympanitic zone caused by
the gas. In right-sided subphrenic abscess the liver is apt to be more
or less displaced downward.

It is recommended by all writers on the subject that careful ex-
ploration with the aspirating needle be made in all questionable cases
— and the diagnosis from the physical signs being so uncertain, makes
the majority of cases questionable. The certainty with which the situ-
ation and size of the abscess is shown in the accompanying radio-
graphs demonstrates their great value in diagnosis, although probably
they would not be so plain in a heavy adult as in a child.

It is believed that had a radiograph been taken in the following
case, the diagnosis might have been made, as was impossible from the
physical signs, and the life of the patient perhaps saved.

M. P., boy, aged 8. Seen in consultation with Dr. J. F. Bell, of Engle-
wood, N. J., Nov. 7, 1910. Patient had a gangrenous appendix and general
peritonitis, a large amount of thin pus being present in the general peritoneal
cavity, as was demonstrated by operation at the Englewood Hospital, three
hours after being seen by the writer. Patient reacted well from the anaes-
thetic, and for ten days temperature was between 99° F. and 100° F., and
bowels moved daily. Patient, however, did not look well, and on the fourth
day complained of pain in the left chest Examination showed pleuritic
friction rales over left base, which disappeared two days later, although he
still complained of pain in left chest and abdomen, which pains continued
irregularly for several days. On the tenth day after the operation he still
complained of these pains, as well as pain in the throat and ears, and the
temperature rose to 104.3° F., pulse 180. Careful, complete examination, as
well as exploration of the wound, was negative. This examination was veri-
fied on the following (the twelfth) day by two additional physicians, who
examined him in consultation. His leucocyte count was 21,400, with 79 per
cent of polynuclear cells. On Nov. 19th, the morning of the twelfth day, after
a period of apparent relief and temperature subsidence, he suddenly developed
at 8 a.m., a harassing cough, with scant mucous expectoration. At 9 a.m. there
occurred an enormous purulent expectoration, which became bloody as edema
developed, with cyanosis, evidently the rupture of an abscess into the lung. This
expectoration showed the presence of streptococci and some diplococci and a
bacillus, apparently the bacillus coli communis. The respiration became more
shallow, cyanosis was marked, and the pulse ran up to 204. In about an hour
and a quarter the patient died, apparently drowned by the pus in the lung.

An autopsy in this case was refused, and while it is possible that
the abscess which ruptured might have been in the lung or mediasti-
num, there were certainly no physical signs indicating its presence

Fig. 2. — Showing tube in abscess cavity, between liver and diaphragm.

Fig. 3. — Showing condition on discharge.

SUBPHRENIC ABSCESS COMPLICATING APPENDICITIS 89

except the friction rales over the left base for a few days, and no sub-
jective symptoms except pain in the left chest and shoulder. It is,
therefore, believed that this was a subphrenic abscess which ruptured
through the diaphragm into the lung, which, in the absence of physi-
cal signs, might have been demonstrated by the X-ray in time to save
the patient.

Treatment of subphrenic abscess consists of evacuation of the pus,
either by means of an incision in the loin or abdomen, after dealing
with the primary cause, and drainage with a rubber tube. This
method was followed in the first case reported, and was satisfactory
as long as the drainage tube was kept in place.

In abscess high up under the diaphragm, more satisfactory drainage
is obtained by the subpleural route, the tenth rib being resected in the
mid axillary line and the abscess opened through the diaphragm be-
low the pleural reflection.

If the incision opens the pleural cavity (trans-pleural route), the
pleura above should be closed, and the diaphragm sutured to the in-
tercostal muscles in the incision, to close off the cavity above before
opening the abscess, which is then drained with a large rubber tube.

FIVE CASES OF ESOPHAGEAL OBSTRUCTION FROM
THREE DIFFERENT CAUSES.

Nathan W. Green, M.D.

During the past eight months there have occurred on the ser-
vice of Dr. Robert Abbe (Surgical Division A) five cases of ob-
struction of the esophagus from three different causes. The first
was in a child of 2 years, due to a foreign body which had lodged
in the lower part, just above the diaphragmatic opening. The next
two were also in children, one of 3, and the other of Sy2 years, due
to the drinking of caustic fluids which had been carelessly left about.
These were practically impermeable strictures except to small amounts
of fluid. The last 2 cases were due to cancer, one situated 10y2 inches
from the upper alveolar border, and the other at the cardiac extremity
of the esophagus.

Brief histories of these cases follow :

OBSTRUCTION OF THE ESOPHAGUS FROM A STEEL BALL CAUSING A BALL VALVE.

Surgical No. 85,611.— J. G., 2 years old, was admitted to the service of
Dr. Robert Abbe (Surgical Division A) May 20, 1911. He was previously
a normal, healthy baby. For twenty-four hours before admission, he had
been unable to retain food. Although he appeared hungry, he expelled
everything a few minutes after eating. There was no blood and no
fever nor chill. For the three or four hours previous to admission, he had
refused both solids and liquids. He had not cried, nor did he have severe
pain or discomfort.

On examination he appeared restless and anxious. His mouth and tongue
were clean. Skin and mucous membranes clear. There were no rashes. I lis
heart and lungs were normal. There was no distention, no tenderness nor
rigidity of the abdomen. No mass was felt, nor localized tenderness in any
part of the body. The child vomited everything given him as soon as the
smallest quantity was taken. There was obstruction to the passage of food.
The child could not swallow water. In the evening of the day of admission
(May 20th), he vomited a small quantity of brownish fluid tinged with blood.
He was taken to the operating room shortly after, and an instrument was
passed about ten inches, but no metal nor stone object could be felt.

Fig. 1. — This picture shows steel ball at cardiac end of the esophagus before

its displacement.

Fig. 2. — X-ray, showing steel ball displaced into stomach, with coin
catcher at its side. This picture has been reversed in printing. A. — Picture
of steel ball, % inch in diameter, which caused esophageal obstruction.

ESOPHAGEAL OBSTRUCTION 91

An X-ray was taken on the 21st, showing an object opposite the 8th rib,
round and looking like a button. Fig. 1.

On the 22d, he was again taken to the operating room, and the esoph-
agoscope was passed under ether with the aid of vision. The entire mucosa
of the esophagus looked healthy, but no definite foreign body could be seen.
At the end of the tube there was, however, a dark spot, but this was not
clearly defined. The esophagoscope was withdrawn and a coin-catcher thrust
into the stomach. An X-ray was taken with this instrument in place, and
showed that the foreign body had been displaced, and now lay in the stomach,
below the diaphragm. Fig. 2.

The night following this treatment the child did not vomit, nor did he
vomit since that time while in the hospital.

On May 26th he passed a large semi-formed stool "containing a marble."
This marble proved to be a steel ball such as is used in ball bearings of
motor cars. Fig. 2A. This had acted at the cardiac end of the esophagus.
as a ball for a ball valve, and had absolutely prevented his swallowing.

On June 1st he was discharged in good condition.

TWO CASES OF STRICTURE OF THE ESOPHAGUS FOLLOWING THE INGESTION OF A

CAUSTIC FLUID.

Surgical No. 86,880.— C. D., 3 years old, was admitted to the service of
Division A, September 12, 1911, with the history of having swallowed some
concentrated lye in April, 1910. For a short time after this he was able to
swallow solid food, but gradually obstruction increased, and everything solid
would be regurgitated immediately after taking. By feeding with thin
broths and milk, he had been kept alive.

On admission he was thin, pale and delicate, with some involvement of
the right lung. His heart and other viscera were normal, with the excep-
tion of an obstruction of the esophagus, impermeable except to small amounts
of fluids.

Two days after admission, a gastrostomy was performed by Dr. Schley,
and through this his nourishment was given until his condition sufficiently
improved to warrant further interference. With the co-operation of Dr. L. T.
Le Wald, it was possible to obtain good X-ray pictures of his esophageal
condition. Fig. 3.

On the 3d of November he was taken to the operating room, and by the
aid of the esophagoscope a filiform bougie was passed through the stricture
into the stomach. This was followed by a silk string, and the esophagus
was then dilated by means of the Abbe string cutting method1 * * to about
a 20 French bougie. The next day the patient retained the water given him
by mouth.

On the 6th of November he was again X-rayed, and on the 10th still
another picture was obtained, after which he went to the operating room for

]G. Gottstein, Keen's Surgery, 1910, vol. iii, p. 808.
3R. Abbe, N. Y. Med. Record, 1893, Nr. 25.
3R. Abbe, Ann. of Surg., 1893, vol. xii.

92 ST. LUKE'S HOSPITAL REPORTS

a second string cutting operation. The esophagoscope was introduced about
6 inches to the top of the first stricture, a small bougie then introduced
through the constriction into the stomach, and to it was tied a silk string.
The operation of the previous week was repeated until a number 34 French
bougie was passed into the stomach. An attempt was made before passing
this bougie to pass a bougie & Boule. This engaged its tip at the lower
stricture, but it could not be forced through even with the aid of the string-
sawing.*

On November 17th and 18th, the note is made that an 8-oz. feeding was
taken by mouth, and he retained his nourishment. A number 28 bougie has
since been passed twice a week for a number of weeks, and the patient now
takes the greater part of his nourishment by mouth.5

Highest temperature after operation was 102 3-5°, and highest pulse rate
160°.

Surgical No. 87,688. — D. B., 3% years old, was referred by Dr. Withington,
of Pittsfield, Mass., to the service of Dr. Robert Abbe, Division A, and was
admitted November 26, 1911.

About 9 months previous to admission, the child swallowed some potash
used for cleaning. Prom that time there was a constantly increasing diffi-
culty in swallowing. Finally, everything taken into the mouth was regurgi-
tated. Upon examination, she was found weak, greatly emaciated and im-
passive. Heart and lungs normal. By X-ray examination (Dr. Le Wald),
with the aid of bismuth, a distention of the upper part of the esophagus
with an almost complete obliteration of the remainder was shown. Fig. 4.

On November 27th a gastrostomy was performed under ether and a tube
left in place. Feedings of fluids were begun at once through this tube.

On December 22d, by aid of the esophagoscope, and impossible without it,
a Aliform bougie was passed through the stricture as in the previous case.
This was followed by a silk string, and the string cutting operation was
performed by Dr. Abbe. This was continued until the esophagus would per-
mit of the passage of a number 30 French bougie. After a few days, a num-
ber 28 bougie was passed every week, and latterly twice a week.

The patient then took and retained almost all of her food by mouth. On
January 7th she had not had any gastrostomy feeding for 10 days. On the
31st she weighed 31 lbs. 4 ozs., a gain of 12 pounds. The gastrostomy
wound was closed, and all food was taken and retained by mouth."

Highest post-operative temperature, 101°; highest pulse rate, 120°.

TWO CASES OF MALIGNANT STRICTURE OF THE ESOPHAGUS.

Surgical No. 87,414.— Mrs. I. A., 54 years old, Russian, and a widow, was
admitted to the service of Dr. Robert Abbe (Surgical Division A), on

*It was interesting to note that the distance from the upper teeth to the
cardiac opening, by palpation with the index finger in the stomach, was
precisely 10y2 inches; in this child 37 inches long.

5On May 1, 1912, he had gained several pounds, and takes all his nourish-
ment by mouth, and has a No. 34 F. bougie passed once in 7 to 10 days.

•She now weighs 37 pounds and 4 ounces, April 15th.

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ESOPHAGEAL OBSTRUCTION 93

October 31, 1911. Her chief complaint was inability to swallow. About
six months ago she first noticed this difficulty, which was limited chiefly
to solid food. She had grown thin, was hungry, but could not eat. She
had no pain, with the exception that she had feeling of discomfort when
a piece of food lodged in her esophagus. Neither her past nor her present
history had salient points. Her family history was negative. Upon her
admission she appeared to be a poorly nourished woman, chronically ill.
Upon attempts to swallow, food regurgitated frequently. Her lungs were
clear, heart slightly enlarged, her abdomen soft and relaxed, with no
tenderness nor masses.

Her liver was two inches below costal margin in middle line. There was
no tenderness. Examination of her esophagus showed some obstruction.
A gastrostomy was done on November 3d, by Dr. Abbe, under local anaesthesia,
and a tube introduced, and by means of this the necessary feedings were
carried on.

Examination of the esophagus by bougies showed the presence of a stric-
ture 8 mm. in diameter and 10y2 inches from the upper incisor border.

An X-ray and bismuth picture of the stricture was taken with the as-
sistance of Dr. Le Wald. The lower end of the esophagus was plugged by
pulling up through the gastrostomy opening the ball of a bougie a Boule
upon a stout silk thread. The patient was then directed to swallow 2 ozs.
of bismuth sub-carbonate suspended in a fermented milk product, and at
once the X-ray was taken. The result is shown in the accompanying
picture (Fig. 5). The whole clinical picture was one of malignant disease,
but it was impossible to confirm this by a pathological section.

After some dilatation of the stricture with the appropriate bougies and
the string sawing method, a lead capsule containing 100 mg. of radium was
introduced by Dr. Abbe and left there for six hours. After this procedure
the stricture was dilated with a bougie once a week. She was shortly able
to swallow with comfort. Upon her discharge from the hospital, Decem-
ber 18th, although it was not possible to hope for a cure, she was much
improved. She said she could swallow "everything," and certainly there
was a great amelioration of her symptoms. She has returned once a week
to the hospital for observation.

Surgical No. 88,040.— Mrs. L. L., aged 59. a widow, was admitted to the
service of Dr. Abbe (Surgical Division A), on December 29, 1911. Her chief
complaint was inability to swallow. About a year previous to admission,
she began to notice that food other than soft food was vomited at once.
The beginning was gradual, but the condition grew steadily worse, so that
on admission all foods were regurgitated. There was discomfort, but no
accompanying pain. Her past history was good and her family history
negative. Upon examination her viscera appeared to be normal, with the
exception of her esophageal and esophago-gastric region. In her esophagus
a bougie passed but 13% inches and then met with obstruction. (She was
rather a short woman and this distance proved to be nearly the length of
her esophagus, as was shown later at operation.)

An X-ray and bismuth picture of the esophagus and stomach by Dr. Le

94 ST. LUKE'S HOSPITAL REPORTS

Wald showed a stricture at the cardiac end of the esophagus (Fig. 6). The
diagnosis of carcinoma of this region was made. It was confirmed at the
operation by Dr. Abbe a few days later. A gastrostomy was performed, and
a more or less annular carcinoma was demonstrated.

Fig. 5. — This picture shows the dilated portion of the esophagus above
the stricture (A), which in this case presents the appearance of malignancy.
Before taking this picture the esophagus was plugged by pulling up through
the gastrostomy oj ening the ball of a bougie a Boule. The patient was then
directed to swallow the bismuth mixture, and the X-ray was taken. The
position has been reversed in printing. The stricture and the lumen of the
esophagus have been outlined to facilitate interpretation.

Fig. (J. — This picture shows a malignant stricture (A) at the cardiac
end of the esophagus. The esophagus is seen dilated above it, and the
stomach is also seen containing bismuth below it. Contour of the esophagus
has been outlined to facilitate interpretation. The tumor mass is indicated
by the dotted line.

THREE CASES OF ILEO-COLIC INTUSSUSCEPTION WITH

REDUCTION AND ANCHORAGE BY MEANS OF THE

APPENDIX— TWO RECOVERIES.

Nathan W. Green, M.D.

Since April, 1911, there have occurred on the surgical service of
Dr. Abbe, Division A, three cases of acute intestinal intussusception.
All three came to operation. Two of them recovered. Two of these
cases were sent in early, one had lasted a longer time. The histories
and method of dealing with the intussusception may serve to promote
discussion, and may be of interest.

Surgical No. 85,972.— J. H., 6 months old, was admitted to the service of
Dr. Robert Abbe, Division A, June 19, 1911. For 21 hours previous to
admission, his mother noticed he was very cross, and would gag and scream
with pain. He refused to nurse, and would not take water. At 5 o'clock
in the morning of the day of admission, his mother noticed a bloody stool.
Frequently thereafter this was repeated. At 8 o'clock he began to vomit
light yellow material. The family physician was called, and sent the infant
directly to the hospital. He arrived at 1 o'clock.

Upon examination, a typical sausage-shaped tumor was found extending
across the abdomen. By rectal examination, the tip of the intussusceptum
could be felt presenting the feel of a "cervix." The child was operated upon
at 3 o'clock in the afternoon.

Operation (Dr. Green).— A median incision was made from the umbilicus
to the pubis. The transverse colon was found distended and bluish, and the
ileum was seen passing into it. This sausage-shaped "tumor" extended
down to the rectum. By gentle squeezing and traction, the intussusception
was entirely reduced. There was no lack of lustre, nor was there any at-
tempt at adhesion formation. Some means for preventing its recurrence was
looked for, and the appendix, presenting itself, was drawn through a small
slit in the iliac region, where it was anchored. Irrigation with salt solu-
tion was performed through it. The median wound was closed in layers.
The appendix sloughed off in two days and both wounds healed uneventfully,
leaving no sinus.

The patient was discharged cured July 5, 1911, eighteen days after
operation.

Surgical No. 86,746.— G. A. W., 8 months old, was admitted to the service
of Dr. Robert Abbe (Division A), on the 30th of August, 1911. The chief

96 ST. LUKE'S HOSPITAL REPORTS

complaint was "a prolapse of the rectum." His illness began 3 months
previous to admission, when what appeared to be a small piece of rectal
mucosa protruded from the anal ring. There was no vomiting nor passage
of blood. The "prolapse," which was at first small, gradually became larger.
It could be apparently reduced. Later the stools contained mucus and much
blood, still there was no vomiting nor visible distress. On admission, the
child vomited once, but did not look ill.

Physical examination showed no rigidity nor tenderness of the abdomen.
On the left side, extending from the brim of the pelvis to the left costal
border, there was a hard sausage-shaped mass which was not tender. This
was best felt when the "prolapse" was reduced. Protruding from the anus
there was a large sausage-shaped mass consisting of bowel. The tissue was
quite red and bled easily on handling. At the end of the mass there were
two openings, one of which was blind, but admitted a probe for 2 inches,
the other admitted a catheter indefinitely. This entire mass was easily
reducible just within the sphincter ani, but came out immediately upon re-
laxing pressure.

On rectal examination, a firm ring could be felt as far as the finger
reached, and the ring was much enlarged.

The child was operated upon the afternoon of September the 1st.

Operation (Dr. Green).— Through a median incision, the lower part of the
ileum, the caecum with appendix and ascending colon were found intus-
suscepted into the transverse and descending colon to an extent sufficient to
allow the ileo-csecal valve and the mouth of the appendix to present at the
tip of the prolapsed tumor 5 inches outside of the anus (see picture). With
gentle traction and pressure below the intussuscepted gut, it was quite easily
reduced and found in a good and healthy condition. The appendix was
identified and carried through a small stab wound made in the abdominal
wall just above and in front of the anterior superior spine of the ilium. It
was anchored here and the main wound closed. The child returned to the
ward in fairly good condition, but at 11 o'clock that evening he suddenly
became worse, and died ten minutes later.

Surgical No. 87,792.— M. H., 4 months old, was admitted to the service of
Dr. Abbe, Division A, on December 6, 1911. In the early morning of
the day of admission, the mother noticed that the child was restless, and
refused to nurse. Five hours later it passed a bloody stool. The mother
then sent for her family physician, who came that afternoon and sent the
child immediately to the hospital. Upon examination, the patient presented
the appearance of a fat, healthy baby. A typical sausage-shaped swelling
existed, extending transversely across the abdomen just below the umbilicus.
The diagnosis of an acute intussusception was made and at 5 o'clock in the
afternoon she was operated upon.

Operation (Dr. Green).— Through a median incision extending from the
umbilicus to the pubis, the bowel was reduced by careful squeezing with one
band and traction with the other. The intussusceptum proved to be the
appendix, caput coli ileum and ascending colon in the order named. The
Intussuscipiens was the transverse colon. There was no evidence of any

Fig. 1. — Ileo-colic intussusception, showing protrusion of tumor, with ileo-
cecal valve at the tip.

Fig. 2. — Another view ot protruding ileo-colic intussusception in Case. 2.

ILEOCOLIC INTUSSUSCEPTION 97

tendency to adhesion formation, nor was any lymph thrown out. Through
a stab wound in the right iliac fossa the appendix was drawn out, and its
mesentery and serosa anchored to the peritoneum, the appendix being placed
between two wipes. The median wound was closed, using one suture for
the peritoneum and closing the remaining layers with through and through
silkworm gut.

The appendix sloughed away on the 5th day. The stump was closed by
touching it from time to time with silver nitrite, and 4 weeks after operation
the patient was discharged cured.

The child was chiefly breast-fed, after the operation, with the addition
of a little extra feeding at the suggestion of Dr. Charles F. Collins, who
kindly regulated the post-operative diet for a week.

MESENTERIC THROMBOSIS WITH RESECTION OF SIX
FEET OF SMALL INTESTINE— RECOVERY.

Nathan W. Green, M.D.

Surgical No. 85978.— W. A. H., American, school teacher, 43 years old,
was admitted to the service of Surgical Division A, on the 19th of June,
1911. Her family history recorded the death of three brothers and one
sister from tuberculosis. Two sisters were living and well. Her previous
history was good, and she has had two children, the last eleven years ago.
Both were well. One week previous to her admission, she ate something
at a restaurant to which she attributed a diarrhoea, with cramps, which
lasted two days in spite of castor oil (her elder boy, 14 years old, was also
ill after eating the same). Three days previous to admission she passed,
without accompanying pain, a black stool. After that she felt well until
the morning of the day of admission, when at three o'clock she was awak-
ened by a severe pain one inch to the left of the umbilicus. The pain did
not change its position but became steadily worse. She then took an enema
with but slight result, and collapsed. She had nausea, and after medication
she vomited. The pain was so severe that a hypodermatic injection of mor-
phine was required. Her physician, Dr. E. J. Richardson, came in the after-
noon, and at once sent her to the hospital. The appearance was that of in-
testinal obstruction. On admission, her temperature was 99° F., pulse 106°,
respiration 28. She appeared severely and acutely ill. Her abdomen was
somewhat distended, with acute tenderness all over, but most severe near the
midline. The distension was symmetrical, percussion tympanitic, but no
mass was felt. She was operated upon 16 hours after her initial pain.

Operation (Dr. Green). — Resection of 5 feet 9 inches of ileum with end
to end anastomosis with a Murphy button. A median incision was made,
and on opening the peritoneal cavity, a litre of blood-stained fluid drained
off. Lying more or less transversely from the left iliac-fossa to the ileo-
cecal region was a coil of gut V/2 feet which was of a reddish-black
color, with 4 feet of a dark red color. There was no lymph exudate observ-
able. The intestinal border of the mesenteric fan attached to the impaired
gut was thickened, red and dusky. There was no angulation nor volvulus.
The affected portion of gut, together with the thickened part of the mesen-
tery, was cut away about 4 inches each side of the line of demarkation.
But as there was not satisfactory bleeding from the remaining ends, more
was removed until sharp arterial bleeding was encountered. The mesentery
was ligated with an interrupted chain ligature, and the ends of the gut were

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a.m}oij — v ■Suuui.kI m pasaaAaj uaaq sisq ean;oid stqj, "apis sh ;u .laqojuo
nioo iuiav 'qo^rao^s opn peo'Btdsip qBq [99}s SniMoqs "a'iu-x — "S 'Sij

MESENTERIC THROMBOSIS 99

united with a Murphy Button reinforced by a Cushing Stitch. The peri-
toneum was washed with a Blake Tube. Drainage to the site of anasto-
mosis was instituted and the wound closed with, through and through, silk
worm gut sutures.

As deliberation in testing the ends of the remaining gut was used before
anastomosis, the time of the operation lasted nearly an hour. The first day
after operation her temperature rose to 100 4-5° F., pulse, 156; respiration, 28.
Her highest post-operative temperature was 102 2-5 on the 14th day after
operation, and was due to an accumulation of pus which then escaped
through the drainage sinus. She had an intercurrent apical bronchitis, of
rather severe type, and her sinus discharged for some weeks. An X-ray
taken July 18, 1911, to locate the Murphy button, showed it in the pelvis
(Fig. 1). It passed a few days later.

The patient has gained 35 pounds since her discharge from the hospital
on August 29, 1911, and has been for several months discharging her duties
as a teacher. She reported, on February 1st, that she was as well as she
ever was.1

The section of intestine (Fig. 2), when freshly removed, measured 5 feet
9 inches, without traction upon it. Later, when it was received in the Path-
ological Department, the length was reported as 2y2 meters. The pathological
report is as follows : "Specimen consists of 2M> meters of small intestine,
with mesentery attached. The diameter of the bowel is about normal. The
greater portion is of a purplish-red color, and the surface has lost its normal
gloss. Ten centimeters from the anterior end is a definite line of demarka-
tion, on the proximal side of which the intestine appears normal. Imme-
diately beyond this point, it assumes a dark-colored appearance, which grad-
ually becomes less marked. At a point about 50 centimeters from the distal
end is a less distinct line of demarkation, but even beyond this the intestine
is much congested. The mesentery contains much fat, and the veins are
distinctly dilated.

"Microscopical examination of a section taken from near the root of the
mesentery shows a large vein occluded by a thrombus, in which are a num-
ber of fibro blasts indicating beginning organization. There is some hemor-
rhage into the areolar tissue, but no marked inflammatory reaction. A sec-
tion of the mesentery, made nearer the intestine, shows a smaller vein with
a thrombus attached to its wall on one side, which does not, however, com-
pletely block the vessel, and shows no signs of organization. The tissues
about the vessel contain many red blood cells and a few leucocytes. In
other areas, both arteries and veins are free from thrombi.

"A section of the intestinal wall shows no remains of epithelial lining.
The villi and muscularis are densely packed with blood cells, which almost
completely hide the connective tissue framework and the muscle. The nuclei
of the muscle and connective tissue cells stain very faintly. The small
blood-vessels beneath the peritoneum are free from thrombi."

*For the first two or three months after her resection she suffered from a
diarrhoea, or, rather, a frequency of defecation. This has corrected itself, and
now she is normal In this respect

100 ST. LUKE'S HOSPITAL REPORTS

The striking appearance at operation, the lack of both arterial and
venous bleeding on sectioning the gut and its mesentery and the find-
ings in the Pathological Eeport all warrant the diagnosis of Mesen-
teric Thrombosis. The clinical picture was almost a facsimile of Dr.
W. S. Schley's case, reported before the New York Surgical Society
in 1911, and which is on record in the Medical and Surgical Reports
of St. Luke's Hospital for 1910.

PAPILLOMA OF THE BLADDER TREATED BY EXCISION-
RECURRENCE TREATED WITH RADIUM AND THE
HIGH FREQUENCY CURRENT.

Henry G. Bugbee, M.D.

Prior to 1910, tumors of the bladder were treated by one method —
excision. In the Journal of the American Medical Association for May
28, 1910, Dr. Edwin Beer, of New York, described a new method of
treating papillomata of the bladder by the high frequency current.
At that time he reported 2 cases so treated with excellent result.

Since then, Keyes, in the American Journal of Surgery, July, 1910 ;
Buerger and Wolborst, New York Medical Journal, October 27, 1910,
and McCarthy, have reported cases which have confirmed Beer's ob-
servations.

Beer's second report, Annals of Surgery, August, 1911, gives a
more detailed account of his early cases, and he adds 3 more. He
comments as follows: ''From all of these observations (references
above), based on the application of the high frequency treatment as
used in some 38 papillary growths, it must be evident to the most
sceptical that in this new method we have raised a mighty rival to
the older suprapubic and to the transperitoneal and operative cysto-
scopic methods. I believe it will supplant previous methods, because
of its greater simplicity and its great effectiveness."

The case which I wish to report is that of a patient, 56 years of
age, who has been under the care of Dr. Robert Abbe since 1903, and
which I have had the pleasure of studying in conjunction with him,
for the past 2 months.

The record of the case is as follows:

There is nothing of note in the patient's history until 1903. He had
always enjoyed good health, was of large frame, well nourished. Eight years
ago he began to notice a slight irritation in the bladder and a faint, bloody
tinge to the urine. Urination became more frequent, was accompanied by
slight burning, but no pain or actual distress, and the stream had good
volume and force. An X-ray examination was made with negative result.

This condition prevailed until July, 1905, when a cystoscopic examination

101

102 ST. LUKE'S HOSPITAL REPORTS

by Dr. Abbe revealed a papilloma of the bladder. The growth was benign,
villous, pedunculated, the size of a hen's egg, located above and slightly
posterior to the right ureter in the Bas-fond. This Dr. Abbe removed
through a suprapubic opening. Not only was the growth removed, but a
wide excision of the bladder mucous membrane made about the pedicle.
The convalescence was rapid, the wound closing at once, and the patient
was well until 1907, when blood again appeared in the urine. Cystoscopy
revealed a recurrence of the growth at its former site, i.e., above and pos-
terior to the right ureteral orifice. This recurrence was a tumor of the same
characteristics as the original growth, but smaller (about the size of a wal-
nut). An application of a radium tube, bound to a probe, was made to
the growth through a direct cystoscope, by Dr. Abbe and Dr. F. Tilden
Brown. The tumor disappeared rapidly and the patient was free from sym-
toms for 1 year. In 1908 he again had hematuria, but a cystoscopic ex-
amination by Dr. Abbe showed no growth. The blood disappeared after
administering gallic acid.

The following year, a return of the hematuria led him to consult
Dr. Charles A. Powers, of Denver, near which city he was then re-
siding, and Dr. Powers reported to Dr. Abbe on the case at that time,
December 8, 1909, as follows:

Mr. J. S. B. consulted me December 6th, regarding a recent recurrence of
bladder hemorrhage. I learn of your operation for the removal of a growth
in June of 1905, of your application of radium in December, 1907, of the
slight bleeding through the winter of 1907-08, this controlled by capsules of
gallic acid. Also of your further examination and good report in December,
1908. Mr. B. seems to have gone on without definite symptoms until a re-
turn of hemorrhage during this past month. Of this he will doubtless give
you a detailed history. He consulted me in order to ascertain, if possible,
whether it is now best for you to see him in New York. I told him that 1
could give no opinion without a complete cystoscopic examination, and this
was made yesterday morning.

Mr. B. presents no symptoms whatever, excepting hematuria. He has
no evidence of cystitis, he does not arise at night to urinate, the bladder
capacity is good. Urination is not painful, there is no residual urine, there
is only occasional slight staining of the clothing from the meatus. The
prostate is but very slightly enlarged, its consistency is good, it is not tender.

A cystoscopic examination was made by Dr. Lyons and myself yester-
day morning. The bladder wall presents a typically healthy appearance.
We did not learn the site of your operation, but there seemed to be evidence
of a scar a little above and to the right of the base of the trigone. Just
back of the trigone and about in the midline, there is a reddish area less
than one-half inch in diameter. This area is not ulcerated. It was not
bleeding at the time of the examination, even when rubbed with the end
of the cystoscope.

There was a slight hemorrhage coming from the right side of the pros-
tatic urethra, little flakes of blood fell from this area, and the membrane

PAPILLOMA OF THE BLADDER 103

here was a bit raised. I judge that all portions of the bladder were thor-
oughly examined; at the end of the 35 minutes the bladder solution was
not at all discolored.

Dr. Lyons and I think it probable that the bleeding comes from the pros-
tatic urethra. Urine was seen coming from the orifice of the left ureter ;
we could not be certain of this on the right side. The ureters were not
catheterized. The patient has no kidney symptoms.

Mr. B. is in excellent general condition; his weight and strength are good;
he presents no other symptoms than the hematuria. He will send this letter
to you, and you will advise him. The condition seems to be splendid, in
view of the removal of a growth in 1905.

The hematuria was again controlled by gallic acid, and did not
again appear until June, 1911, when a slight tinging of the urine was
noticed by the patient. This color became deeper, and he again con-
sulted Dr. Powers, who cystoscoped the patient, with Dr. Lyons. Their
report, June 25, 1911, is as follows:

The bladder held with little or no pain about 12 ounces of fluid; the
right ureteral opening was found presenting a normal appearance, also the
superior posterior wall of the bladder and the trigone; the left ureter was
found a little puffy and edematous, blood was noticed coming from around
the opening, but on passing a catheter, the urine from the left kidney was
found to be clear; there was found situated a little above and to the outside
of the left ureteral opening a smooth, white, heavily stocked growth, the
size of a hickory nut, a slight congestion and edema of the bladder wall
surrounded the tumor, but no indurations could be detected.

From June 25, 1911, to October 17, 1911, the patient passed blood
very frequently. There was no pain accompanying urination, or at
other times, but an irritation and sensation of an incomplete emptying
of the bladder.

I saw the patient with Dr. Abbe on October 17, 1911. He was then
in excellent general health. There was slight frequency of urination,
a good stream, no pain, and but slight irritation about the vesical neck.
There was a tinge of blood in the last of the urine passed. Eectal
examination showed enlarged prostate, but the remainder of the phys-
ical examination was negative.

A cystoscopic examination was made, with the following results :

The cystoscope entered the bladder without difficulty or discomfort to the
patient. The urine evacuated from the bladder was pale and clear. There
was no blood in it, in contradistinction to that passed by voluntary urination,
where the last contraction of the bladder, in emptying itself, caused a very
slight hemorrhage. The bladder was filled and held 10 ounces of fluid with-
out discomfort. An examination of the mucous membrane of the bladder
showed a smooth, grayish, glistening surface, throughout the fundus, with
the exception of 2 areas. The blood vessels were slightly congested. The

104 ST. LUKE'S HOSPITAL REPORTS

first of the 2 areas above mentioned was located posteriorly and to the
outer side of the right ureteral orifice. This area, about 1 cm. in diameter,
was paler than the surrounding mucous membrane, devoid of blood vessels,
and resembled scar tissue. This was apparently the site of the original
growth, and the first recurrence. The second abnormal area was in a sim-
ilar position on the opposite side of the bladder. Here was found a growth
about 2x/o x iy2 cm. in size. The growth was grayish in color, villous, and
fairly solid in appearance. On first sight, it appeared to surround the left
ureteral orifice, but a pedicle was later observed. The mucous membrane
about the growth was edematous. The urine coming from the ureteral ori-
fice was clear. The growth could be made to bleed by touching it with the
cystoscope.

The prostate gland was moderately enlarged, and the vessels on its sur-
face congested. The right ureteral orifice was normal in appearance and
functionated regularly, clear urine being emitted.

The area of the trigone was negative.

October 18, 1911.— Through an indirect catheterizing cystoscope the in-
sulated wire from the high frequency machine was passed into the bladder
and made to impinge the growth. Four applications of 30 seconds each
were made to the growth, which became charred and gray and rapidly dis-
integrated. The operation gave the patient no pain. Following the appli-
cation the urine was tinged with blood for 3 days, but there was no dis-
comfort.

November 3, 1911.— Cystoscopic examination showed the central area of
the growth destroyed, and a gray spot, 1 cm. by 1 cm., to the outer and
posterior aspect of the left ureter. Above and below this spot was a small
nodule of growth, soft, villous, and not bleeding. The mucous membrane
about the ureteral orifice was edematous. Clear urine came from the open-
ing. Remainder of the bladder as when first examined.

November 16, 1911.— There is much less edema of the mucous membrane
about the site of the growth. A soft, villous, reddish growth the size of a
pea has appeared high up on the left lateral wall of the bladder since the
last cystoscopy. The high frequency current was applied to this and to the
small nodules at the margin of the left ureter, for iy2 minutes each.

November 20, 1911.— Cystoscopy showed that the new growth on the lat-
eral wall, high up, had disappeared. One of the nodules about the left
ureteral orifice had disappeared, and the second was so small as to be
scarcely visible. There was less surrounding edema than after the first ap-
plication of the current.

November 27, 1911.— Cystoscope passed for the purpose of making one
more application of the high frequency current, but examination showed
that the bladder wall was everywhere normal, no vestige of a growth being
visible.

December 3, 1911.— Patient states that he has been perfectly comfortable,
and left for his home in the West.

This case is reported primarily to show the results of the treat-
ment of the tumor with the high frequency current.

PAPILLOMA OF THE BLADDER 105

Two applications, an aggregate of 3y2 minutes of contact with the
current, destroyed the growth, first seen about the left ureteral orifice.

One application of iy2 minutes destroyed the small growth on the
lateral wall.

Fig. 1. — Cross-section of bladder, showing position of recurrence; also
small growth in fundus, which appeared between treatments, and was destroyed
by one application of the high-frequency current.

The treatment was painless, and followed by no uncomfortable or
serious consequences. There was no resulting ulceration, and but
slight bleeding after the application of the current.

This method of treatment of benign papillomata is simpler than
any other, and in this case, as in others reported, is quite as effectual.
There is no reason to believe that the growth will not recur, but
recurrence is the rule after removal by any method.

BILATERAL STRICTURE OF THE URETERS.
Henry G. Bugbee, M.D.

Mrs. H., 33 years, married. Family and past history to 1897 negative.
At this time she was operated upon for double pyosalpinx and both tubes
and ovaries were removed. Following this operation she developed dull pains
in the lumbar region of the back on either side and severe pain in the pelvic
region. In 1907 she was operated upon for pelvic adhesions and a second
operation for the same cause was performed later in the year. There was
little relief from the lumbar pains.

In 1908 a third operation for a pelvic tumor. The pain in the lumbar
region has continued. Urination has been more frequent by day; once or
twice at night. Slight burning at the end of urination. No blood or cloud
in urine.

November 1, 1911. Chief Complaints.— Frequency of urination, pain in
each lumbar region of the back.

Physical Examination.— Medium frame. Well nourished. Good color.
Chest, negative. Abdomen: There is a scar 4 inches long in the lower,
median line of the abdomen. Also one 2 inches to either side of it. There
is a slight bulging of the median scar when the patient coughs. Each kidney
can be palpated, is tender, but not perceptibly enlarged. Liver and Spleen:
not felt ; no masses or other points of tenderness.

Vaginal Examination.— Uterus normal size and position. Analysis of 24-
hour specimen of urine was negative. Cystoscopic examination shows a
normal bladder.

The right ureteral orifice was slightly edematous, the left normal. Each
shows very slight contraction when functionating. No swirl of urine could
be observed coming from either.

A catheter entered the orifice on either side, but was arrested 3 cm. from
the bladder on the left side and 4% cm. from the bladder on the right side.
Other catheters were substituted, but none would advance beyond these
points of constriction. A filiform was passed through the constriction and
on to either kidney. The feeling conveyed by the filiform was that of grip-
ping rather than encountering an obstruction. The condition was that of a
stricture of each ureter.

The catheters placed in either ureter, low down, allowed a separation of
the urine from the kidneys. The dropping of the urine was not in four or
five drops, then a pause, but was very slow and regular. The urine was
clear.

106

Fig. 1. — The ureteral catheters show the point of constriction in either
ureter. The inability to distend fully the pelves and calices of the kidneys is
also shown.

Fig. 2. — The ureteral catheter on the right side is seen, having passed
through the stricture. The left ureteral catheter is not clearly defined, but
both kidneys are distended. The left kidney, pelvis and calices are dilated.

BILATERAL STRICTURE OF THE URETERS 107

Following the examination, the patient had a sharp attack of pain
in either kidney region, resembling renal colic. This lasted several
hours, and subsided.

November 14, 1911.— The cystoscope was again introduced and an attempt
made to catheterize the ureters, but the same obstruction was encountered.
Filiforms were passed as before, followed by olivary bougies, sizes 2 and 3 F.
There was no pain following the stretching, but some relief of the old pain
in the back with less frequency of urination.

November 23, 1911.— It was possible to pass a No. 5 F. catheter through
the constriction of the right ureter and the flow of urine from the catheter
was rapid. The catheter was obstructed 3 cm. from the bladder on the
left side. Dilatation was carried out as on the previous occasions.

December 1, 1911.— Catheters were passed up the right ureter to the pelvic
brim, and in the left but 3 cm. Argyrol injections of the ureters and kidneys
were made (40% Argyrol in 2% boric acid). Six c.c. in the right and 4 c.c. in
the left. There was slight pain in either kidney following the injection.
The patient stated that this pain was exactly like the pain which she had
previously suffered. X-ray pictures were taken which show the point of
stricture in either ureter, that in the left being lower down. There is a
slight dilatation of the pelvis of the left kidney.

December 12, 1911.— It is possible to pass a No. 5 F. catheter to either
kidney. Patient has very little of the old pain and but slight frequency of
urination.

December 19, 1911.— Ureters again dilated and catheters passed. No. 5 F.
catheters to both kidneys.

December 27, 1911.— Catheters passed beyond stricture of either ureter
and Argyrol injections made. The Argyrol passed to the kidneys easily,
allowed a dilatation of the kidney pelvis, and the patient had a slight renal
colic on either side.

The X-ray photograph shows the ureters to be open throughout
their extent and a dilatation of the pelvis of the left kidney.

The condition is stricture of either ureter, caused by an inflamma-
tion in the ureteral wall, probably from the same cause as the tubal
infection. It is analogous to a urethral stricture and may be treated in
the same manner. A relief of the urinary symptoms and diminution
of the renal pain have followed the dilatation of the strictures, and
show the possibilities of conservative treatment. This dilatation can,
in all probability, be carried up to No. 8 or 10 F., and the stretching
done less frequently.

The process of slow dilatation has given the patient no pain or
inconvenience, and seems to be justified in every case where a stricture
can be diagnosed.

Kelly, in the Journal of American Medical Association, August 16,

108 ST. LUKE'S HOSPITAL REPORTS

1902, reports several cases treated in this manner. The symptoms in
his cases were similar to the above. He states that the diagnosis is
seldom made, and that the majority of cases are treated for hydro-
nephrosis. Strictures are rarely bilateral, usually found in the pelvic
ureter, and are caused most frequently by a gonorrheal or tubercular
inflammation.

The symptoms are those of vesical and renal inflammation. The
ureters can often be palpated through the vaginal wall.

The ureteral orifice, through the cystoscope, appears swollen, may be
ulcerated, the opening is often obscured, may be a dimple, or indicated
only by radiating lines.

Urine usually flows freely after passing a catheter through the
stricture.

Kelly has found dilatation the ideal treatment, except in tubercu-
losis.

Other methods of treatment are ureteral catheterization and irri-
gation, freeing of adhesions, resection of the ureter, extirpation of the
tract, and transplantation.

Medical Service

MEDICAL STATISTICS FOE 1911

DISEASES DUE TO MICRO-ORGANISMS

INFECTIVE DISEASES

Sex

Results

•o

■d

o
u
a

Cerebrospinal fever

Diphtheria

Dysentery (amoebic)

Dysentery (amoebic), bronchitis, polycythemia.

Enteric fever, intestinal hemorrhage

Erysipelas

Filiariasis, chyluria

Gonococcus arthritis of elbow

Gonococcus arthritis of knee

Gonococcus arthritis, pregnancy

Gonococcus arthritis, urethritis

Influenza

Influenza, otitis externa

Malaria

Malaria (tertian)

Rheumatism (subac. artic. )

Rheumatism (subac. artic), cardiac arrhythmia
Rheumatism (subac. artic), mitral insufficiency
Rheumatism (subac. artic), retroversion of

uterus, nephritis, cardiac hypertrophy

Rheumatism (subac artic), strongyloides intes-

tinalis

Rheumatism (ac. art.)

Rheumatism (ac. art.), bronchitis, emphysema,

nephritis, uremia

Rheumatism (ac art.), carcinoma of gall bladder

Rheumatism (ac art.), herpes zoster

Rheumatism (ac art.), lymphangitis

Rheumatism (ac art.), mitral and aortic insuffi

ciency

Rheumatism (ac. art.), mitral insufficiency

Rheumatism (ac art.), mitral stenosis, fibrinous

pericarditis

Rheumatism (ac. art.), nephritis

Rheumatism (ac art.), pericarditis

Rheumatism (ac art.), pericarditis (fibrinous),

lobar pneumonia

Rheumatism (ac. art.), regurgitation (mitral),

pericarditis (fibrinous)

Syphilis (secondary)

Syphilis (secondary), multiple alcoholic neuritis

Syphilis (tertiary)

Syphilis (tertiary), aortic aneurysm

Syphilis (tertiary), aortic insuff., aortitis....
Syphilis (tertiary), aortitis, mitral and aortic

insufi*., cardiac decompensation

Syphilis (tertiary), aortitis, tabes dorsalis, chr

nephritis, cirrhosis of liver

Syphilis (tertiary), cerebral endarteritis, throm

bosis

Syphilis (tertiary), gumma of post-pharyngeal

walls, keratitis

Syphilis (tertiary), gumma of spinal cord

Syphilis (tertiary), hepatitis

Ill

112

ST. LUKE'S HOSPITAL REPORTS

DISEASES DUE TO MICRO-ORGANISMS—
Continued

Infective Diseases — Cont.

Syphilis (tertiary), hepatitis, aneurysm of arch
of aorta

Syphilis (tertiary), periosteitis of cranium

Syphilis (tertiary), periosteitis of femur

Syphilis (cerebral)

Syphilis (cerebral), hemorrhage into cerebrum..

Syphilis (cerebral), lobar pneumonia

Tuberculosis of axillary glands, tbc. fibrosis of
lungs and pleurae

Tbc. of chest wall

Tbc. of kidney

Tbc. of kidney and bladder

Tbc. of knee joint

Tbc. of lungs

Tbc. of lungs, arterio-sclerosis, chr. nephritis. . . .

Tbc. of lungs, bronchitis

Tbc. of lungs, diabetes mellitus, hydropneumo
thorax, gangrene of lung

Tbc. of lung, gastritis, cirrhosis of liver

Tbc. of lungs, lobar pneumonia

Tbc. of lungs, ischio-rectal abscess

Tbc. of lungs, nephritis

Tbc. of lungs, pernicious anemia, arterio-sclerosis

Tbc. of lungs, pleurisy with effusion

Tbc. of lungs, pneumothorax

Tbc. of lungs, tbc. enteritis

Tbc. of lungs, tbc. fistula in ano

Tbc. of lungs, tbc. of larynx

Tbc. of lungs, tbc. of larynx, aortic regurgitation

Tbc. of lungs, tbc. meningitis

Tbc. of lungs, tbc. of spine, bronchitis, fibrinous
pleurisy

Tbc. of lungs, tbc. of spine, tachycardia

Tbc. of hip

Tbc. of peritoneum

Tbc. of pleura

Tbc. of spine

Tbc. of spine, tbc. of lungs, tachycardia

Tbc. meningitis

Tbc. meningitis, chr. nephritis

Tuberculosis (miliary), tbc. peritonitis, nephritis

Typhoid fever

Typhoid fever with hemorrhages

Typhoid fever with relapse

Typhoid fever, bronchitis

Typhoid fever, broncho-pneumonia

Typhoid fever, ischio-rectal abscess

Typhoid fever, laryngitis (ac.)

Typhoid fever, mitral and aortic insuff

Typhoid fever, otitis media

Typhoid fever, periosteitis

Typhoid fever, phlebitis

Typhoid fever, pulmonary embolism

Typhoid fever, pneumothorax, cholecystitis

Typhoid fever, pyelitis

Typhoid fever, peritonitis, ac. catarrhal cholecys-
titis

Typhoid fever (para-typhoid)

Typhoid meningitis

ALIMENTARY SYSTEM

INTESTINES

Colitis

Colitis (ulcerative)

Colitis (ulcerative), bronchitis

Colitis (ulcerative), ethmoiditis

Constipation, arterio-sclerosis

Constipation, mitral stenosis and insuff., aortic
insuff

166

189

171

1
2
1

128

MEDICAL STATISTICS— 1911

113

ALIMENTARY SYSTEM— Continued

a
fa

o
H

Intestines — Cont.

' 2

1
1

1
1
1

Entero-colitis

Enteroptosis, hyperchlorhydria, pyloric stenosis.
Enteroptosis, retroversion of uterus, constipa-
tion (chr. )

1
1

3
3

1
1

Gastro-enteritis

1
1

Ileus

Ileus, aortic and mitral insuff., aortic stenosis. . .

1
1

2
1

LIVER

8
1

1
1
5
4

1
1

" i
1

' i
l
l

8
. . ._.

. . ...

6
3

1
2

1
1
1

' i
l

Cirrhosis of liver

1
1

Cirrhosis of liver, alcoholic peripheral neuritis ,
Cirrhosis of liver, alcoholic psychosis

4
1

Cirrhosis of liver, arthritis (ac), ascites, myo-
carditis

Cirrhosis of liver, ascites, cardiac dilatation, ne-

Cirrhosis of liver, catarrhal gastritis

1
1

Cirrhosis of liver, hematemesis

Cirrhosis of liver, hemorrhoids, mitral insuff
Cirrhosis of liver, fistula in abdominal wall...

1
1
1

Cirrhosis of liver, intestinal hemorrhages, alco-
holic delirium

Cirrhosis of liver, Korsikoff's psychosis

Cirrhosis of liver, mitral regurgitation

Cirrhosis of liver (hepatic), secondary anemia.

BILE PASSAGES

Catarrhal jaundice

18
1

' '4

i
i
i
i

9
1

' i

1
1

30
1

1
1

Cholelithiasis, biliary colic

5
1
2

Cholelithiasis, cholecystitis

1
1

Cholelithiasis, goiter, hypochlorhydria

Stenosis of bile duct (congenital), icterus

MOUTH, TBBTH AND GUMS

1
. . ._.

1
1
1

1
1

Stomatitis (mercurial), ac. nephritis

OESOPHAGUS

2
1

1
1

4
1

PANCREAS

1
1

PERITONEUM, ETC.

1
1
1

Subphrenic abscess

114

ST. LUKE'S HOSPITAL REPORTS

ALIMENTARY SYSTEM— Continued

PHARYNX, TONSILS AND NASOPHARYNX

Abscess (peritonsillar.)

Pharyngitis

Quinzy

Tonsillitis

Tonsillitis, pharyngitis

Tonsillitis (follicular)

Tonsillitis (follicular), stomatitis

Tonsils (bypertrophied), phimosis, sciatica.

RECTUM

Fecal fistula, mitral and aortic insufficiency....
Hemorrhoids, epididymo-orchitis, empyema of tu-
nica vaginalis

Hemorrhoids (internal)

STOMACH

Anacidity, fracture of rib

Atony, hyperchlorhydria, senile dementia

Dilatation

Dyspepsia

Dyspepsia (nervous)

Dyspepsia (nervous), anacidity

Gastritis (alcoholic

Gastritis (alcoholic), catarrhal jaundice, mitral

and aortic insufficiency

Gastritis (alcoholic), multiple neuritis, tbc. of face

Gastritis (acute.)

Gastritis (acute), mitral stenosis

Gastritis (chronic)

Gastritis (chronic), hyperacidity

Gastritis (chronic), neurasthenia

Gastroptosis

Hyperchlorhydria

Hyperchlorhydria, gastritis

Hyperchlorhydria, gastroptosis

Hypochlorhydria

Hypochlorhydria, insomnia

Hypochlorhydria, senile atrophy of stomach

Stenosis of pylorus of stomach

Stenosis of pylorus of stomach, gastric dilatation,

cardio-spasm

Ulcer of stomach

Ulcer of stomach, cystic kidney

Ulcer of stomach, pyloric stenosis

VERMIFORM APPENDIX

Appendicitis (chronic)

Appendicitis (chr. ), catarrhal gastritis.

Appendicitis (acute) with abscess

Appendicitis (acute) with peritonitis...
Appendicular colic

CARDIO-VASCULAR SYSTEM

BLOOD

Anemia (pernicious.)

Anemia (secondary)

Anemia (secondary), nervous exhaustion..

Anemia ( simple)

Anemia (splenic)

Chlorosis

Chlorosis, influenza, otitis media

Chlorosis, mitral stenosis and insufficiency.
Leukemia (lymphatic)

6
2

' 9

1
17

2
1
9
1
17
1
1

1
1
7
2
1
3

1
1
6
1
10
1
1
2
2
2
1
1
1
1
2

1
9
1

MEDICAL STATISTICS— 1911

115

CARDIOVASCULAR SYSTEM— Continued

Blood— Cont.

Leukemia (myelogenous)

Leukemia (lymphatic), herpes zoster, broncho-
pneumonia, mitral insufficiency

Pseudoleukemia, suppuration of axillary glands.

ARTERIES

Aneurysm of aorta

Aneurysm of aorta, aortitis, aortic insufficiency,
arterio-sclerosis, ac. art. rheumatism

Aneurysm of aorta, cholelithiasis, nephritis

Aneurysm of aorta (ruptured), arterio-sclerosis
nephritis

Aneurysm of aorta (ruptured), broncho-pneumo-
nia, emphysema

Aneurysm of iliac and femoral arteries

Aneurysm of innominate artery

Arterio-sclerosis

Aneurysm of aorta (ruptured), hemothorax, sero-
fibrinous pleurisy, lobar pneumonia

Arterio-sclerosis, bronchitis (acute)

Arterio-sclerosis, constipation (chr. )

Arterio-sclerosis, emphysema, myocarditis

Arterio-sclerosis, emphysema, senility

Thrombosis of cervical arteries, paralysis of
pharynx

Ventricular hemorrhage

Embolism (cerebral), rheumatic endocarditis. . . .

Embolism (coronary), mitral and aortic insuff.
mitral stenosis

Thrombosis of innominate vein, pyelitis

Thrombosis of popliteal vein, varicose veins of
legs

Angina pectoris ( ?), mitral and aortic insuff. . . .

Dilatation, cardiac hypertrophy, mitral and
aortic insuff., mitral stenosis

Dilatation, mitral stenosis, aortic insuff

Endocarditis (chr.)

Dilatation (acute), hydrothorax, pneumonia....

Endocarditis (septic)

Endocarditis (septic), cerebral embolism

Endocarditis (septic), emphysema, mitral steno-
sis and insuff

Endocarditis (septic), mitral stenosis, aortic in-
suff., sero-fib. pleurisy

Endocarditis (septic), mitral and aortic insuff..

Endocarditis (rheumatic), aortic regurgitation..

Endocarditis (rheumatic), pregnancy

Endocarditis (rheumatic), terminal pneumonia. .

Fatty heart, sclerosis of coronary arteries

Myocardial degeneration, arterio-sclerosis, chronic
nephritis

Myocardial degeneration, fatty degeneration of
liver

Myocarditis

Myocarditis, aortic stenosis

Myocarditis, arterio-sclerosis, emphysema

Myocarditis, arterio-sclerosis, hydrothorax

Myocarditis, decompensation

Myocarditis, endocarditis, angina pectoris

Myocarditis, nephritis

Myocarditis, osteo-arthritis of hip

Myocarditis, polycythemia, cardiac insuff

116

ST. LUKE'S HOSPITAL REPORTS

CARDIOVASCULAR SYSTEM— Continued

Heart — Cont.

Valvular Diseases :

Mitral insufficiency

Mitral insuff., artic. rheumatism

Mitral insuff., bydrothorax, nephritis

Mitral insuff., oedema of luDgs

Mitral insuff. and stenosis

Mitral insuff. and stenosis, aortic insuff. . . .

Mitral insuff. and sten. arterio-sclerosis, ehr.
nephritis

Mitral insuff. and sten., aortic stenosis

Mitral insuff. and sten., decompensation

Mitral insuff. and sten., pleurisy

Mitral and aortic insufficiency

Mitral and aortic insuff., fibrinous pleurisy,
inguinal hernia

Mitral and aortic insuff., rheumatic endocar-
ditis

Mitral and aortic insuff. and stenosis

Mitral and tricuspid insuff., mitral stenosis.

Mitral stenosis

Mitral stenosis and aortic insuff

Mitral stenosis, decompensation, anasarca. . .

Aortic insufficiency, aortitis, hemorrhoids. . . .

Aortic insuff., aortitis, angina pectoris

Aortic insuff. and stenosis, decompensation. .

Aortic stenosis

LYMPH GLANDS

Ac. lymphangitis, lymphadenitis, tenosynovitis.
Supp. lymphadenitis of axilla

DUCTLESS GLANDS

Goitre (simple), hyperthyroidism, mitral stenosis
and regurgitation

Goitre (exophthalmic)

Goitre (exophthalmic), cardiac hypertrophy and
dilatation, pneumothorax

Elephantiasis, abscess of leg

Hodgkin's disease

Toxemic hyperthyroidism

MUSCULAR SYSTEM

Chr. muscular rheumatism. . . .

Myalgia

Progressive muscular atrophy.

NERVOUS SYSTEM

BRAIN

Abscess, eupp. meningitis, polycythemia

Apoplexy

Abscess of brain, otitis media, mitral stenosis.

Apoplexy, cerebral thrombosis

Apoplexy, hemiplegia.

Meningitis, bulbar paralysis, pulmonary tbc. . . .

Meningitis (pneumococcus)

Paralysis (facial), hyp. tonsils ,

Paralysis (post-diphtheritic)

DISEASES OF THE MIND

Mania (acute), bronchitis, emphysema, mitral
insuff

1
' i

i
l

MEDICAL STATISTICS— 1911

117

NERVOUS SYSTEM— Continued

Diseases of the Mind — Cont.

1
1

I
1
1

Paresis (general)

NERVES

Neuralgia of cranial nerve

2
' ' 3

' ' '2
2
3

' ' '2

1
1
1
1
2

' '5

1
2

4
2

Neuralgia of intercostal nerve

2
4

1
1

7
1

Neuritis (alcoholic multiple), Korsikoff's syn-
drome, pulmonary the

' i

1
1

2
2

4
1

2
1
3

8
2
13
1
1

NERVOUS DISEASES OF UNKNOWN ORIGIN

2
1
3
9
2
15
1

13
3

' i

27
5

1
1

1
2

Neurasthenia, retroversion of uterus

SPINAL CORD

1
1

2
1

1
1

' i

1
1
4
1
1

1
3

1
1

OSSEOUS SYSTEM

BONES

1
2
1
1

I
2
1

Leontiasis ossia, Paget's disease, mitral insuff . . .

4
5

' 'i

5
1
1

JOINTS

1
1

6
2

REPRODUCTIVE SYSTEM

OVARIES AND TUBES

PREGNANCY

1
3

' ' 3

1
1

1
3

....

118

ST. LUKE'S HOSPITAL REPORTS

REPRODUCTIVE SYSTEM — Continued

a p

UTERUS AND FALLOPIAN TUBES

Dysmenorrhea

Endometritis, ac. bronchitis

Menorrhagia

Pyosalpinx

Pyosalpinx, appendicitis

Pyosalpinx, fibroma uteri, broncho-pneumonia,

fibrinous pleurisy

Retention of placenta, septic uterus

RESPIRATORY SYSTEM

BRONCHI

Asthma, bronchitis

Asthma, emphysema

Asthma, erysipelas

Asthma, nephritis (chr.)

Bronchiectasis

Bronchitis

Bronchitis (ac), cardiac incompetency

Bronchitis (ac), dextracardia

Bronchitis (ac), emphysema

Bronchitis (ac), mitral insufficiency

Bronchitis (ac), mitral regurgitation, purpura

rheumatica

Bronchitis (ac), myelogenous leukemia

Bronchitis (ac), strongyloides intestinalis

Coryza

Laryngitis

Laryngitis (catarrhal), fibromyomata uteri, neu-
rasthenia

Abscess of lung and gangrene, following lobar
pneumonia

Emphysema (pulmonary), bronchitis

Emphysema (pul.), bronchitis, asthma, paroxys-
mal tachycardia

Emphysema (pul.), bronchitis, mitral insuff . . . .

Pneumonia (broncho-)

Pneumonia (broncho-), arterio-sclerosis, chr. ne-
phritis

Pneumonia (broncho-), varicose ulcer

Pneumonia (lobar)

Pneumonia lobar), arterio-sclerosis, chr. nephri-
tis

Pneumonia (lobar), alcoholic delirium

Pneumonia (lobar), articular rheumatism, mitral
insuff., fibrinous pericarditis

Pneumonia lobar), atresia of lung

Pneumonia (lobar), bronchitis, emphysema

Pneumonia (lobar), fibrinous pleurisy, child-
birth, dilatation of stomach

Pneumonia (lobar), fibrinous pericarditis, infarct
of lung, mitral insufficiency

Pneumonia (lobar), mitral insufficiency

Pneumonia (lobar), mitral insufficiency, infarct
of lung

Pneumonia (lobar), oedema of lungs

Pneumonia (lobar), cedema of lungs, myocarditis,
'chr. nephritis

Pneumonia (lobar), morphinism

Pneumonia (lobar), nephritis, hydrothorax. . .

Pneumonia (lobar), pleurisy (dry)

Pneumonia (lobar), pleurisy (suppurative)...

MEDICAL STATISTICS— 1911

119

RESPIRATORY SYSTEM— Continued

Lungs — Cont.

Pneumonia (lobar), pleurisy with effusion

Pneumonia (lobar), streptococcic bacteremia.. . .
Pneumonia (lobar, resolution delayed), fibrinous

pleurisy

Pneumonia (lobar, unresolved)

Pneumonia (terminal), chr. nephritis

Pleurisy (dry)

Pleurisy (dry), pneumonia

Pleurisy (fibrinous)

Pleurisy (fibrinous), tachycardia

Pleurisy (sero-fibrinous), retroversion, endome-
tritis

Pleurisy (suppurative)

Pleurisy with effusion

Pleurisy with effusion, asthma, bronchitis

Pyopneumothorax

SENSE ORGANS

ORGAN OF HEARING

Mastoiditis

Mastoiditis, influenza, otitis media.
Otitis media (suppurative)

ORGAN OF VISION

Atrophy of optic nerve.

Cataract, diabetes

Choroido-retinitis

Keratitis

Strabismus

TEGUMENTARY SYSTEM

SKIN, ETC.

Erythema multiforme

URINARY SYSTEM

KIDNEY

Albuminaria

Nephritis (acute)

Nephritis (chronic interstitial)

Nephritis ( chr. in. ) , anemia

Nephritis (chr. in.), appendicitis

Nephritis (chr. in.), arterio-sclerosis

Nephritis (chr. in.), arthritis deformans

Nephritis (chr. in.), anemia, stomatitis

Nephritis (chr. in.), aortic insufficiency

Nephritis (chr. in.), cirrhosis of liver

Nephritis (chr. in.), cirrhosis of liver, cerebral
hemorrhage

Nephritis (chr. in.), cirrhosis of liver, parotitis,
pericarditis, fib. pleurisy

Nephritis (chr. in.), cystitis, dilatation, myocar-
dial insufficiency

Nephritis (chr. in.), colitis, aortitis, rheumatoid
arthritis, diphtheria

Nephritis (chr. in.), dry pleurisy, cirrhosis of
liver

1
19

1
31

1
1

1
1
29
2
1
4
1
1
2
S

1
1
1
1

120

ST. LUKE'S HOSPITAL REPORTS

URINARY SYSTEM— Continued

Kidney — Cont.

Nephritis (chr. in.), emphysema, cardiac insuf-
ficiency

Nephritis (chr. in.), hydrothorax

Nephritis (chr. in.), mitral stenosis and insuffi-
ciency

Nephritis (chr. in.), myocarditis

Nephritis (chr. in.), peritonitis

Nephritis (chr. in.), oedema of lungs, lobar
pneumonia, myocarditis

Nephritis (acute), parotitis, status lymphaticus

Nephritis (chr. in.), pleurisy with effusion, car-
diac insufficiency

Nephritis (chr. in.), pulmonary hemorrhages, en-
tero-colitis, uremia

Nephritis (chr. in.), pulmonary tbc, cirrhosis
of liver

Nephritis (chr. in.), mitral regurgitation, hemi-
plegia, motor hysteria

Nephritis (chr. in.), uremia

Nephritis (chr. in.), uremia, fib. pericarditis. . .

Nephritis (chr. in.), uremia, mitral and aortic
insuff

Nephritis (chr. in. with acute exacerbation) . . .

Nephritis (chr. parenchymatous)

Nephritis (sub-acute), facial paralysis

Nephritis (sub-acute), hemianopsia papillitis...

Nephritis sub-acute) hemorrhage into pons. . . .

Hydronephrosis

Nephrolithiasis

Pyelonephritis

Pyelitis

Pyonephrosis, broncho-pneumonia

Uremia

Uremia apoplexy

Enlarged spleen, polycythemia.

UBINABY BLADDER

Cystitis, nephritis, cardiac decompensation.
Cystitis, urethral stricture, catheter fever. .

DISEASES DUE TO ANIMAL PARASITES

Tapeworm .
Unciniarisis

GENERAL INJURIES

Heat prostration

Smoke inhalation

Starvation, psychosis, chr. colitis.

LOCAL INJURIES

Concussion

Incised wound of hand.

NEOPLASMS

Carcinomatosis

Carcinoma of breast, mediastinal metastases.
Carcinoma of breast, mitral regurgitation, sub-
acute rheumatism

10
2

1
1

1
1
1
1
1
2
1
1
2
8
1
3
1

109

MEDICAL STATISTICS— 1011

121

NEOPLASMS— Continued

H P

Neoplasms — Cont.

Carcinoma of colon

Carcinoma of liver and bile duct

Carcinoma of oesophagus

Carcinoma of pancreas

Carcinoma of stomach

Carcinoma of stomach and rectum, chr. nephritis

Carcinoma of stomach, metastases in liver

Carcinoma of stomach, omental metastases, tabes
dorsalis, arterio-sclerosis

Carcinoma of uterus, anasarca, secondary ane-
mia, cardiac insufficiency

Cyst-adenoma (papillary), metastases in lung. .

Epithelioma of oesophagus

Epithelioma of pleura, hydrothorax

Epithelioma of scalp, chr. nephritis, arterio-
sclerosis

Exostoses on humerus

Fibromyoma of uterus, anemia

Infected arm

Infected finger

Sarcoma (retroperitoneal)

Sarcomata in lumbar region

Tumor of brain

Tumor of brain, pulmonary tuberculosis

Tumor of mediastinum

Tumor of abdomen

Tumor of spinal cord

INTOXICATIONS AND POISONS

EXOGENOUS INTOXICATIONS

Alcoholism, acute

Alcoholism (chr.) delirium tremens

Alcoholism (chr.), Korsikoff's psychosis

Chronic poisoning by lead

Chronic poisoning by mercury

Chronic poisoning by morphine

Chronic poisoning by morphine, aneurysm of iliac

and femoral arteries

Chronic poisoning by veronal

Chronic poisoning by strychnine

Acute poisoning by Paris green

Pneumococcus septicemia, pulmonary tbc

Septicemia following abortion, mitral insuff . . . .
Streptococcic septicemia, imitative meningitis. . .
Streptococcic septicemia, septic endocarditis. . . .

ENDOGENOUS INTOXICATIONS

Auto-intoxication

Auto-intoxication, cardiac arrhythmia.

Diabetes mellitus

Diabetes mellitus, chr. nephritis

Diabetes mellitus, pulmonary tbc

Diabetes mellitus, eczema

Diabetes mellitus, lobar pneumonia. . . .
Gout

MISCELLANEOUS CONDITIONS

Debility

Heat stroke, meningitis.

Malingering

No diagnosis made

122

ST. LUKE'S HOSPITAL REPORTS

SUMMARY

Micro-organic Diseases. .

Alimentary System

Cardio-vascular System .

Ductless Glands

Muscular System

Nervous System

Osseous System

Reproductive System . . .

Respiratory System

Sense Organs

Tegumentary System. . . .

Urinary System

Animal Parasites

General Injuries

Local Injuries

Neoplasms

Intoxications

Miscellaneous

166

189

102

171

95
2
1

27
3
3
2
2

12
1

128

"•40

18
8

' '4

7
6

16
3
9

53
7

49
3

375

178

153

179

112

REPORT OF CASES OF HODGKIN'S DISEASE.
Austin "W. Hollis, M.D., Otto H. Leber, M.D., and F. C. Wood, M.D-.

Case 1. — The patient, a civil engineer, aged 31 years, came to the
hospital September 5, 1910, with a general history of fever, and
progressive loss of flesh and strength extending over a period of a
whole year. In September, 1909, he had been taken sick with fever
and general prostration, but stayed in bed for a few days only, and
then was able to get up and go about his work until January 1. Dur-
ing all this time, however, he felt badly, and having acquired the
habit of taking his temperature himself, frequently found that he had
fever. He then spent 3 months at home, taking moderate exercise,
but doing no work. At this time he was thought to have incipient
tuberculosis, and in April went to a boarding-house in Sullivan
County, and then, 4 weeks before admission, to the Loomis Sanator-
ium. He thought he had fever three-fourths of the time during the
past year, but during the month of June there was a complete re-
mission.

At the Loomis Sanatorium his temperature ranged from 100.8° to
105°. According to the patient, he had a moderate cough at the
times he had fever, and occasionally expectorated a small quantity of
whitish or yellowish sputum, which once contained a clot of blood.
He thought he lost about 20 pounds in weight. He had a number
of heavy night sweats in the spring, and had them almost nightly
when admitted to the hospital. His appetite was poor when he had
fever; he had no epigastric pain or symptoms of indigestion; the
bowels had moved regularly with slight catharsis, and he was never
troubled with pain anywhere.

His past history was negative, except for the diseases of childhood.
His work in engineering has been in this part of the country, mostly
in wet, swampy districts. He took a glass of beer occasionally, and
smoked to excess before the onset of his illness.

There was no family history of tuberculosis. His mother died of
carcinoma of the stomach ; his father is alive and well.

123

124

ST. LUKE'S HOSPITAL REPORTS

On admission to the hospital, the patient was moderately pros-
trated, and markedly emaciated, the latter being accentuated by the
patient's height of 6 feet 6 inches. The eyes, mouth and throat ap-

C»se /Vo. /

,2<r+-..xJ- ,

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peared normal; the chest showed very markedly the great degree of
emaciation ; expansion was good, and equal on both sides. The heart
appeared normal in size, at the apex and over the pulmonic area there

HODGKIN'S DISEASE 125

was a soft systolic murmur. The action was regular, rapid and forci-
ble. The lungs showed moderate dulness at both apices. At the
right apex, and just below the spine of the scapula were a few sub-
crepitant rales. The abdomen was scaphoid; the liver appeared nor-
mal in size; the spleen descended about 2 fingers below the free bor-
der on inspiration. The right kidney could easily be felt. The ex-
tremities were negative. There were no signs of any glandular en-
largement, superficial or deep. The temperature on admission ranged
between 102 and 104 4/5, pulse about 100, and respirations 20 to 32.
The blood count showed 3,300,000 red blood cells, with 35 per cent
hemoglobin; white blood cells 3,400; polynuclear 46 per cent; leuco-
cytes 54 per cent.

A blood culture, taken a short time after admission, showed what
appeared to be a short chained streptococcus, and from this an auto-
genous vaccine was prepared, and the patient received increasing
doses with what appeared to be excellent results, for in 2 weeks his
temperature had gradually come down to normal, and remained there
for almost 3 weeks, when, without any apparent cause, it jumped to
103, and thereafter remained above normal, ranging between 100°
and 104°. The vaccine was discontinued shortly after, as 2 subse-
quent blood cultures remained sterile.

The course of the disease was uneventful, and marked only by
progressive asthenia, anemia and emaciation, finally ending fatally
3^ months after admission, on December 18.

In view of the findings at autopsy, the symptom complex presented
was peculiarly confusing, especially from the standpoint of the tem-
perature course and the glandular involvement.

The temperature course in Hodgkin's disease can be very variable,
as is well known, but has been classified by Longcope1 into 3 more
or less distinct types:

1. Mild and continuous, slightly irregular fever, varying a few
degrees, rarely going above 101 or 102°.

2. Temperature quite irregular, light and intermittent; and

3. The relapsing type, a very unusual one, showing periods of
pyrexia lasting several days or weeks, and alternating with similarly
variable periods of apyrexia.

While this last type was observed as far back as 1870 by Murchison,2

longcope: Bull. Ayer Clin. Lab., No. 1, 1903; N. Y. Path. Soc, 1908, N.
S. viii, 153.

2Murchison: Trans, of the Path. Soc. of London. 1870, xxi, 372.

126 ST. LUKE'S HOSPITAL REPORTS

and again by Pel3 4, in 1885, Ebstein5 in 1887, Ruffin6 in 1906, and
by a few others, it will be seen from the scarcity of the cases that it
is by far the most unusual type, so much so that Ebstein considered
the peculiar temperature course sufficient ground for a separate clas-
sification, and called the disease "Chronic Relapsing Fever."

While the present case was under observation for only part of the
course of the disease, there were apparently 3 periods of pyrexia, and

2 of apyrexia, the first of about a month, the second lasting almost

3 weeks.

The second and more unusual phase of this case was the distribu-
tion of the glandular involvement. At no time in the course of the
disease was there any enlargement of lymph nodes palpable, and
at no time was there any enlargement of the deeper nodes, either by
direct evidence, or by secondary pressure signs. The patient never
suffered from any pain which might have been taken as sign of pres-
sure on any nerve. There was no sign of any pressure upon the
larynx, trachea, bronchi or esophagus, and so also, no dyspnea or dys-
phagia. There was never any edema or evidence of ascites. By no
physical signs in the chest could one assume the enlargement of any
bronchial or mediastinal lymph nodes, and no amount of palpation
could elicit any enlargement of the abdominal glands. There have
been cases of Hodgkin's disease reported in which the deep glands
were apparently the only ones involved,7 but they seem quite regu-
larly, at least in the later stages, to have given secondary signs of
pressure, so notably absent here; and Reed,8 in the comprehensive
discussion of the disease, goes so far as to say, "We know of no case
where the pathological anatomy was described in sufficient detail to
permit of a positive diagnosis, in which the disease commenced else-
where (than in the cervical region)."

The blood findings in our case were interesting. While at the
Loomis Sanatorium, in August, he first had 4,640,000 red blood cells,
and in 2 weeks actually gained 700,000. On September 6, he had
3,332,000, and 50 per cent hemoglobin. On September 23 he had
3,500,000, and 50 per cent hemoglobin. Thus, in spite of fever, he

3Pel: Berliner Klin. Wochenschrift, 1885, xxii.
4Pel: Berliner Klin. Wochenschrift, 1887, xxiv.
"Ebstein: Berliner Klin. Wochenschrift, 1887, xxiv.
"Ruffin: Am. Journ. Med. Sciences, 1906, cxxxi.
7Stall: Medical Record, N. Y., 1905, Ixvii, 773.
"Reed: Johns Hopkins Hospital Reports, 1902, x, 133.

HODGKIN'S DISEASE 127

gained in red blood cells and hemoglobin, but this may have been
from blood concentration, and not a true numerical gain of cells. The
resistance of the blood and general strength under such a high fever
was, however, striking. The digestive ability was always good.
Leukopenia was a marked and constant feature, the leukocytes were
never higher than 6,500, and more often were between 3,000 and
5,000 per cubic millimeter; the polynuclear and lymphocytes were
variable, though in normal range proportions ; eosinophyles were not
present.

The clinical picture was extremely puzzling. Dr. O. D. Kingsley,
of White Plains, who first treated him, thought of a tuberculous con-
dition. The fever, night sweats and signs at the right apex at this
period of his illness would seem fully convincing, but 8 months later,
under the observation of Dr. H. M. King, at the Loomis Sanatorium,
the diagnosis of pulmonary tuberculosis was abandoned, and he
pointed out the necessity of investigation on other lines, and sent him
to St. Luke's Hospital, with the suggestion that the spleen was at the
bottom of it, and its removal might be considered. Under our in-
vestigation a short chained streptococcus was found once in blood
culture, and an autogenous vaccine was employed with prompt re-
mission of his fever, followed by general improvement, but a return
of fever after three weeks' remission without subsequent confirm-
atory blood cultures, led us to believe that our previous positive cul-
ture was a contamination.

A few weeks before the patient's death, Dr. S. W. Lambert sug-
gested the possibility of Ebstein's variety of Hodgkin's disease, but
prominent clinicians, to the time of his death, were quite in doubt
as to the true condition, and considered the probabilities of a cryp-
togenic septicaemia, chronic miliary tuberculosis and multiple sarco-
matosis.

That such cases should be enigmas, is due in the first place, to their
infrequency, but chiefly to the poor and meager description of their
symptoms found in the text-books, which classify them as a variety
of Hodgkin 's disease without pointing out their wide divergence from
the ordinary clinical picture of that disease. The number of cases
reported with long febrile periods with more than one remission,
show clearly that we are dealing with a specific affection running a
very definite clinical course. In the two cases which I have seen,
this one, and one in consultation with Dr. Everett W. Gould, periods
of pyrexia and apyrexia alternated, in neither case were the super-

128 ST. LUKE'S HOSPITAL REPORTS

ficial lymphatic glands implicated, but moderate splenic enlargement,
with some involvement of the abdominal and thoracic glands, was a
feature in both cases.

This case resembles most strikingly, both in its relapsing tem-
perature curve, as well as in the absence of any definable glands, the
cases reported by Pel and Ebstein, in 1885 and 1887, one of which
had as many as 9 periods of pyrexia, and which were considered by
Pel to be pseudo leucemia, and by Ebstein, a new clinical entity.

PATHOLOGICAL REPORT BY F. C. WOOD, M.D.

The body is that of an emaciated young man of small frame. The
skin shows a brownish tint. There is a decubitus ulcer over the sac-
rum. On the anterior wall, over the left costal cartilage, there is a
small nodule partially invading the cartilage about 1.5 cm. in di-
ameter. The cut surface is mottled with yellow and white areas. The
left pleural cavity contains about 150 c.c. of clear, straw-colored fluid,
the right about 100 c.c. There is an old fibrous adhesion between
the right lung and the thoracic wall.

The lungs show considerable hyperstatic fluid and are deep red in
the posterior portions. Microscopically, there is a little bronchial
pneumonia. The right lung shows a scar at the apex, but no other
evidences of tuberculosis. The bronchi contain a little thick, mucoid
pus.

The lymph nodes of the hyla are enlarged to a considerable mass,
the individual nodes measuring 1 to 2 cm. in diameter. They are
very dark in color and considerable fluid exudes on section.

The heart shows no lesions except that the leaflets of the anterior
and right posterior aortic cusps are united by a fibrous nodule about
5 mm. in diameter.

The spleen is large and soft, weighing 470 grams. The surface is
irregular owing to the presence of small nodules underneath the
peritoneum. On section nodules are found scattered throughout the
organ. They are of opaque yellow color, irregular in outline, and
measure from 5 to 10 mm. in diameter. There is one nodule which
is much larger, measuring 4 cm., very soft and dark red.

The kidneys show no lesions. The suprarenals, bladder, and other
genito-urinary organs are normal.

The mucous membrane of the intestine shows no lymphatic hyper-
plasia. The stomach mucous membrane is destroyed by post-mortem
digestion.

#<)°

Fig. 1. — Nodule from liver. Case I.
X 1000.

m *

Fig. 2. — Nodule from spleen, sbowiug giaut cell. Case I.
X 1000.

HODGKIN'S DISEASE 129

The mesenteric lymph nodes are moderately enlarged, measuring 5
to 20 mm. in diameter. They are pale yellow in color, firm and homo-
geneous on cut section.

The liver weighs 2,240 grams. It is deep red in color, and scat-
tered through the tissue are a large number of yellow, irregular
nodules, 5 to 15 mm. in diameter.

Scattered about the thorax and abdomen are a considerable num-
ber of enlarged nodes, some lying along the aorta and the esophagus,
others under the iliac vessels and in the inguinal region. They are
rarely above 1 cm. in diameter. About the trachea, however, the
nodes are considerably enlarged, measuring 2 to 4 cm., and form a
nodular mass. The largest node measures 2 to 4 cm., and shows on
section mottled areas of yellow and deep red color. There were also
on the parietal pleura a number of small, yellowish nodules, which
are firmly attached to, and in some cases extend into, the substance
of the ribs.

The thyroid shows no lesions. The bone marrow of the femur is
a deep red in color in its upper third. The humerus contains red
marrow in its middle portion. The marrow of the lumbar vertebrae
is increased in amount and very deep red in color. The sternum and
ensiform contain a considerable amount of reddish marrow.

Microscopical Examination. — Study of the bone marrow from the
femur shows a hyperplasia of all the elements, with many plasma
cells and a large number of eosinophiles in the tissue. There are also
many areas closely set with normoblasts, such as are seen in the severe
anemias. Megakaryocytes are abundant. The whitish nodule in the
sternal marrow shows areas of necrosis surrounded by fibrous con-
nective tissue, which contains many large multinuclear cells, plasma
cells, and numerous eosinophiles. The lesions in the lymph nodes are
typical of those of Hodgkin's disease ; in other words, a fibrous hyper-
plasia with disappearance of the normal lymphoid structure and the
growth of many multinucleated cells. A moderate number of eosino-
philes are also present. A similar picture is seen in the nodules from
the liver. There were no evident nodules in the kidney.

case 2. — hodgkin's disease complicated with diabetes mellitus
cerrhosis of the liver.

The patient, a male, of 39 years, was under observation in the
hospital from September 25, 1911, to October 5, 1911. The reason
for the patient's application to the hospital was that he had pain in

130

ST. LUKE'S HOSPITAL REPORTS

the abdomen, swelling of the feet and legs, and cough. Of his family
history, the only fact of importance was that his father died at the
age of 72, having had diabetes. The patient had been well until 6
years before his admission, at which time he developed diabetes, but
improved under treatment. Some 3 years ago the glycosuria re-

Case NO....S.1 o..l 0...

NameJTk.

Sept 1411.

Admitted

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170
160
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140
180

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<: 1

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81, f,

mmHg J
280 1

260 I

240 J

220 1

200

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120

100
90
80
70
60
50

10'3°5
102' E
101' ^
loo' E

99° E
08° E
97° _
96° E

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180

140
120

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turned, sugar being present amounting to about 4 per cent in tie
urine, but no attention was paid to this fact, and except for having
lost weight, he had not suffered from any inconvenience. He had not
attempted to keep up a strict diet. Four months ago he had herpes
zoster. About this same time he began to have attacks of vomiting
after meals, but only rejected the food which he had taken, and never

HODGKIN'S DISEASE

131

noticed any blood. He began to be constipated and lost weight.
Shortly after it was noticed that he was jaundiced, with clay-colored
stools and dark-colored urine. He had at the same time a great deal
of abdominal pain, but no acute attacks. The pain also extended
into the lumbar region. The symptoms continued until about 6 weeks

Name.nk,_..;?.xr

OcV. - 1 9 ii

Case No....?. X?..'° _

Adflrttted.s_«..tdri*.c^^^

Day of Month.

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Pita

Temo

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160

150

140

130

120

110

100

80
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99°

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280

260

240

220

200

180

160

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140

120
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80
60
40
20

70
60
60
40

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97"
96'
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ago, when he noticed that his feet and ankles were swollen, and a little
later his abdomen began to enlarge, and for the last 10 days he had
not been able to walk. He had an annoying cough for about 4 Weeks.
His shortness of breath had not troubled him much.

Physical examination of the patient shows that he is a fairly well developed,
poorly nourished man, with considerable jaundice of skin and sclerotic. He

132 ST. LUKE'S HOSPITAL REPORTS

has moderate dyspnea and is more comfortable sitting up, but be is not cyan-
otic. Tbe pupils are equal and react to light. Tbere are no conjunctival
hemorrhages. A few small lymph nodes are palpable in the neck. Tbe heart
shows only a faint systolic murmur at the apex and soft systolic murmur over
base. The second pulmonic sound is accentuated. The pulse is regular and of
good force, and the vessel walls are not thickened. There is evidence of fluid
in the pleural cavity, and a few rales can be heard in the lung. Tbe abdomen
is moderately distended, there is edema of the abdominal wall and of the back,
and a fluid wave is present. The liver and spleen are not palpably enlarged.
There is marked edema of the lower extremities. In the left axilla there is a
group of much enlarged lymph nodes.

The day following admission, 8 ounces of fluid were removed from
the abdominal cavity, and then the liver was found to be 3 inches
below the costal margin. The spleen was just palpable. The urine
was 1,024 acid, contained a trace of albumin, 2 per cent of sugar, no
acetone, no acetic acid. The red cells were 3,900,000 ; hemoglobin 75
per cent; polynuclears 72 per cent; lymphocytes 28 per cent. The
patient ran an irregular fever. A few days after his admission, a
lymph node was removed from the left axilla, measuring 2 x 2 x 1.5
cm. Microscopical examination showed that the capsule of the node
was intact, but the reticulum was largely converted into a fibrous
tissue mass. The lymph structure was greatly diminished in extent,
and many large cells with 5 or 6 nuclei were scattered in greater or
smaller numbers throughout the fibrous tissue meshwork. Eosino-
philes were not found.

The patient's condition gradually became worse, and he died 10
days after admission to the hospital. An autopsy was not obtainable.

A CASE OF THROMBOSIS OF THE VERTEBRAL ARTERY.

Henry S. Patterson, M.D.

Of recent years, much interest has centered around the vascular
accidents of the posterior fossa of the skull in general, and of the
vertebral artery in particular. A number of cases of thrombosis of
that vessel have been recorded in the literature of the subject, but
as yet the symptomatology is sufficiently undefined to warrant a report
of the following case :

F. B., 52 years of age, married, housewife. Admitted to the hospital
May 20, 1911. Chief complaint, inability to swallow.

Present Illness. — Eight days previous to admission the patient became
suddenly faint, and was obliged to sit down. When she attempted to drink,
she found that she was unable to swallow, the fluid returning through the
nose. She has had some slight numbness of the right side of the face. She
has had no pain. She thinks that her hearing has not been good for the last
few days. She has been gradually growing weaker, and has been obliged to
take to her bed.

Past Illnesses. — None but an attack of swelling of the legs and abdomen,
six months ago, lasting seven weeks. Menopause five years ago. Seven chil-
dren ; no miscarriages.

Family History. — Negative.

Physical Examination. — Large-framed, extremely obese woman, not acutely
ill. Facies alcoholic. No icterus. Herpes on lips. Patient is conscious and
rational, and speaks without difficulty, and distinctly. She is quite deaf in
the right ear. She is apparently unable to swallow. The tongue is dry and
coated, and does not deviate. The mucous membrane of the mouth is normal.
The teeth are in very bad condition. The throat is red and congested. The
tonsils are not enlarged. The muscles of the pharynx and soft palate are
paralyzed on the right side. On phonating, the uvula and pharyngeal wall
move to the left. No anesthesia of the pharynx. On swallowing fluid, it
comes out through the nose, especially the left nostril. Very slight flattening
of the left naso-labial fold. Patient says that sensation is more marked on
the left than the right cheek. The right pupil is contracted; both react to
light and accommodation, the left more actively than the right.

Heart. — Apex impulse in the fifth space, 12 cm. to the left of the mid-line.
Left border percusses 13 cm. to the left of the mid-line. Right border just

133

134 ST. LUKE'S HOSPITAL REPORTS

to the right of the sternum. Action irregular in force and frequency. The
first sound at the apex is valvular, and varies in quality. The second aortic
is louder than the second pulmonic. Reduplication of the second sounds at
the base occasionally. No murmurs. Pulse is rapid, and irregular in force
and frequency, of poor size and force with increased tension. Vessel wall is
palpable.

Lungs. — Clear front and back, except for a few scattered subcrepitant
rales. Breathing diminished over the bases behind.

Liver. — Area of dulness not enlarged ; edge not felt.

Spleen. — Area of dulness not enlarged; edge not felt.

Abdomen. — Diastasis of the recti, with a large ventral hernia, showing
impulse on coughing. No masses nor tenderness ; no ascites. Many old
striae.

Extremities. — No paralysis. Varicose veins over the lower part of legs,
with scars of old ulcers. Slight oedema of the legs. Knee jerks present.

The temperature was 98° F. on admission, and gradually rose until it
reached 105.6° at death, on May 23d.

The blood pressure ranged from 210 to 195 mm. of mercury.

Two leucocyte counts gave the following: 16,000; polymorphonuclears, 83
per cent ; red cells, 6,200,000 ; haemoglobin, 100 per cent.

Urine : Sp. gr., 1,020 to 1,022 ; albumen, 15 to 20 per cent. No casts found.

The patient gradually became weaker, lapsed into unconsciousness and
coma, the temperature gradually rose, and death occurred on the fourth day
of her stay in the hospital. From the sudden development of symptoms, and
from the disturbance in the innervation of the right pharyngeal muscles, it
was inferred tbat a hemorrhage had taken place into the nucleus of the right
glossopharyngeal nerve.

Extract from the notes taken at the autopsy

There is considerable cedematous fluid filling the pial spaces of the sulci,
which is most marked in the posterior fossa. The right vertebral artery is
distended to a diameter of 4 mm. by a thrombus which extends from a point
just below the basilar artery to the anterior condyloid foramen, and appar-
ently beyond. It occludes the orifice of the posterior cerebellar artery. On
sectioning the medulla, about the level of the olive, an area of softening is
seen, which occupies the upper right portion of the section, and is about
7 mm. in diameter. It includes the restiforme body, the upper portion of the
olivary nucleus and the intervening structures. It extends up into the inferior
cerebellar peduncle. A number of very small branches of the inferior cere-
bellar artery pass into the medulla at the level of the softened area. The
medulla, below this point, and the region supplied by the right inferior cere-
bellar artery are normal. The cerebrum is normal. The ventricles are free.

REPORT OF A CASE OF ACUTE ENDOCARDITIS WITH IN-
FLUX OF ALL THE CHORD M TENDINE.E OF THE
ANTERIOR CURTAIN OF THE MITRAL VALVES.

Lewis F. Frissell, M.D.

T. T., hotel manager, 52 years of age, married, was admitted to the med-
ical ward of St. Luke's Hospital, July 5th, complaining of severe dyspnoea.
Until eight weeks before admission, he felt perfectly well, but at that time
noticed that his customary mode of life fatigued him and that he became
short of breath on exertion. He has not noticed precordial pain or sudden
exacerbation of symptoms. Gradually his dyspnoea increased, confining him
to bed, and of late has amounted to orthopnoea. He has not been conscious
of fever, but his wife thinks there has been some elevation of temperature
in the last few weeks.

There has been a little cough without expectoration. Urination frequent.
His occupation required no severe physical work, and his habits were in-
clined to be sedentary.

Until the onset of his present trouble, he had been remarkably free from
illness since his childhood, in which he had suffered from measles, scarlet
fever, diphtheria and chicken-pox. No history of venereal disease or rheu-
matic fever is obtainable. His personal habits are bad. He is a constant
user of alcohol, five or six whiskeys or beers daily with periodic sprees.

Tobacco is used in moderation. Coffee six cups daily.

The family history is good; his father died of pneumonia and mother of
apoplexy.

Physical Examination. — Patient is a fairly well-developed and well-nourished
man of 52 years, appearing moderately prostrated. There is some dyspnoea
and orthopncea. No jaundice or cyanosis. Skin and mucous membrane
somewhat pale.

Eyes. — Pupils equal and react. Slight icteroid tinge to sclerse.

Tongue.— Moist, not coated.

Throat— Negative.

Teeth. — In rather poor condition; a few missing.

Neck.— Visible venous pulsation.

Chest.— Well developed, expansion good.

Heart. — Lifting impulse general over precordium. At apex region is a
thrill, diastolic in time. Diffuse visible and palpable apex impulse in 5th and
6th spaces 5% inches from m.l. Left border 6% inches out. Right border 2^
inches to rt. of m.l. At apex sds. are loud and booming in quality. At apex

135

136 ST. LUKE'S HOSPITAL REPORTS

and heard over whole preeordium and transmitted to back is a loud systolic
murmur, almost replacing first sd. This murmur has a maximum intensity
at apex. To left of sternum in 5th space, murmur is almost musical in
character. Within nipple and to sternum action of heart is gallop rhythm.
Over base there is a soft systolic murmur. Both second sds. accentuated.

Pulse.— Regular, small, fair force, vessel wall palpable.

Lungs. — On right side posteriorly, beginning just below scapula, is slight dul-
ness, increasing to base. At extreme base fremitus, voice and breathing
sounds much diminished. An occasional rale heard at left base. Otherwise
lungs are clear.

Abdomen.— Lax; liver percusses to free border, edge not felt, but liver
region is somewhat tender on pressure. Spleen not palpable. No dulness
in flanks. No masses.

Extremities.— Knee-jerks present. Considerable edema present.

The day following admission there was noted a presystolic murmur of
rather short duration but distinct crescendo character just within and above
the apex, and at the apex a very faint diastolic murmur of a transitory
nature as it disappeared not to reappear.

The temperature was elevated, remaining between 102-101, the greater
part of his stay in the hospital, but toward the end becoming subnormal.

Repeated blood cultures failed to reveal the infecting organism.

The physical signs in the heart did not change, though at one time the
conduction time was increased owing to the effects of digitalis, and the sys-
tolic murmur became more intense and musical. His hydrothorax and con-
sequent dyspnoea were several times relieved by thoracentesis, but after a
long illness the patient died October 5 of a terminal infarction of the lung.

At no time did he complain of sudden, intense precordial pain, nor did
his dyspnoea suddenly become aggravated.

Autopsy, October 19, 1911, 2 P. M., by Dr. C. H. Bailey.— Body of well-
developed but emaciated adult male. Marked edema of hands, legs, and de-
pendent portions of body. Slight general jaundice. Pupils, 3 mm., normal;
conjunctivae, yellow.

Peritoneum.— About one liter of clear yellow fluid in abdominal cavity.
Over anterior surface of liver, especially right lobe, are patches of firmly ad-
herent organized exudate, also over surface of spleen, and a few patches on
intestines. Firm adhesions join the omentum to the parietal peritoneum on
the left side in the region of the splenic flexure and upper portion of the
descending colon.

Pleura.— Pleural cavities contain together 3,300 c.c. clear yellow fluid.
Somewhat more in right than left. Left lung firmly adherent at apex.

Lungs.— At the base of the right lung anteriorly is a roughly circular area
of consolidation, about 3 cm. in diameter, deep red on section, slightly raised
base surrounding surface and with fairly sharply defined outlines.

A branch of the right pulmonary artery leading to the right lower lobe
Is completely thrombosed. The thrombus extends from the root of the lung,
where it protrudes into the auricle as a free tongue-like mass to the posterior

RUPTURE OF CHORD.E TENDINE^E 137

portion of the left base. It completely plugs the vessel, is a little more than
1 cm. in diameter at its upper part, is grayish in color, with red mottling
and generally firm, but in places softened. The whole lung, especially the
base, is congested and edematous, but the tissue surrounding this vessel
shows no sign of infarction. No thrombosed vessel is found leading to the
area of consolidation in the anterior portion of right base already described.

Left lung.— At left apex are two or three fibrous scars and one calcareous
nodule about 2 mm. in diameter. On anterior edge of upper lobe, about 3
inches below apex, is a roughly wedge-shaped area of consolidation, deep red
on section, and with rather sharply defined limits. At its apex is a
thrombosed vessel about 3 mm. in diameter. This thrombus is rather firmly
attached to the vessel wall in places. A similar area is present in the an-
terior edge of the lower lobe.

Pericardium.— Contains about 50 c.c. of clear yellow fluid. On surface of
heart are numerous large irregular whitish areas of organized exudate which
are torn from the wall with some difficulty. The surface of these is generally
smooth; one, about 2 cm. in diameter, on anterior surface of left ventricle,
has an irregular, ragged surface.

Heart.— Very large, 570 gms. weight. A tough grayish clot is firmly ad-
herent to the musculi pectinati of the right auricle. Tricuspid orifice dilated,
16.5 cm. Cusps normal. Pulmonary, 11 cm., normal.

On opening the left auricle, the anterior cusp of the mitral, and its chordae
tendineae, is seen protruding into the auricle, the latter having been torn from
their attachment to the muscles. On the auricular wall, about 3 cm. above
the auriculo-ventricular orifice, are a few small, rough, yellowish vegeta-
tions. The mitral orifice measures 14 mm. The anterior cusp, all the chordae
tendineae of which are torn from their attachment to the heart-wall, contains
several nodular thickenings, but no recent process is apparent. The chordae
tendineae attached to it are of apparently normal length, but enlarged, soft and
yellowish in color, and appear to have been recently ruptured. At the sum-
mit of the anterior papillary muscle is a small stump which was evidently
the point of attachment of one of the broken chordae. There are two similar
nodules in one of the cords of the posterior cusp near its attachment to the
posterior papillary muscle. It is impossible to tell in the gross, whether
these are vegetations or former points of attachment of the ruptured cords.

The posterior cusp also shows numerous nodular thickenings. Two hard,
calcareous nodules, one nearly a centimeter in diameter, are felt in the sub-
stance of the cusp at its base. Over the larger of these, at the point of junc-
tion of cusp and auricular wall, is a small depressed area with rough surface.
Over the other nodules the endocardium is smooth and glistening.

The aortic cusps are normal— 9 cm. Heart-muscle appears normal. Right
ventricular wall measures 2 cm. Coronaries normal.

Spleen.— 255 gms. On surface are several patches of firmly adherent or-
ganized exudate. Capsule thickened. Very firm, deep red, trabecula
prominent.

Liver.— Greenish-yellow with thickly scattered deep red points ("nutmeg
liver").

138 ST. LUKE'S HOSPITAL REPORTS

Gall-Bladder.— Contains large amount of very thick greenish-red bile.
Hepatic and common ducts admit passage of probe easily, and on dissection
no calculi or other obstruction found.

Pancreas.— Normal.

Kidneys. — L. 195 gms., R. 195 gms. Capsules strip easily. Tissue slightly
yellowish and opaque. Otherwise normal.

Stomach. — Intestines normal. Bladder normal.

Anatomical Diagnosis.— Chronic adhesive peritonitis; pericarditis; healed
tuberculosis; double hydrothorax; thrombosis of branches of pulmonary ar-
tery; infarction of both lungs; cardiac hypertrophy; acute endocarditis; rup-
ture of chordae of anterior cusp of mitral; chronic passive congestion of liver
and spleen.

Bacteriological. — Culture from heart's blood: No growth.

Microscopical. — Liver: Intense congestion about central veins with result-
ing atrophy of liver cells in center of acini. Many of liver cells about these
areas filled with dark pigment.

Pancreas.— Slight increase of interstitial tissue.

Kidneys.— Capillaries congested. A few sclerosed glomeruli.

Pulmonary Artery. — Branch shows occluding thrombus of fibrin. It is ad-
herent to wall in places. Degenerated in center. Undergoing organization at
attachment to wall on one side. Another section shows occluding thrombus of
large branch, extensively organized, except in center, which consists largely
of red blood capsules. Surrounding lung tissue infarcted.

Lung.— Area of infarction consists of extravasated blood and exfoliated
cells of alveoli; over a large portion outlines of alveoli only roughly indi-
cated by broken-down connective tissue septa. Many of the exfoliated epi-
thelial cells of the air-vesicles are loaded with pigment. Two small vessels
show partial obliteration of lumen by fibrin and red cells, partially organized.

Heart. — Muscle, slight brown atrophy.

Chordse tendineae show evidence of old chronic inflammation.

The case presented is of unusual interest on account of the rarity
of the lesion, its mode of production and the occurrence of a pre-
systolic murmur in the absence of stenosis of the mitral valve. A
review of the literature shows 50 reported cases, including 8 ruptures
of papillary muscles, a synopsis of which is appended to the present
report. Many of them are old, some in the days before the use of
refined methods of physical examination, and even that reported by
so great a master as Laennec is difficult of analysis, owing to the in-
correct views obtaining as to the production of the second heart tone,
so that his statement that "The contraction of the auricle as long as
that of the ventricle donnait le bruit de sufflet" leaves one in doubt
as to his meaning. Presumably, as he regards the second sound of
the heart as synchronous in time with auricular systole, the murmur
heard was diastolic in time. As regards the cause of the rupture, the

RUPTURE OF CHORDS TENDINEiE 139

tendency of the early observers is to lay stress on physical effort and
trauma, though if the cases be analyzed, in many of them an endo-
carditis was obviously present, as proven by vegetations or valve
change, described in the autopsy reports. These changes were con-
sidered by some to be secondary, but precisely on what ground it is
difficult to see, except from the absence of symptoms prior to the
trauma or strain.

On dividing the cases as reported, it seemed wise to classify as
follows :

1. Those cases due to severe traumata, such as fractured ribs from
violent compressions, falls from a considerable height, stab wounds, gun-shot
wound, in one the kick of a horse. Of this group seven cases were found
resulting in a tearing of papillary muscle rather than the chorda? themselves,
these latter being due to stab and gun-shot wounds, and a fall from a win-
dow, respectively. That trauma of such severity in the region of the pre-
cordium could result in rupture of the chordae will, I think, be admitted with-
out comment.

2. Cases of ruptured chordae in which the rupture has followed efforts
such as straining, lifting, excessive fatigue, severe cough, in which the
autopsy disclosed no reported endocardial lesions in the heart. Of these five
cases are reported of which two showed blood-vessel lesions, one an aortic
aneurism, and the other coronary sclerosis. Two cases also showed papil-
lary muscle rupture, leaving only one case of actual chordae rupture in hearts
apparently free from any other lesion. This is the case of Dickinson. The
patient, a young male, twenty-one years of age, had a severe pain under the
left nipple while lifting a load of bricks, developed immediate signs of cardiac
insufficiency and died in two months. Autopsy carefully describes the valves
as normal, except for rupture of the chordae attached to the posterior cusp
of the mitral valve.

3. Cases of rupture said to be due to or preceded by strain, but in which
endocardial or myocardial lesions were also found at autopsy. In this class
nine cases are found.

4. Cases of rupture of the chordae, in which endocardial lesion was
found, but not following known history of strain or trauma. In this class
are nineteen cases. Among these are a number in which no history was
given or obtainable, these constituting a sub-class of mere pathological
reports.

5. Reported cases of rupture in which data given are insufficient to de-
termine the probable cause in which no autopsy has been made and one
("Gilbin") whose report was not accessible. In this class are ten cases.

Obviously, the cases with pathological change in the heart vastly
outnumber the cases without 28 to 12, and if we exclude the severe
traumatic cases, we reduce this latter group to 5, which may be still

140 ST. LUKE'S HOSPITAL REPORTS

further reduced to 3 by excluding the 2 cases with vascular disease.
Of the remainder, 2 are ruptures of the papillary muscle, leaving
but 1 in which the chordae alone were ruptured. Over-strain alone
would therefore seem to be an infrequent cause of this occurrence,
unless we regard the rupture itself capable of secondarily causing
an endocarditis. This is the position of de Quervain, who reports a
case of malignant endocarditis following a sudden muscular exertion.
This contention he supports by quoting the production of endocardial
lesion in animals by damaging the valves mechanically.

Experimental evidence of the difficulty of rupturing the healthy
chorda? is afforded by Barie, who, while able to produce aortic rup-
tures with pressures of 170-400 mm. of Hg, was able to produce rup-
ture of the chordae in only one case, and that at 1,085 mm. of Hg., a
pressure that is almost inconceivable in the ventricles, and which ap-
parently, under experimental conditions, is more liable to rupture the
heart-walls themselves than the chordae. The ordinary pressure in
the ventricle is but slightly higher than the pressure in the aorta,
which may be taken roughly as its measure, maximal 3-400 mm.
Other authors, as Libman, report in cases of subacute endocarditis
such as are caused by his streptococcus viridans, the not infrequent
localization of vegetations on the chordae and occasional rupture, so
that the number of ruptured chordae may be much greater than the
reported cases indicate.

It seems fair to assume, then, that the healthy chorda is rarely
if ever ruptured by strain or exertion, and that a pre-existent endo-
carditis is necessary to rupture. That effort may rupture a diseased
chorda is obvious. From the examination, it is impossible, in the re-
ported case, to state the date of the rupture of the chordae. Prob-
ably, giving way one by one, the lesion dates from his onset of symp-
toms, the gradual increase in symptoms being due to the increasing
insufficiency of his mitral valve.

The symptoms of such a lesion are, of course, outspoken signs of
mitral insufficiency with signs of cardiac insufficiency in proportion
to the number of chordae ruptured and the suddenness of the onset of
leakage before the heart can accommodate itself. In a case where the
patient is known to have had no cardiac signs, no enlargement of the
heart murmurs or symptoms due to insufficiency, and where following
a straining effort in which the intraventricular pressure may be as-
sumed to be greatly raised, a sudden severe pain is felt or a feeling
as of something having given way, followed by severe dyspnoea and

RUPTURE OF CHORDAE TENDINEiE 141

signs of mitral leakage, a rupture of this sort may properly be sus-
pected. On the other hand, when without history of strain, a mitral
leakage is found which gradually becomes worse owing perhaps to
the consecutive giving way of the tendons, the lesion is indistinguish-
able from an ordinary mitral insufficiency, and this will be the case
in the vast majority of such ruptures.

The origin of the presystolic murmur is less clear. Apart from
complicating mitral stenosis or outspoken aortic insufficiency, but
three instances are reported of a murmur occurring in diastole. The
doubtful case of Laennec, previously alluded to, makes a fourth. One
of these, that of Barie, may be attributed to the perforation in the
aortic valve producing a Flint murmur. The other two occurred in
cases where the papillary muscle was torn off, leaving the flap with
its tendons and muscles free to travel between auricle and ventricle,
respectively, in systole and diastole. The murmur was described, in
one case, as a systolic and diastolic murmur ; in the other, as a murmur
in time presystolic, but not having a true presystolic character. "It
was not soft, nor was it a squeak."

Our murmur was a fairly localized short murmur inside and above
the apex, heard at times as far as the left sternal border, and though
not intense, of a clearly rumbling, crescendo character.

As the anterior curtain of the mitral valve swung free it must
have traveled from auricle to ventricle with each diastole, and the
sound may conceivably have been due to the vibrations set up, par-
ticularly by the strong current of blood due to auricular systole.
Much as a sail flaps in the wind when a fore and aft vessel comes
about in a stiff breeze, so the increased strength of the blood current,
at this period of the cardiac cycle, may readily cause a murmur in
the heart due to the vibrations of the free flap.

A second possibility is that the abrupt termination of its course
from auricle to ventricle brought it up with much the effect of crack-
ing a whip.

SYNOPSIS OF PREVIOUSLY REPORTED CASES.

By Portal:

Observation concerning a case of rupture of two fleshy columns of the
mitral valve. The lesion also involved the wall of the left ventricle.

By Corvisart:

Man 39 years of age, abuser of alcohol; transitory attacks of rheumatism;
died soon after admission to hospital with symptoms of extreme dyspnoea.

Autopsy findings: Protuberant vegetations on margin of mitral valve
and on semilunar aortic valves. The segment of the mitral valve in front

142 ST. LUKE'S HOSPITAL REPORTS

of the aortic orifice was no longer attached by tendinous cords to the fleshy
columns. The chordae tendineae were ruptured, or detached, and it was
barely possible to trace two of these cords at the level of one of the fleshy
columns.

By Corvisart:

Man, 34 years of age, injured himself in trying to move, unaided, a barrel
of alcohol; suffered from cough and palpitation of the heart, mitral valve
studded with soft vegetations. In the examination of the pillars which sup-
port the mitral valve, two of them were seen to have been ruptured some
time ago. The extremities of these two tendons were soft, smooth, and
rounded at the site of rupture. It was not possible to locate on the border
of the valve the exact spot where they must have been inserted before the
rupture.

By Corvisart :

Courier, 30 years of age, was admitted to the hospital immediately after
a horseback ride of one thousand miles, without any rest; he had crossed the
Channel after this ride, and while at sea had felt a sudden great oppression,
with haemoptysis. He died soon after admission, under symptoms leading
prior to the autopsy to the diagnosis of an acute lesion of the heart, "un-
doubtedly a rupture of one of its parts." The left ventricle contained one
of the large columns which support the mitral valves, floating free in the
ventricular cavity. It had ruptured at its base, evidently quite recently, and
a small clot was found near the site of the rupture.

By Laennec:

Man, 35 years of age, was admitted to the Neckar Hospital in Paris, with
a history of heart trouble dating five months back. Thrill 5, 6, 7 spaces.
The contraction of the auricle as long as that of the ventricle "gave the bel-
lows sound." Death soon after admission.

Autopsy findings: The heart was enlarged, especially the left ventricle.
One of the tendons which pass from the extremity of the columns to the
free border of the mitral valve was ruptured towards its middle. The upper
portion was smooth, and was folded under the mitral valve, but without ad-
hesions. There were warty vegetations on mitral valve and left auricle.

By Bertin :

A consumptive girl, 22 years of age: a severe coughing fit led to rupture
of one of the muscular columns in which the tendons of the tricuspid valve
are inserted; at the autopsy this fleshy column was found to be broken, float-
ing free in midst of the ventricular cavity.

By R. Adams :

Cheyne's case : A musician, 34 years of age, strong and well nourished,
of irregular habits, was suddenly attacked with a very severe pain in the
left side of the chest, about the precordial region. The condition became
steadily worse, with edema of the lower extremities, digestive disturbances,
dyspnoea, loss of strength, cerebral symptoms, and so forth. Death about
two months after the onset of the symptoms.

Autopsy findings: The most interesting feature consisted in the rupture of
the chord;e tendineae which attach the left auriculo-ventricular valve to the

RUPTURE OF CHORDAE TENDINEiE 143

columnae carnese. This rupture concerned variable levels, four of these
tendons being found floating by one of their extremities in the interior of the
ventricular cavity. Excrescences on mitral and segmoid valves.

By Marat:

A man, 44 years of age, on laboriously rolling a very heavy barrel, sud-
denly felt something snap in the back, and was attacked by dyspnoea and
palpitation. Death twenty months after the accident.

Autopsy findings: One of the columnse carnese at which the tendinous
cords of the mitral valve are inserted, was entirely ruptured, and pulled
out. The patient also had an aneurism of the aorta, but he had never
before complained of disturbances, which did not begin until the painful sen-
sation referred to above.

By Nicod:

Autopsy findings, in case of a woman who had suffered from two attacks
of suffocation, the last terminating in death: Rupture of two fleshy columns
of the heart, at a distance from each other, of unequal length, with a different
coloration of the ends.

By Legendre:

Autopsy findings in the case of a man who died with symptoms of
dyspnoea, soon after fracture of the ribs, from violent compression: On
opening the left ventricle of the heart, a large fleshy column, with tendons
passing to the posterior segment of the mitral valve, was seen to be entirely
broken and curled up on itself, entangled in two of its tendons.

By Prescott Hewitt:

A boy of twelve years fell from a height and died four hours after the
accident. Autopsy findings: No external lesion on thoracic wall. Peri-
cardium intact. Ecchymosis at point corresponding to upper portion of in-
traventricular septum; this bloody extravasate came from a small tear of the
heart-wall which extended to the upper portion of the septum and established
a communication between the two ventricles. Two columnar carnese in the
left ventricle were torn.

By Williams :

Policeman, age 27 years, habitual user of alcohol, lost flesh and strength
for two years. Three months ago, on quickly mounting stairs, felt a very
sharp pain in epigastrium; some days later, edema of lower limbs, dyspnoea,
etc. At time of admission, urine was scanty, blood-tinged, and slightly al-
buminous. Heart hypertrophied. Auscultation: systolic murmur loudest
under left breast. Death a few days after admission.

Autopsy findings: The two mitral cusps were found to be thickened and
ossified; the chordae tendinese, inserted at the anterior valve, were ruptured at
unequal heights, and the fragments were lined with soft vegetations. Pos-
terior cusp was ossified, and its chordae tendinese were agglutinated.

By R. B. Todd:

A man, 31 years of age, was admitted to the hospital, with general edema,
enlargement of the liver, marked dyspnoea and frequent cough. History of
a stab wound, three years previously, in right side of chest, below nipple.
Death ten days after admission to hospital. Systolic murmur apex and base.

144 ST. LUKE'S HOSPITAL REPORTS

Autopsy findings: Other valves normal, but the tricuspid presented sev-
eral interesting lesions. The anterior segment of the valve, namely that
which separates the infundibulum from the auricular portion of the ven-
tricle, was suspended free in the ventricular cavity, retaining its connection
with the heart only at the level of the fibrous auriculo-ventricular orifice.
All the fibrous cords, inserted at the valve, were ruptured at different heights,
leaving a fringed valvular border. The fleshy columns in which the cords
originate were contracted and showed the rudiments of the broken chordae
tendinese. The extremities of the latter presented small bulgings, similar to
those seen at the end of the nerves in an amputation-stump.

By Gordon:

A woman, 26 years of age, who had been admitted to the Whitworth
Hospital with violent hsernoptosis. The diagnosis of rupture of the chordae
tendinese of the heart was rendered, on the basis of the sudden and violent
pain in the region of the heart, followed by intense palpitation and weakness,
as well as the decided character of the bruit, and fremissement at the root
of the neck. She lived ten days after her admission and then sank ; the im-
mediate cause of death was pulmonary apoplexy.

Examination showed very slight disease in the aortic valves; there was a
sight deposit in the central valve. Several of the chordse tendinese of the
anterior portions of the mitral valve were ruptured, and covered with a soft
cheesy matter. There seemed to have been slight endocardial inflammation,
followed by rupture of the chordse tendinese, and this by the effusion of
lymph, which lay in great quantities loose in the ventricle.

By Allix:

A prostitute, 25 years of age, was admitted to the St. Jean Hospital in
Brussels, having become unconscious a few instants before. Auscultation was
impossible ; heart sounds were confused and arrhythmic, but accompanied by a
distinct vibratory thrill. Patient died one hour after admission. Thrill
marked.

Autopsy findings: Trace of an old endopericarditis, marked hypertrophy
of the left ventricle. On opening the cavities, it was seen that the chordae
tendinese, passing from the summit of the principal left columna carnea to the
free border of the anterior segment of the mitral valve, were ruptured in the
middle; these tendons were very fragile and easily torn; their surface was
found to present a large number of small, round, wartlike vegetations.

By Charles A. Lee:

Man, age 65 years, while driving a stake into the ground with a heavy
piece of wood, felt something give way suddenly in the region of the heart,
and immediately fell to the earth, gasping for breath, and laboring under ex-
cessive pain and dyspnoea. He never was well again, but lived for about ten
months afterwards, with increasing symptoms of heart disease.

Autopsy: The endocardial membrane was much thickened from chronic
inflammation; organized lymph was deposited beneath it. Several of the
chordse tendinese of the mitral valve had evidently been ruptured, as only
their shriveled remains were visible, while others, both of the tricuspid and
mitral, were so contracted and adherent to each other as to contract the cir-

RUPTURE OF CHORDAE TENDINEAE 145

cumference of the valves to such an extent as almost to close their orifice,
and, of course, to prevent entirely their healthy play.

Blakiston found the chordae tendineae shortened in 20 out of 46 cases of
tricuspid regurgitation. In one he says, "One of the chords had apparently
been broken, and was curled up into a nodule, like a pin's head" (p. 291)
(cit. Lee).

By Austin Flint:

Woman. 35 years of age, who had suffered for some years from heart
disease. "The interesting point connected with the specimen is not the con-
traction of the mitral orifice, which is common enough, but the presence of
two vegetations of considerable size, one as large as a bean, the other some-
what smaller. The larger one is attached to the papillary muscle of the
inferior curtain by what appears to be a small pedicle, which is a fractured
extremity of one of the tendinous cords. The other concretion is upon an-
other tendinous cord which has not been fractured.

By van Giesen :

Man, aged 24 years, was admitted to U. S. Naval Hospital, and presented
hypertrophy of the heart, with tumultuous action, and a murmur with the
first sound transmitted along the course of the aorta. Gradual aggravation,
death about six months later.

Autopsy findings in heart : On opening the left ventricle, the aortic valves
are found to be thickened, contracted and studded with tenacious, fibrinous
vegetations. The anterior portion of the mitral valve is also covered with sim-
ilar vegetations. The chordae tendineae of the anterior portion of the mitral
valve are all ruptured, shortened, and covered with tenacious, fibrinous effu-
sion. The free extremities, which are expanded into small bean-shaped bodies
when drawn with moderate force toward their original muscular attachment,
will not meet by about a quarter of an inch. The chordae tendineae of the
remaining portions of the mitral valve are healthy, presenting no traces of
atheroma or ulceration.

Dr. Stokes (cit. v. Giesen), in his work upon Diseases of the Heart and
Aorta, details a case, extracted from the records of the Pathological Society,
which in many respects is similar to the one observed by v. Giesen :

"The cords of the anterior portion of the mitral valve were all broken
across near to the fleshy columns; they were thickened, softened, and cov-
ered with beads of very soft lymph."

By J. Pollack:

A woman, 42 years old, was admitted to King's College Hospital with
severe pain palpitation, dyspnoea, and haemoptysis. Dr. Johnson diagnosed
rupture of one or more of the chordae tendineae of the mitral valve.

Post-mortem examination of heart: The pericardium contained four ounces
of serum. The heart was large, the left ventricle being hypertrophied more
than the right. One of the chordae tendineae of the mitral valve was rup-
tured. Mitral valve was diseased, and the orifice contracted. Aortic valves
much thickened.

By Kelly:

Description of specimen derived from a woman aged 49 years. Symp-

146 ST. LUKE'S HOSPITAL REPORTS

toms of heart disease for about two months prior to death. Autopsy: Left
ventricle somewhat dilated, aortic valves healthy, slight atheroma of ascend-
ing aorta. The anterior curtain of the mitral valve was fringed on the auric-
ular side with some fibrinous beads, and some were found on the tendinous
cords also. The posterior curtain was found lying loose; all the chordae
tendineae were ruptured, and many were much shorter than usual ; some had
a small bead of fibrin on their free extremity; all broke off close to a
fibrinous deposit. It is probable that they were not all ruptured at once, as
in some the fracture seemed quite smooth, while in others there was a little
fibrin on the free extremity.

By Dickinson :

Patient, male, age 21 years. Perfectly well until four months previously,
when he suddenly felt pain under left nipple whilst lifting heavy loads of
bricks. Unable to work since, became worse in hospital, and died after two
months.

Diagnosis of laceration of chordae tendineae in mitral valve was confirmed
by autopsy findings. The chordae tendineae attached to the lower edge of the
posterior flap of the mitral valve were all broken close to their insertion into
the fleshy columns, excepting that one or two cords remained entire at one
corner of the curtain. A solitary tendinous cord, which was attached at the
base of the flap near its center, remained entire. The segment of the valve
of which the cords had been broken, appeared to have lost all valvular action,
and must have swung uselessly from its base. The broken cords hung with
loose ends, which had become somewhat thinned. The free edges of the
mitral valve had become somewhat thickened and opaque.

By Bristowe:

Patient, man, age 62 years, died under symptoms of heart disease, which
came on almost suddenly about three weeks before his admission to hospital.

Autopsy findings: One of the tendinous cords attached to the posterior
flap of the mitral valve was ruptured, the cord was much swollen, and of
an opaque yellow tint; this change was most marked in the situation of the
rupture. The lower portion of valve was dilated into a pouch and had a
deep rugged notch. Mitral was normal in all other respects. Aortic valve
was perfectly healthy. Coronary arteries, calcareous.

By Hanot:

The patient, a man, 37 years of age, was admitted with all the signs of
mitral insufficiency: systolic murmur at apex, edema of lower limbs, enlarged
liver, signs of bronchitis, etc. After three weeks' stay in the hospital, he was
suddenly attacked by oppression and breathlessness; the face was livid, the
body covered with clammy sweat; irregular heart-action, rapid death.

Autopsy findings: Aorta, intact; valvular lesions of mitral valve; also
three valvular tendons, about one centimeter long, whitish and thickened,
were found to be ruptured and floating in the ventricular cavity.

By Le Piez :

A woman, 24 years of age, died suddenly (in syncope) on getting up out
of bed, a fortnight after the onset of symptoms pointing to heart disease (no
abnormal sounds in heart). At the autopsy, the heart-wall was found to be

RUPTURE OF CHORDS TENDINE^] 147

friable and in a state of fatty degeneration. One of the fleshy columns of
the heart was ruptured, cut in two, at the junction of the two lower thirds
and the upper third. The segment, where the chordae tendineae are inserted,
was displaced between the two mitral valves. One rather large-sized ten-
dinous cord was completely ruptured; it did not belong to the ruptured
column.

By Gilbin:

Personal observation of a case of rupture of the tendons of the mitral
valve. Records not accessible.

By A. W. Foot:

Man, aged 23 years, who had died suddenly while in the act of getting into
bed. (All the physical signs of regurgitation through the mitral valve had
been present.) The cords, which were found broken across about the middle
of their course, were two or three of those attached to the musculus papil-
laris, which regulates the larger curtain of the mitral valve, and were those
nearest to that portion of the curtain which is adjacent to the interventric-
ular septum. The broken cords were studded with warty nodules of fibrin ;
both the ventricular and auricular surfaces of the principal curtain of the
valve were covered with vegetations of a similar character, and continuous
with those creeping along the chordae tendineae.

By Willard Parker, 1859:

The patient lived several years, suffering with heart disease. There were
also fibrinous granulations upon the cords.

By Willard Parker:

Sudden rupture of the chordae tendineae, while running to a fire. Death
occurred a few months afterwards.

By J. C. Dalton, 1859:

A man. aged 40, whose previous history was unknown, was found in his
room comatose and died one hour later.

Autopsy: The mitral valves were covered with several small vegetations.
Two of the tendinous cords attached to the inner portion of the anterior cur-
tain of the valve were ruptured.

The rupture was at the point of attachment of the cords to the valve.
The free ends of the cords were covered with fibrin, giving them a bulbous
shape.

By Alonzo Clark:

There were vegetations on the broken ends of the cords, and upon the
valves connected with them. There were vegetations on the cords of three
or four other specimens which had been presented to the Society. In one
case there was a thinning of the cords, ending in rupture; in other cases,
the cords were thickened, but softened. Chordal inflammation is apt to
be followed by vegetations, softening, and rupture.

By J. T. Metcalf:

Man, age 23 years, became rheumatic after an injury to the side and ex-
posure to cold; developed dyspnoea, edema of face, ascites, anasarca. Rough
systolic murmur over mitral valves, effusion into pericardium and both
pleurae; albuminuria. Death from exhaustion.

148 ST. LUKE'S HOSPITAL REPORTS

Autopsy: Several chordae tendineae were ruptured. The aortic valves were
studded with fibrin and insufficient; there was a large white clot in the
heart.

By Lionville:

Case of an old woman, in whom the columns of the mitral valve were
ruptured in consequence of a fall from a window on the third floor.

By Terrillon :

Man, age 48 years, gun-shot wound of chest, penetrating the seventh rib;
death twelve hours later. Autopsy showed extensive ecchymoses in the peri-
cardium and myocardium of the anterior wall of the left ventricle; no solu-
tion of continuity; rupture of individual trabecules and mitral tendons.

By Potain cit. Barie. Revue de Medicine, 1881, p. 318.

A young woman died rapidly, in the Petie Hospital of Paris, under symp-
toms which were referred to puerperal endocarditis. At the autopsy, all the
tendinous cords of the flaps of the mitral valve were found to be ruptured,
so as to produce a true acute insufficiency.

By BariS:

Woman, age 56 years; history of articular rheumatism, followed by symp-
toms of heart disease; mitral systolic murmur; thrill, death one week after
admission to hospital. Autopsy: Heart not enlarged, cavities small, walls
of left ventricle slightly thickened. The mitral valve was whitish and some-
what thickened; on testing with water, it was found that the posterior valve
did not fit against the anterior valve, but floated in midst of the fluid, in
consequence of rupture of four of its tendons. These tendons were broken
about the level of their middle portion; they were somewhat thinned, but
on examination presented no inflammatory changes. The aortic valves were
normal. The tricuspid valve was intact and sufficient.

By Potain:

Rupture des tendons de la valvule mitrale. L'Union Midicale, 1891, p. 279.

Man, 72 years of age, who had died with symptoms of mitral insuffi-
ciency; the autopsy showed the presence of rupture of one of the tendons of
the great mitral valve. The tendon had given way close to its insertion,
and either floated in the ventricle, or became interposed between the flaps
of the valve, preventing their accurate junction, and giving rise to intermit-
tent mitral insufficiency.

By C. W. Sharpies:

Laborer; systolic and presystolic murmur, latter not characteristic in
quality.

At the autopsy of a man 45 years of age, there were found lesions of
auricular endocarditis, and a rupture of the chordae tendineae, which were
changed in appearance and character, being all that were attached, most
anteriorly and nearest the center of the valve, with only one remaining on
the left; thus leaving the valve to flap back and forth without its normal
control. The longest chordal fragment on the valve was three-fourths of an
inch long. It was softened, thickened, and beaded, smooth over most of its
length, with one hanging vegetation. Attached to another broken chorda
was a mass half an inch long and one-eighth in diameter, fastened by a

RUPTURE OF CHORDAE TENDINESE 140

narrow, small, short pedicle. Otherwise it was free to flap about in the
ventricle. The other chordae presented no peculiarities, except that they
were thick, soft, and very friable. One of the transverse bands connecting
two chordae near their origin presented a large vegetation.

By Degny Huchard :

Man, 42 years of age, mitral insufficiency, also aortic insufficiency.
Autopsy: The tendinous cords inserted at the posterior pillar (angle of sep-
tum and ventricular wall) were adherent to the posterior commissure of the
great mitral (cardio-aortic) valve. These parts were rigid and calcified, on
one arterial surface. Analogous lesions were noted at the summit of the
anterior pillar and the anterior commissure of the great mitral valve and
the connecting chordae tendinese. But here the chorda? tendinese were rup-
tured, one large tendon in particular being broken off about one centi-
meter from its insertion at the valve, so that this anterior portion of the
great mitral valve, being free from all tendinous chords, had become dis-
placed upwards, into the left auricle. Only the presence of the rigid calci-
fied tendon stump, which remained adherent to the great valve for about
one centimeter, caused the luxation of this portion of the valve to remain
stationary. The rigidity of the chorda? tendinese in front, opposite the small
valves, acted like a rigid body placed crosswise, and prevented the great
valve from resuming its normal position.

By Halle:

In the case of a man 63 years of age, who had died from broncho-pneu-
monia, after suffering for two months from symptoms of heart disease, the
autopsy showed the rupture of several tendons and chorda? tendinea?, on
the left pillar of the mitral valve; two of these small tendons floated free
in the auricle.

By Poupon :

Man, 41 years of age, who had died rrom a ruptured gastric ulcer; the
mitral valve was found to be insufficient and the seat of peculiar changes.
A softened vegetation, probably a band attached to the lower border of the
anterior pillar, floated free in the cavity, toward the cardiac apex, and
therefore in the direction of the blood-stream. The flaps of the mitral valve
were extremely thick and hard, with scattered calcified spots. The an-
terior pillars of the second class were connected by fibrous bands; one of
these pillars presented an ulcer, with calcified margins. All the constituents
of the mitral valve and its pillars were considerably hypertrophied.

The emboli found at the autopsy were attributed to the rupture of a
tendinous band of a pillar of the mitral valve; the band itself was inter-
preted as the result of an old endocarditis. Murmur at apex. Time not de-
termined.

By Henry :

Rupture of the posterior papillary muscle, 2 cm. in length (one in thick-
ness), of the mitral valve, in a young robust male, known to be in good
health two years previously. Death after about eight months, after transi-
tory improvement, following upon traumatism (a kick from a horse) directly on
precordium. The clinical picture showed a complicated recent cardiac af-

150 ST. LUKE'S HOSPITAL REPORTS

fectlon, with the sole symptoms of diastolic-systolic murmurs and dilated
heart (ox-heart), which were explained by the free floating papillary muscle;
this hung suspended from the chordae tendineae, and was necessarily thrown
constantly from the ventricle into the auricle, and back again through the
blood-current and the cardiac contractions.
By de Quervain:

Man, age 35 years, in good health, experienced a sudden painful sensa-
tion In the chest, when holding up a very heavy barrel; this was followed
by epistaxis and bloody expectoration. Later, cyanosis, increased frequency
of pulse-rate, and cardiac distress. No findings early on auscultation, but
three weeks later, a rough systolic murmur was heard at the mitral valve.
The general condition became worse, and seven weeks after the accident,
the patient died with symptoms of cerebral embolism.

Autopsy findings: Circumscribed thickenings at free margins of anterior
mitral flap, 1% cm. long, 1 cm. wide, irregular and friable. The valve in
this area presented no chordae tendinese, but there was the stump of one.
Microscopically, the thickening was interpreted as a fresh endocarditis pro-
liferation, in part ulcerative in character.

By Schmidt:

A man 85 years old fell out of the window, from the second floor, land-
ing on the left side of the thorax.

Autopsy findings in heart: Posterior aortic valve presented a rupture
through its entire thickness. There was also a tear 2 mm. long at the
lower surface of the anterior mitral flap. The simultaneous rupture of the
mitral valve is explained by the author in such a way that after the aortic
rupture, the sudden back-flow of the aortic blood struck the open mitral
valve, thrusting it up, and partly tearing it away from its support, the
chordae tendinese. The rupture had occurred immediately above the inser-
tion of a tendinous cord of the second class, which is inserted at some
distance from the free margin, on the surface of the valve. Otherwise the
mitral valve and its tendinous cords, as well as the right-sided valves, were
unchanged. The heart was slightly atrophic; no degeneration of the
myocardium.

By Buchanan :

Male. Symptoms, cardiac insufficiency with fever four years before.
Systolic murmur over cardiac area toward axilla over vessel of neck.

Autopsy: Mitral admits 3 fingers; anterior curtain presents an irregular
fringe of ruptured chordae, 8 in number. Free extremities bulbous and
granular from endocardial thickening. One papillary muscle, soft, pale, atro-
phied, is completely severed from tendon. A few vegetations on margin of
curtain freed by rupture.

By Hawthorne :

Male. Gave up rowing three years before death on account of "weak-
ness." No definite mitral insufficiency. Presystolic thrill and murmur at
apex. Systolic over whole precordium.

Autopsy: Mitral stenosis. Anterior flap projects into and half closes

RUPTURE OF CHORDAE TENDINE^J 151

orifice. Three tendons are torn. Endothelium granular and swollen. Free
edge of curtain studded with vegetations.

By Barie :

Case showing presystolic thrill and presystolic and systolic murmur at
apex. Also diastolic at base.

Autopsy: No mitral stenosis. Two chordae of anterior valve ruptured,
mitral calcareous. Hole in posterior cusp of the aortic valve.

By Gordon :

Not accessible.

By Jayle:

Systolic murmur at apex.

Autopsy: Rupture of the tendon at anterior flap.

By Norris:

Signs of mitral disease following lifting effort. Examined before; no
signs. After systolic murmur at apex. Suspicion of presystolic.

Diagnosis made of ruptured chordae. No autopsy.

BIBLIOGRAPHY.

Portal. Acad. Sciences, 1784.

Corvisart. Essai sur les maladies du coeur, 1811. Lection. P. 218.

Corvisart. Ibid. P. 267.

Corvisart. Ibid. Observation 40, p. 263.

Laennec. Auscult. Mediate, T. II, p. 626 (1819).

Bertin. Trait6 des Maladies du Coeur et des Gros Vaisseaux. Paris, 1824.

R. Adams. Dublin Hospital Reports, 1827, p. 404.

Marat. Journal de M6d. Contemp., T. VI, p. 587.

Nicod. Jour. Hebdom. des Progres des Sciences Med., IV, 1834, p. 42.

Legendre. SocietS Anatom., 1839, p. 195.

Prescott Hewitt. London Medical Gazette, 1847.

Williams. London Medical Gaaette, 1847.

Todd, R. B., Dublin Quarterly Jour, of Medicine, 1848.

Gordon. Dublin Medical Gazette, I, 1854, p. 123.

Allix. Annales Societe anat. patholog., Bruxelles, Vol. I, 1859.

Lee, Charles A. American Medical Gazette, Vol. XI, Sept., 1860, p. 641.

Blakiston. P. 2911 (cit. Lee).

Austin Flint. N. Y. Med. Times, March 29, 1862.

Ransford E. van Giesen. The Medical and Surgical Reporter, Vol. VIII,
1862.

Dr. Stokes. Diseases of the Heart and Aorta (cit. v. Giesen).

Pollock, J. Transactions of the Pathol. Society of London, Vol. 16, 1865,
P. 82.

Kelly. Trans. London Pathol. Soc, XX, 1869, p. 153.

Dickinson. Trans. London Pathol. Soc., XX, 1869, p. 150.

Bristowe. Trans. London Pathol. Soc., 1873, p. 22.

Hanot Soci6t6 Anatomique, 1879, p. 867.

Gilbin. These de Paris, 1873.

Le Piez. These de Paris, 1873.

152 ST. LUKE'S HOSPITAL REPORTS

Foot, A. W. Dublin Journal of Medical Science, Vol. 58, 1874, p. 254.

Willard Parker, 1859. Trans. N. Y. Pathol. Soc, I, 1876, p. 98.

Willard Parker, 1849. Ibid.

Dalton, J. C. Trans. N. Y. Pathol. Soc., I, 1876, p. 97.

Alonzo Clark. Trans. N. Y. Pathol. Soc, I, 1876, p. 98.

Metcalf, J. T. Trans. N. Y. Pathol. Society, I, 1876, p. 97.

Lionville. Mem. Med. Milit, 1878, p. 377.

Terrillon. Le Progres Medical, 1879, p. 237.

Potain, cit. Barie, Revue de Medicine, 1881, p. 318.

Potain, Union Medicale, 1881.

Baric Revue de Medicine, 1881.

Potain. L'Union Medicale, 1891, p. 277.

Sharpies, 0. W., Medical News, March 12, 1892, p. 295.

Huchard, Degny. Journal des Praticiens, 1898, p. 164.

Halle. Journal des Praticiens, 1898, p. 143.

Poupon. Bulletins de la Soc. Anatom. de Paris, 1885, 7, 201.

Henry. Korr. Blatt fur Schweizer Aerzte, Vol. 37, 1907, p. 761.

de Quervain. Semaine M6dicale, No. 21, 1902, p. 169.

Schmidt. Miinchener Med. Wchschrft, No. 38, 1902, p. 1565.

Buchanan. Glasgow Med. J., 1894, XLII, 65-67.

Hawthorne. Glasgow, Med. J., 1894, XLII.

Barie. Rev. Med. de l'Est Nancy, '85, XVII, 374-378.

Gordon. Proc. Path. Soc, Dublin, 1875.

Jayle. Bull. Soc. Anat. de Paris, 1893, LXVIII, 170-172.

Norris. International S. J. M. & S., Melbourne, 1894, T. 242.

A REPORT OF TWO UNUSUAL CASES OF SEPSIS.
Lewis F. Frissell, M.D.

S. H., boy, 12 years old, was sent to the hospital July 12th, with a
diagnosis of appendicitis. He had been a Boy Scout, and was per-
fectly well up to July 9th, in camp. On this date he had had some
altercation with the other boys and thinks the parts in the neighbor-
hood of the root of the penis were injured. Since that time he has
felt weak and has had pain in the right inguinal region, low down.
He was nauseated and vomited several times.

There had probably been fever for some time, as patient on ad-
mission was irrational and his history is not dependable, that of the
trauma being due possibly to a delusion arising from catheterization.
His admission temperature was 1$5 2/4, P. 100, P. 28. When first
seen in consultation on the surgical division, at the request of the at-
tending surgeon, the boy looked acutely ill, and presented, on physical
examination, no focal symptoms beyond acute local tenderness in the
right groin, apparently maximal at a point just to the right of the
symphysis pubis. This, with an enlarged spleen and one or two
erythematous spots on the abdomen, were all that could be found.

Evidence of wounds, trauma, pus pockets around the teeth, tonsils,
or ears were not present.

A blood culture was taken and positive diagnosis withheld.

Two days later, on July 15th, he was admitted to the medical ward.
The complete physical examination follows.

The patient is an undersized, fairly well nourished boy of 12 years, appear-
ing acutely ill. There is no dyspnea, cyanosis or jaundice. The skin and
mucous membranes are of good color. He is slightly irrational ; muscular
tremor of hands and arms. On turning in bed, he moves slowly and carefully,
as if motion were painful. Patient is generally hypersesthetic.

Eyes.— Pupils equal and react to light and accommodation. Tongue dry,
coated, tremulous.

Throat.— Tonsils are slightly enlarged. Neck, sub-maxillary gland on left

153

154 ST. LUKE'S HOSPITAL REPORTS

side of jaw palpable; no other glands enlarged. Chest, fair development and
expansion.

Heart. — Visible apex beat in fifth space, 3 inches from mid-line. Left
border, 3% inches. Right border, 1 inch to right of mid-line. Sounds of
good quality, no murmurs heard. Second sound loud and snapping. Pulse
regular, good force, vessel wall not thickened. Lungs clear. Abdomen,
even contour, not soft, no rigidity made out. Spleen, sharp edge palpable
1 inch below costal margin in nipple line. No abdominal tenderness. There
is marked tenderness to gentle pressure on the rim of pelvis just to right
of symphysis. An inguinal gland is palpable on right side, smaller one to
left.

Extremities.— K. J. present. Kernig's sign present. Babinski's absent
Abduction of right leg causes pain, but not flexion or rotation.

The elbow of the right arm is swollen, red and tender; there is limitation
of motion, due to pain. On the outer edge of hand is a small pustule.

Rectal Examination.— There is tenderness on right side at the line of the
pelvis; the sharp edge of rim is not felt as plainly as on the other side.

Eye Grounds.— Normal.

Ears.— Normal.

Urine. — Acid 1,020 ; alb. trace sugar 0 ; few granular casts. Leucocytes 13,-
000, P. 75%. Widal negative.

In 48 hours there had developed an inflamed joint and a pustule; a ten-
tative diagnosis of septicemia was made.

July 16.— Right ankle and left hip involved; another pustule developed
on shin. The heart showed a systolic murmur over the pulmonary area.
There was some rigidity of neck.

Lumbar puncture; no increase of pressure; fluid clear; few cells; all
lymphocytes.

July 18.— Culture from pustules shows staphylococcus aureus. Report of
blood culture shows staphylococcus aureus; spinal fluid shows no growth.

The temperature has been high, 101-104°, without chills, perspiration or
extreme variations.

The right ankle joint was opened and treated surgically.

On July 28, an extensive urticarial eruption appeared on the chest and
abdomen, and the autogenous vaccine treatment stopped in consequence.

July 29.— The urticarial eruption has disappeared, but on right chest and
in axillary region and along right costal margin are large hemorrhagic
spots.

Heart. — A soft systolic murmur has appeared at the apex, transmitted to
the axilla.

Death occurred on August 1.

The entire case presents the appearance of a malignant sepsis,
the main interest being the site of the original focus.

The arduous life of a Boy Scout in camp precludes the possibility
of an acute septic process before July 9th, and, while the heart valves,

MALIGNANT SEPSIS 155

of course, may have been involved from the start, evidence of old
valvular trouble was lacking.

If the boy's tale of maltreatment, told in delirium, be true, this
may account for the localization of the process in the os pubis, the
infection being caused by some wandering staphylococcus.

Case 2.— M. M., 44 years, housekeeper. Patient was admitted to the
ward July 23, 1911. At the time of admission she was irrational. Her
history, in consequence, was not to be depended on. From members of her
family an incomplete anamnesis was obtained. Since infancy she had suf-
fered from some paralysis of the left side, which had caused a limp and a
deformity of the fingers of the left hand, which, however, was not func-
tionless.

Otitis media of right ear for years. Date of original trouble unknown.
It probably followed an attack of measles, which occurred in childhood.

Six weeks ago the patient complained of severe pain over left gluteal re-
gion, running down the posterior aspect of the thigh as far as the knee. The
continuation of this pain caused her to go to bed 4 weeks ago, and a diag-
nosis of "sciatica" was made by her physician. It is not known whether
or not there has been fever, but patient has been thirsty. Two days before
admission she complained of pain over the other sciatic nerve, and her
mental condition became cloudy. Mentality is said to have been good
previously. Increased frequency of urination during the past 2 days. The
temperature was continuously high, running regularly from 101-105°.

Patient is a poorly developed, emaciated, middle-aged woman, at times
irrational, who lies in bed with elbows and knees flexed. Patient mumbles
incoherently, but will answer simple questions in a thick voice. The eyes
are sunken and the face has an anxious expression. The respirations are
rather shallow and somewhat irregular. There is no dyspnea, cyanosis or
jaundice. Skin and mucous membranes are pale.

Eyes.— Pupils equal and react.

Tongue. — Dry, coated with brownish material.

Throat— Dry, coated with brownish material.

Teeth.— Gums and lips covered with sordes. Teeth in poor condition.

Neck.— No glands palpable. No neck rigidity.

Chest.— Poor development and expansion.

Heart.— Apex impulse seen and felt in fifth space, SV2 inches from median
line. At the apex there is a very slight thrill, systolic in time. Left border,
4 inches out. Right border, under sternum. At apex the sounds are loud
and forcible, first sound somewhat impure. No murmurs heard. Action
regular. Over the base there is a soft systolic murmur. The second aortic
is slightly accentuated.

Pulse.— Regular, medium size, fair force, vessel wall moderately thickened.

Lungs.— Hyperresonant note everywhere. Breathing sounds are faint on
account of shallow respirations. On right side of sternum and left outline of
cardiac region are heard short pleuritic rales with inspiration. On an oc-

156 ST. LUKE'S HOSPITAL REPORTS

casional deep breath by patient fine crackling rales are heard in bases of
both axillae, posteriorly and at both bases.

Abdomen.— Muscles are held rigidly. Liver percusses to free border; edge
not felt. Spleen not palpable. No pelvic masses or tenderness made out.

Back.— On upper part of left buttock is a red, excoriated area, 2 x 2%
Inches, with round, black, central slough. No masses or tenderness found
In sacro-iliac joint region.

Extremities (Upper).— There Is considerable rigidity of arms, but no joint
involvements made out. The left hand is deformed, being flexed at wrist,
with extension of first three fingers, and flexion of last two fingers. The
grip Is weak. There is no atrophy of muscles. Reflexes are active.

Extremities (Lower). — Knees are flexed; extension causes pain. K. J.
are active. No edema. The left knee is slightly swollen, red, hot and tender.
No fluid made out. There is evidently a partial foot drop on left side. The
ankle is slightly red, and causes pain when touched or moved. There is no
marked response to pressure over either sciatic nerve, but flexion of legs causes
pain, particularly on left side.

Eye grounds normal, except for physiological excavation.

Ears. — Right, acute inflammation on the site of an old purulent otitis. Left,
scar in inferior portion; serum thick.

The admission temperature was high, 103°. A leucocytosis of 19,500, with
a polynuclear count of 85 per cent, and joint inflammation combined with
a suppurating ear, made a septic process the probable diagnosis, the only
question being the location of the process. The deformity of the hands and
partial foot drop, with a history of a limp and deformed hand, made one fairly
confident of an old infantile lesion in the neighborhood of the right internal
capsule, and probably not related to the present condition. The following
day rigidity of the neck developed, and lumbar puncture was performed to
determine the presence or absence of meningitis. A clear sterile fluid was
obtained under only slight pressure. Blood cultures proved sterile. The
leucocytosis grew more intense, 35,000. The systolic murmur at the base
became louder and harsher, and a soft systolic murmur was heard at the
apex on July 29th, on which date lumbar puncture was again performed, and
10 c.c. of clear fluid obtained.

Early in August she was transferred to the surgical side, and the right
mastoid explored and the dura inspected, but without result, the autopsy
showing an acute vegetative endocarditis and old calcareous cerebral lesions,
which may have been either old solitary tubercles or inspissated masses of
pus with calcification.

Autopsy. — August 6 and 7. Body of much emaciated woman of middle
age. Several large pigmented moles on abdomen. Left leg abducted, and
pelvis tipped to left in compensation. Left hip enlarged. Two bed sores on
this surface. Both forearms wasted. Contractures of left hand. Many teeth
missing, others in bad condition. Right mastoid chiseled out and packed
with gauze.

Peritoneum normal, except for old, dense adhesions about the spleen.

Pleurae obliterated by old adhesions, which are very dense posteriorly.

MALIGNANT SEPSIS 157

Lungs. — Left apex voluminous and firm, base collapsed and boggy. On
section, surface moist and gelatinous. A large amount of edematous fluid can
be expressed, leaving some granular areas. Base deep red on section, and
contains edema fluid. Rigbt upper lobe voluminous and firm, lower collapsed
and boggy. On section, upper presents a moist gray and red surface, quite
solid, witb yellow clots of thick pus scattered throughout. Further sections
show cavities up to 2 cm. in diameter, fixed by their fibrous tissue, and filled
with brownish, turbid fluid. Base congested. Bronchial nodes enlarged and
caseous.

Heart. — Pericardium normal. Heart small, atrophied; mitral valve has a
row of large fibrinous vegetations along line of closure, some projecting 4 mm.
into lumen. Aortic cusps show smaller vegetations, y2 mm. in diameter, about
the corpora arantii and on folds where the cusps join. The heart muscle
is pale and brownish.

Spleen. — Small, very soft, and adherent.

Kidneys. — Normal size; capsule strips readily. Cortex very pale; epithe-
lium opaque. Markings well preserved and regular.

Liver. — Normal size.

Stomach. — Normal.

Intestines. — Normal.

Pancreas. — Normal.

Aorta shows slight atheroma.

Brain. — Very dense and fibrous ; moderate edema of pia in temporal fossa.
Cerebellum adherent to dura over lateral posterior portion of left lobe. At
this point there is a dense calcareous mass, about 2 cm. in diameter, in the
cerebellar tissue. Cortex normal.

On section, a cavity is found occupying the position of the head of the
caudate nucleus, and partially replacing the lenticular nucleus and anterior
limb of the internal capsule on the right side. It measures 18 x 10 x 10 mm.
in diameter, and is separated from the lateral ventricle by a delicate wall.

From the floor of the cavity a papillary calcified mass projects upward
into the cavity. The cavity is filled with thin, slightly turbid, brownish fluid.
Scattered about the sulei, beneath the pia, are a number of spherical nodules
3 cm. in diameter, of about the color and consistence of white matter of lime.

Anatomical Diagnosis. — Acute endocarditis, septic pneumonia of right upper
lobe, and broncho-pneumonia of left upper lobe.

Healed tuberculosis of brain and cerebellum. Section and microscopical
examination did not prove tuberculosis.

Bacteria. — Smears from heart valves gave + cocci in pairs and short chains,
also large, coarse Gram + bacilli and smaller Gram negative bacilli. No
tubercle found.

Cultures from lung and heart valves all showed a colon-like bacillus. (Prob-
able post-mortem contamination.)

Section apparently through basal ganglion shows thickening of glia
usual about subependymal vessels. There is also an island of glia tissue in
the ganglion.

158 ST. LUKE'S HOSPITAL REPORTS

The case is mainly of interest in disassociating the old from her
recent symptoms. How much importance to attach to her chronic
ear as a site for the portal of infection, whether or no a pus focus
lay under the old otitis in the silent area of the lesion, was difficult to
make out in the presence of increasing meningeal symptoms such as
rigidity of the neck and Kernig's sign, with increasing signs of
cerebral irritation.

The site of the active focus was probably in the vegetations on the
heart valve, with a probable portal of entry from the ear or the oral
cavity.

THE DILATATION TEST FOR CHRONIC APPENDICITIS.*!

W. A. Bastedo, M.D.

That many persistent digestive disturbances are manifestations of
a latent or chronic appendicitis has been repeatedly demonstrated by
the disappearance of the disturbances after the removal of the ap-
pendix. It is also well known to operators that in some of these cases
the appendicitis was not recognized for a long time, and that even
after long observation there were cases in which there was a large ele-
ment of uncertainty as to whether the appendix was involved or not.
In other words, the appendicitis was latent, and could not be de-
tected by the ordinary means of examination. Hence any measure
by which such a latent appendix involvement can be recognized de-
serves consideration. "We would, therefore, again call attention to the
usefulness of dilating the colon with air to determine the presence
or absence of a latent or chronic appendicitis. Since our first report
of the test, we have applied it in a large number of abdominal cases,
and have been able in a number of instances to establish the diagnosis
of appendicitis when all other methods of examination failed com-
pletely or left the examiner in a state of reasonable doubt. In ad-
dition, we have received verbal reports from several surgeons who
have been employing the test as a routine in their hospital cases. In
their experience, as well as our own, the test as checked by operation
has proved reliable, failure being reported in only 4 or 5 cases in
several hundred.

To make the test a colon tube is passed 11 or 12 inches into the
rectum and air injected by means of an atomizer bulb. If, as the
colon distends, pain and tenderness to finger-point pressure become
apparent at McBurney's point, there is appendicitis. We have com-
pared the test in a number of instances with the Rovsing test and

*Read before the Medical Society of the County of New York, May 23,
1911.

J Extracted from the American Journal of the Medical Sciences, July, 1911.

159

160 ST. LUKE'S HOSPITAL REPORTS

find the dilatation test much the more certain; but at times, after
moderate dilatation with air, the Rovsing method of forcing the air
back into the cecum may be used with advantage. "We might sound
a warning that if most of the air is not allowed to escape before with-
drawal of the tube, colicky pains are likely to ensue.

The test is not needed in an acute case, and in such would be con-
traindieated ; neither is it required in an undoubted chronic case.
But the indication for the test is a suspected chronic or latent appen-
dicitis, or any persistent digestive or abdominal disturbance, in which
no cause can be found for the trouble. Ordinarily one may entertain
doubt about the diagnosis, or at least hesitate about urging operation,
when tenderness at McBurney's point can be elicited only on very
deep pressure, or is accompanied by a similar tenderness elsewhere
in the abdomen. At times, for example, we have thought of appen-
dicitis because of McBurney's point tenderness, but have found in
addition puzzling points of tenderness along the transverse colon or
at a spot on the left side corresponding with McBurney's. In such
cases, dilatation frequently results in the disappearance of all the
points of tenderness except that at McBurney 's, which it intensifies.

Again, in persistent cases of hyperchlorhydria or gastrosuccorrhea
the test should be performed. For just as in the case of a cholecystitis,
so a latent appendicitis may have its chief manifestation in stomach
derangement, even so marked at times as to simulate an ulcer. And
since it has become our routine practice to dilate the colon in all long-
standing cases of the kind, we have had the good fortune in a number
of instances to discover an unsuspected appendix and to see the gastric
symptoms disappear with the removal of the offending vestige.

A further application of the test may be to distinguish between
an inflamed appendix and a right-sided pelvic trouble. Pain and
tenderness in a right-sided chronic salpingitis or cystic ovary some-
times result from the colon dilatation, but the tenderness is regu-
larly less acute, is low down in the abdomen, and extends toward the
middle line. In three instances we have been able to diagnosticate
pelvic inflammation in young women in whom appendicitis was sus-
pected and in whom a vaginal examination was impossible except
under ether. In each of these the subsequent operation revealed a
cystic right ovary and a free uninvolved appendix. We have em-
ployed the test in not a few other gynecological cases, and while in
some we have been able merely to corroborate the findings of a vaginal
examination, in others we have demonstrated appendicitis in addition

DILATATION TEST FOR APPENDICITIS 161

to the pelvic lesion. In every such case operated upon the finding
of the dilatation test has been found correct.
A few typical case reports may be of interest :

Case 1. — G. L., painter, has had attacks of pain in the abdomen at inter-
vals for iy2 years, without nausea or vomiting. Recently such attacks have
become more numerous, and in the last, he had to lie down for one afternoon;
he was thought to have painter's colic. He told us that the pain occurred
mostly just above the umbilicus or high up beneath the right ribs. He had
no lead line on the gums, no polychromatophilia in the blood. On colon dila-
tation, the gall-bladder was not made out, and no pain appeared in the he-
patic region; but in 2 spots there were pain and tenderness, 1 spot just at
McBurney's point and another just below the navel. A small umbilical
hernia also made its appearance. The patient was advised to have an oper-
ation for the hernia and the appendicitis, but as the diagnosis was not con-
firmed by others he was treated for 3 months for lead poisoning, intestinal
indigestion, and rheumatism. The attacks, however, increased and were
more localized in the appendix region, so he returned for operation. The
dilatation test was again positive, and operation was performed by Dr. H.
H. M. Lyle. The chronically inflamed appendix was covered by veil-like
adhesions, which extended to the hernial opening; the gall-bladder contained
no stones. The appendix and adhesions were removed and the hernia closed.
The patient has had no more attacks of the old type, and a little recurrence
of the pain beneath the right ribs disappeared quickly under treatment for
hyperchlorhydria.

Case 2.— D., a physician, in 2 years had 5 attacks of severe pain in the
abdomen, with prostration and vomiting. The pain was always diffuse, never
localized, and lasted about one day ; the temperature never rose above 99° F.,
and the pulse was normal or slow. Physicians had suggested appendicitis,
but no positive diagnosis was made. Two days after the last attack, which
was so severe that morphine had been administered, the patient walked to my
office apparently well. Slight tenderness to finger-point pressure at Mc-
Burney's point could be elicited only on very deep pressure, but on dilating
the colon an acute pain appeared in the appendix region, and tenderness
over an area as large as a silver dollar and centering over McBurney's point.
Four days later, Dr. J. A. Blake operated and found a chronically inflamed
appendix with a constriction close to the cecum, and adhesions extending
upward over the cecum. The patient has had no attack since the operation
(about 2 years).

Case 3.— Mrs. R., 12 years ago, had an attack of pain in the abdomen,
with vomiting, and was in bed 1 day. A surgeon saw her in the attack, and
said it was not appendicitis. During the entire 12 years since then she has
taken a laxative pill every night and has had no further severe pain, but for
the last 6 months has been losing appetite and becoming more costive, and
has been irritable and in low spirits. A month ago had a little abdominal
pain on the right side for 1 day, but not enough to require treatment. A
test breakfast showed free hydrochloric, 48; total acidity, 70. No organic

162 ST. LUKE'S HOSPITAL REPORTS

acid. On dilatation of the colon, pain at McBurney's point with sharply
localized tenderness became manifest. It was our belief that hyperchlor-
hydria treatment would be futile in the presence of a chronic appendicitis,
so operation was advised, and Dr. L. W. Hotchkiss removed a retrocecal
swollen appendix with 3 marked constrictions and surrounded by adhesions.
Since the operation, 8 months ago, the patient has had unusually good di-
gestive and bowel functions, and has been in excellent general health and
spirits.

Case 4.— Miss H., aged 24 years, a rather under-developed young woman,
with a mitral stenosis, has had in the last year several attacks of cramp-
like pain in the right iliac region. Two or 3 times this pain came at the
menstrual period, but it occurred also at other times. Vaginal examination
was not feasible, so the colon was dilated. At once there was a dull pain
over the whole lower right segment of the abdomen, extending from Mc-
Burney's point to Poupart's ligament and to the midline. Tenderness was
slight, and was most pronounced about half way between McBurney's point
and the symphysis pubis. Operation by Dr. H. T. Goodwin showed a right
ovarian cyst and a normal appendix.

Case 5.— Miss G., aged 27 years, has had pain in the right side low down
for a year or more. It has never been very acute, never caused vomiting,
and was most pronounced after the patient had been a long time on her feet.
There has been a rather abundant vaginal discharge. Examination per
vaginam reveals a tender boggy mass in the right fornix, and much tender-
ness when the uterus is moved. Out of curiosity, the colon was dilated, and
to our surprise an acute pain appeared in the appendix region, and tender-
ness localized at McBurney's point. Operation by Dr. Frank Markoe showed
right salpingitis with tube, ovary, and chronically inflamed appendix bound
together in a mass of adhesions.

Case 6.— D. S., has never had any acute attack of appendicitis, but has
had some pain in the appendix region when his bowels seemed full of gas.
Dilatation was positive for appendicitis. Some time later, in Chicago, he
had an acute attack which was diagnosticated appendicitis, and though
prostrated, and with fever, he took train immediately for New York. Dr.
H. H. M. Lyle operated and found a retrocecal abscess with a sloughed off
appendix.

These eases illustrate the positive findings of the dilatation test.
In the use of the test during the last four years we have had no case
in which the test was positive and the operation findings negative.
But in two out of all of our cases the negative finding of the test, after
a supposed appendix attack, was followed within six months by a
typical attack of appendicitis, and the test was, therefore, presumably
at fault. Several times in the early days of the test, surgeons operated
for a suspected appendicitis, though the test was negative, and in every
such case the appendix was found normal. "We have had a verbal

DILATATION TEST FOR APPENDICITIS 163

report from one surgeon who has used the test extensively, of two eases
which gave positive test but negative findings at operation. With
very few exceptions, therefore, the test has proved accurate, and it
may well serve as a diagnostic guide in the three classes of cases men-
tioned, viz., suspected chronic appendicitis, persistent gastro-intestinal
or abdominal disturbance with unknown cause, and appendicitis versus
ovarian or tubal inflammation.

THE VACCINE TREATMENT OF TYPHOID FEVER.
Austin W. Hollis, M.D., and Norman E. Ditman, M.D.

During the past few years the undoubted success of the preventive
inoculation against typhoid fever has been proved. Among the 60,000
men in the United States army who have been inoculated against
typhoid fever during the past three years, there have been no deaths
from typhoid, and but 12 cases of fever have occurred.

These figures furnish evidence beyond dispute that the use of
typhoid vaccine in the amounts now employed, at least in men in
health, produces very real immunity.

The practical question of interest which now remains to be solved
is, how late in the course of an attack of typhoid fever is it advisable
to attempt to aid or increase the immunity which the sick subject is
attempting to establish, and what benefits, if any, are to be gained
for the attack of illness already in progress.

It has been difficult to predict, on theoretical grounds, what the
effect would be of adding bacterial products to a case of illness ap-
parently already overburdened with products of a similar nature;
yet, experience is beginning to show that while an attack of typhoid
fever of average intensity may seriously impair the activities of the
person attacked — producing the picture of severe illness — yet their
powers of bacterial resistance through increased immunity may still
be greatly augmented.

During the past few years one fact of undoubted value has been
clearly proved — rendering the path clear and safe for future work
along this line. That is, that the administration of typhoid vaccine
to a case of typhoid — unless that case be moribund from an over-
powering toxaemia — produces no harm or undesirable symptoms of
any kind.

During the past 3 years, on the service of Dr. Austin "W. Hollis,
typhoid vaccine has been administered uniformly to cases of typhoid

164

VACCINE TREATMENT OF TYPHOID FEVER 165

fever. The doses have consisted of 1 c.c. of Parke, Davis & Co. typhoid
vaccine every other day — each c.c. containing 50,000,000 dead bacilli.

In the 1909 series, 11 cases were thus treated. No deaths occurred.

In comparison with 21 unvaccinated cases, there were no deaths
to 4, 30 per cent of relapses to 10 per cent, 34.3 days duration of
fever to 36.7 and an equal number of hemorrhages. In the 1910
series of 40 vaccinated cases, the mortality was 5 per cent, relapses
10 per cent, no hemorrhages and no perforations, with an average
fever duration of 30 days.

In the 1911 series of 35 cases, the mortality was 8.5 per cent, there
were 2.8 per cent of relapses, 5.7 per cent of hemorrhages, no per-
forations and an average fever duration of 28 days in the non-fatal
cases.

During this same year, in other services of St. Luke's Hospital, in
35 cases where typhoid vaccine was not administered, the mortality
was 14.3 per cent, there were 23 per cent of relapses, 2.9 per cent
hemorrhages, 2.9 per cent of perforations and an average fever dura-
tion of 33.2 days in the non-fatal cases.

Summarizing the available statistics for the 3 years, the following
results are obtained:

Vaccinated cases Unvaccinated cases

Number Per cent Number Per cent

Cases 86 .... 56

Deaths 5 5.8 9 16.

Relapses 9 10.4 10 17.8

Hemorrhages 2 2.3 1 1.8

Perforations 0 0 1 1.8

Average duration of fever 30.3 days 33.7 days

Still better results are reported in recent literature as follows:
In 214 vaccinated cases collected by Callison, the mortality was
5.6 per cent, with relapses in 5.1 per cent of the cases.

To realize how vaccination influences the course of typhoid fever, it
is of interest to compare these results with those of a very large series
of typhoid fever cases collected by Osier, in which the standard
methods of treatment were employed. They are as follows:

Per cent

Mortality 11.2

Relapses ]1.4

Hemorrhages 7.0

Perforations 5.7

Average duration of fever 29.4 days

166 ST. LUKE'S HOSPITAL REPORTS

It is therefore apparent that, as far as the present total of statis-
tics goes, there is an appreciable difference in favor of the vaccinated
cases. The proper dosage and frequency of administration is yet to
be determined.

In some of the recent cases of the St. Luke's series some doses of
more than 50,000,000 were given, and in a small number, on alternate
days, small doses of Schaeffer's vaccine was given hypodermatically.

In the St. Luke's non-vaccinated cases, tub baths were given, and
a diet ranging from 2,000 to 3,200 calories; while in the vaccinated
cases the diet did not exceed 1,500 calories and the tub bath was dis-
pensed with — its place being taken by sponges.

In any series of hospital cases which are unselected, a number of
cases are found which enter the hospital late, in a more or less mori-
bund or hopeless condition.

Among the fatal cases in the vaccinated series these are frequent.
Thus, in the 1910 series, both fatal cases entered the hospital in the
fourth week and died 8 and 4 days after admission — the latter from
pneumonia, 6 weeks after child-birth.

In the 1911 series, of the 3 fatal cases receiving vaccines, one en-
tered the hospital on the 16th day, in an extremely toxic condition,
and died on the 20th day — having received but 1 dose of vaccine.
One case was admitted on the 16th day, in an extremely toxic con-
dition, and died from a hemorrhage on the 25th day. The third
case was admitted on the 28th day, and died from a hemorrhage on
the 34th day.

Therefore, it may be said that while vaccination has little influence
on late cases, yet, on the other hand, if vaccination is begun early,
good or even brilliant results may be expected. For, among the large
number of St. Luke's cases during 3 years of observation, in which
vaccination was begun before the 16th day, there were no deaths. On
the other hand, it must be remembered that had all the cases of the
unvaccinated series entered the hospital before the 16th day, the per-
centage of mortality in that series would undoubtedly have been much
lower.

Observers in general who have seen vaccinated and unvaccinated
cases, seem to agree that in the vaccinated cases the ' ' typhoid state is
rare, the early toxic symptoms of the disease quickly disappear and
the disease in general is better borne. ' '

Major Russell, of the United States army, has shown that in normal
subjects the typhoid immunity reaction does not begin until about

VACCINE TREATMENT OF TYPHOID FEVER 167

7 days after the vaccination. Whether the same holds true for fever
cases might be very difficult to determine. A fall in temperature
has often been noted within 48 hours after vaccination ; but it is sel-
dom that any pronounced improvement begins until after the sixth
day from the first vaccination.

If vaccine has been used up to the 25th day of the disease, it is
believed that its further use is not likely to be of benefit; while a
long continued fever of the septic type is more likely to be benefited
by some other form of treatment, and we have undoubtedly seen these
cases clear up quickly under combined vaccine.

From the experience of the past 3 years in St. Luke's Hospital, it
is believed that it may be well to give an initial dose of 50,000,000
as early in the disease as possible, repeated every other day until the
tendency of the fever is downward, when the dose may be doubled
at every succeeding injection, provided the fever is still declining.
Injections should be continued until there is no danger of a relapse —
avoiding, however, a dosage which might be considered excessive in
amount.

Whether this maximum dose will prove to be 500 million or 2,000
million, statistics of the next few years will prove.

A CASE OF PAGET 'S DISEASE.*
Karl M. Vogel, M.D.

In spite of the fact that ostitis deformans, or Paget 's disease, as
it is generally called, is not a remarkably rare condition, at least in
its minor grades, the diagnosis is not very often made, and it is only
comparatively recently that cases have begun to be reported with any
degree of frequency.

Paget, in 1877, first isolated this type of deformity from the gen-
eral hodge-podge of chronic bone diseases, and in the Medico-Chirur-
gical Transactions for that year outlined a clinical picture to which
subsequent observers have made few additions of moment. As he
described it, the disease is one beginning in middle life or later, pro-
gressing very slowly during many years, and causing no disturbances
other than those due to mechanical changes in the diseased bones.
Those most often involved are the long bones of the lower extremities,
the cranium, spine, and clavicles. The bones enlarge and soften, and
owing to the pressure of the body weight become curved and mis-
shapen, so that finally with the shortening thus produced, as well as
through curvature of the spine, the stature steadily decreases. The
pain is variable in severity and is most common in the earlier stages
of the disease, though it may persist indefinitely.

In a later communication, Paget1 summed up the most prominent
symptoms, as follows:

"It usually affects many bones, most frequently the long bones of the lower
extremities, the clavicles, and the vault of the skull. The affected bones
become large and heavy, but with such weakening of their structure that those
which have to carry weight or to bear much muscular traction become unnatu-
rally curved and misshapen. The disease is very slowly progressive, and is
felt only in pain, like that of rheumatism or neuralgia, in the affected limbs,
and in increased heat at the tibiae. But neither the pain nor the heat is

*Read at a meeting of the Section on Medicine of the New York Academy
of Medicine, May 16, 1911, and reprinted from the Medical Record July
29, 1911.

aPaget: Medico-Chirurgical Transactions, London, vol. lxv, 1882.

168

A CASE OF PAGET'S DISEASE 169

constant, nor do they continue during the whole progress of the disease ; and
pain has not been observed in the head even in the cases in which the skull
was greatly thickened. There is not any clear evidence of general disturbance
of health. In all the cases traced to the end of life, death has ensued through
some coincident, not evidently associating, disease, which has been aggravated
by the condition of the bones only in so far as they may have diminished the
range of breathing and the general muscular activity.

"In all of the cases I have seen, the general appearance, postures, and
the movements of the patients, have been so alike that these alone might often
suffice for the diagnosis of the disease. The most characteristic are the loss
of height, indicated by the low position of the hands when the arms are hang-
ing down; the low stooping, with very round shoulders and the head far
forward, and with the chin raised as if to clear the upper edge of the sternum ;
the chest sunken toward the pelvis, the abdomen pendulous ; the curved lower
limbs, held apart, and usually with one advanced in front of the other, and
both with knees slightly bent; the ankles overhung by the legs, and the toes
turned out. The enlarged cranium, square-looking or bossed, may add dis-
tinctiveness to these characters, and they are completed in the slow and
awkward gait of the patients and in the shallow costal breathing, compensated
by wide movements of the diaphragm and abdominal wall, and in deep breath-
ing by the uplifted shoulders."

In regard to the order of involvement of the bones it may be stated
that Packard, Steele, and Kirkbride,2 from an analysis of a very large
number of cases, found that this was as follows: Skull, tibiae, femur,
spine, pelvis, clavicles, ribs, radii, ulnae. The fibulae seem to be but
rarely affected, but Maier has reported a case in which the disease
began in one fibula and in the small bones of the foot.

Paget correctly interpreted the condition as being a chronic inflam-
matory process, and accordingly suggested that it be known as ostitis
deformans. Recklinghausen termed it ostitis fibrosa. The changes in
the bone structure may be regarded as the result of two opposing
processes, resorption and hyperplasia ; that is, a rarefying and a con-
densing ostitis. Both the spongy and the compact portions of the
bone are involved, the destruction of the lamellae being accompanied
by replacement with fatty, gelatinous, or fibrous tissue which fre-
quently shows localized areas of softening and liquefaction, so that
cyst-like cavities filled with fluid develop. In addition, calcification oc-
curs and irregular deposits of new bone are formed throughout the
entire substance of the bone, resulting in an increase in its size and
density. The marrow becomes converted into a more or less fibrous
or gelatinous mass containing giant cells, fat cells, and leucocytes.

'Packard, Steele and Kirkbride : Am. Jour. Med. Sciences, vol. cxxli, 190L

170 ST. LUKE'S HOSPITAL REPORTS

Various authors differ somewhat in their views as to whether the
process begins subperiosteally or in the marrow, and as to the precise
sequence of events; but the essential features are the combination of
softening and curvature of the bone, together with an increase in size
and density, so that the picture presented by the individual bones
may be very variable, and the processes of halisteresis, absorption,
and calcification of newly formed osteoid tissue may be going on
simultaneously. The surface of the bone may be smooth or rough;
the cortex compact or spongy ; the cancellous portion dense or porous ;
the central canal almost obliterated or widely dilated.

In regard to the etiology little more is known than in Paget 's time.
General arteriosclerosis is constantly present and it has been sug-
gested that the bone lesions are due to sclerosis of the nutrient ves-
sels of the bone. French observers have considered that the disease
is a manifestation of hereditary syphilis or a paraluetic condition, and
have reported improvement as the result of mixed treatment. Nerve
lesions and gout have also been mentioned as possible etiological fac-
tors, but without very satisfactory confirmatory evidence. Joint
changes occur, but are not very common, although Richard and Zieg-
ler hold that the disease is allied to arthritis deformans. Prince3,
who regarded the disease as a trophic disorder, has laid stress on the
possibility of there being changes in the central nervous system,
but as yet nothing significant has been discovered. An interesting
fact noted by Paget himself, as well as by later writers, is the com-
parative frequency with which new growths of various sorts, includ-
ing osteosarcoma, occur in the subjects of the disease. A possible
hereditary predisposition has been alleged, since in a number of in-
stances members of the same family have been victims of the disorder.
Bockenheimer4 holds that a congenital anomaly of bone metabolism
is an underlying factor.

The direct prognosis, as far as life is concerned, is good, though a
subject of the disease, through arteriosclerosis and through local con-
ditions dependent upon the deformity, may be more susceptible to
the disorders of old age than an individual not so affected.

The treatment is largely symptomatic and consists chiefly in con-
trolling the pain, when present, though some writers have reported
encouraging results from the administration of thyroid extract. At-
tempts at surgical correction of the deformity of the long bones are

'Prince: Am. Jour. Med. Sciences, vol. cxxiv, 1902.
'Bockenheimer : Arch. f. klinische Chirurgie, vol. lxxxv, 1908.

A CASE OF PAGET'S DISEASE 171

contraindicated. In one case of Sonnenberg V in which an osteotomy
was performed there was no evidence of callus formation 13 months
later.

The question of diagnosis is a more complex one, for while it is
not very difficult to recognize the disease when well advanced so that
the curvature and enlargement of the bones are apparent, the head is
misshapen, the stature shortened, and the patient presents the typical
ape-like aspect, in its earlier stages or in mild cases, when, perhaps,
only a single bone is involved and the patient complains solely of
fleeting pains, it is no doubt often mistaken for sciatica, rheumatism,
neuralgia, arteriosclerosis, etc., and many cases are accordingly over-
looked. Among the bone diseases that might be confounded with it
are osteomalacia, spondylitis deformans, hypertrophic pulmonary
osteoarthropathy, and possibly acromegaly, but these all differ in more
or less striking particulars from Paget 's disease when well developed.
One form of disease, however, requires especial mention in this con-
nection, and that is the diffuse enlargement of the skull described by
Malpighi in 1697, and to which Virchow gave the name of leontiasis
ossea, because, as he said, in looking at representations of such skulls
one is reminded of the appearance of the plaster cast of a case of
leprous leontiasis. Later authors, however, prefer the designation
"diffuse cranial hyperostosis." Most of the writers on bone disease
have apparently taken it for granted that this condition and Paget 's
disease are independent affections, and have given various differential
points by the aid of which the two might be distinguished. These re-
late chiefly to the age at which the disease first appears, and to minor
distinctions in regard to the nature of the bony changes, extent of
involvement of the fissures and foramina of the skull, the occurrence
of nervous disturbances, etc. Recent authors, however, notably Bock-
enheimer, Prince, and FitzR, have suggested that the two conditions
are certainly closely allied and probably identical. But the question
has remained a somewhat open one because until rather recently in-
formation as to the leontiasis skulls was largely derived from more
or less ancient museum specimens generally provided only with in-
adequate clinical histories, so that the possible coexistence of slight
changes in other bones could not be altogether excluded. Latterly
more definite data have been available, for the microscopic examina-
tion of tissue removed at operation on leontiasis patients for the pur-

BGlaessner: Wien. klin. Wochenschrift, 1908, p. 1327.
6Fitz : Am. Jour. Med. Sciences, vol. cxxiv. 1902.

172 ST. LUKE'S HOSPITAL REPORTS

pose of relieving pressure symptoms has revealed changes precisely
similar to those found in the long bones in Paget 's disease. An im-
portant contribution to the matter was made not long ago by Max
Koch7, who presented before the German Pathological Society the
skull of a carefully observed patient clinically suffering from leon-
tiasis, which showed on section the usual appearances of Paget 's dis-
ease ; so that it now seems rational to regard leontiasis ossea as a local
occurrence of lesions which when more widely distributed produce
the picture of Paget 's disease.

The history of Koch 's case is briefly as follows :

The patient was a woman of 65 years, who was observed during a year's
stay in the hospital. The symptoms began twenty years previously, when
she noticed an increase in the size of the head and at the same time tinnitus,
vertigo, headache, and impairment of vision developed. Her hearing became
impaired only a few months before her entry into the hospital. The circum-
ference of the head was 72 cm., or about 29 inches. There was pronounced
enlargement of the temporal arteries, and the ears stood out prominently
from the head. Ophthalmoscopic examination was negative, and the visual
fields were not restricted. Myopia of — 5 D. S. There were hyperostoses of
both external auditory meatuses and hypertrophy of the inferior turbinates and
nasal septum. The hard palate was so much thickened that the laryngoscope
could not be used. The lower jaw was not thickened. The Wassermann
reaction was negative. During her stay in the hospital she suffered chiefly
from headache, pain in the legs, vertigo, and general weakness. Five days
before death she suffered from an apoplectiform attack, with unconsciousness,
but no paralysis. Death appeared to be due to a general loss of strength. At
the autopsy it was found that there was a synostosis between the axis and
third cervical vertebra. There was a moderate kyphosis in the thoracic region,
£>ut no abnormality of the other bones. The blood-vessels were markedly
-sclerotic. On sawing through the skull, it was found that the differences in
structure between the external and internal tables and the diploe had disap-
peared, and the bone was very friable. The thickness of the frontal bone was
from 4 to 6 cm., that of the temporal from 3 to 3.5 cm., and of the occiput,
l2.5 to 3 cm. There was an abscess cavity in the situation of the frontal
sinus on one side, but on the other the sinus had been entirely obliterated.
The cut surface was made up of spongy bone, with grayish-red, dense, fibrous
tissue, with here and there areas of gelatinous marrow, or cavities filled
with fluid. All the foramina and fissures of the base were much narrowed,
except the foramen ovale. The meninges were normal, but the brain appeared
flattened and diminished in size through pressure. The pituitary body was
flattened, but in section showed no abnormalities.

Microscopical examination of the bones showed the changes described by
Paget as ostitis deformans, and by von Recklinghausen8 as ostitis fibrosa,

'Koch: "Verhandlungen der Deutsch. patholog. Gesellsch.," 1909.
•v. Recklinghausen : "Virchow's Festschrift," 1891.

Fig. 1. — Photograph of patient at the
age of 34 years.

Fig. 2. — Photograph of patient at the age
of 44 years.

^^F^ *^

Wi^i

^v>

W.. L

•

1 V

Fig. 3. — Present appearance of the patient.

Fig. 4. — Present appearance of the patient.

Note especially the appearance of

the ear.

A CASE OF PAGET'S DISEASE 173

Koch accordingly believes that this case definitely proves the identity of leon-
tiasis ossea with Paget's disease.

The history of the case forming the subject of the present report
is as follows:

The patient was a woman, aged 68, born in England, a seamstress. Ad-
mitted to St Luke's Hospital on December 5, 1910, to the service of Dr.
Janeway.

Family history negative, except that one sister is said to have died of
cardiac trouble, and various members of the family have had "weak hearts."
There is no history of bone changes similar to those of the patient, and all
other members of the family are well formed, active individuals.

Previous history : When about two years old her head was caught between
a clothes mangle and a door. She says that her head has always been large
and ill-formed, and believes that this is due to this accident. She has no
remembrance of the diseases of childhood. At eleven years of age, after a
fright, she had "fits," during which she would become unconscious, but she
does not remember falling or hurting herself during these attacks. A short
time later she awoke one morning and found that her right side was paralyzed.
For a time she had to be fed, and helped in walking, but the paralysis gradu-
ally disappeared, and she had no more of the fits after her sixteenth year.
About twenty-five years ago she had several abscesses in the left external audi-
tory canal, and at the same time that side of her head became swollen and
bumpy. She believes that the present swelling above her ear is due to this
cause.

Present illness : Dates back about fifteen years. Previous to this time she
had always been a good walker, but she then began to notice a feeling of
weakness in her legs, which gradually increased, until about ten years ago,
when she was obliged to give up her work, as it took her so long to do any-
thing, and she could not think quickly. If she wished to do anything across
the room, it would take her half an hour in thinking about it and in getting
up and crossing the room. She had some dull pains in her legs at this time,
and also began to grow deaf. During the last five years the pains in her
legs have become more severe. Her gait has become very slow and shuffling,
and she cannot lift her feet. Two years ago she noticed that the legs were
becoming crooked. She has suffered from headache most of her life, and lately
her head has felt heavy, so that it drops forward and it is hard for her to
lift it She is afraid to lift her head too high in looking at things, for fear
she will fall over backward. She believes that she has become two inches
shorter during the past five years. She is of a hysterical nature, and has
always cried easily, but she has found that lately she cannot shed a tear,
and has also found that the bridge of her nose has grown too large for her
glasses. For four or five years her legs have been more or less swollen, and
recently her arms also have become edematous. For about a year she has
been short of breath, and the veins in her neck and on her forehead have
become prominent

174 ST. LUKE'S HOSPITAL REPORTS

The patient is depressed, realizing fully her slow mental processes and
her inability to move or act quickly.

Chief complaints : Shortness of breath and swelling of arms and legs.

Physical Examination. — General condition: Patient is a rather poorly
nourished woman, of small frame, past middle age, showing moderate dyspnea,
but only slight cyanosis. Her appearance is very striking, on account of the
marked disproportion between the size of the head and that of the body. The
head is very markedly enlarged, especially in the upper part; it is rather
square in shape, with pronounced bony protuberances above each ear. Cir-
cumference about the forehead is 65 cm., or 26 inches. In the temporal
region and in the neck are numerous markedly distended pulsating veins. The
skin of the face appears rather pale and pasty, with numerous brownish pig-
mented areas. Eyes: Pupils equal, and react to light and accommodation.
Tongue clean. Throat normal. Upper teeth artificial ; lower in fair condi-
tion. Chest poorly developed; slight protuberance of upper part of sternum.
Heart: Rather diffuse pulsation over the lower precordium. The apex im-
pulse is fairly well marked in the fifth space, four inches to the left of the
median line. The right border is one inch from the mid-line ; the ieft border
merges with the dulness of the left chest. At the apex there is a loud, blowing,
systolic murmur, transmitted to the axilla, and heard over the entire lower
left chest. The second sounds are not accentuated; the action is rapid and
irregular. The pulse is rapid, irregular, of poor force and moderate tension.
The vessel wall is thickened. Lungs: Clear anteriorly; posteriorly, there
is dulness, beginning just above the angle of the scapula on both sides, and
becoming flat on approaching the base. Over this area there is diminished
breathing, becoming absent at the base, where numerous subcrepitant rales
are heard. The abdomen is somewhat distended. The liver percusses three
inches below the free border, where its edge can be felt distinctly. It is
markedly tender, and pulsates. Extremities : Both legs are markedly edema-
tous, and show moderate curving of the tibiae.

The patient's height at present is 4 feet 10% inches, whereas she says that
previously it was 5 feet V/2 inches, a shortening of a little over 2y2 inches.
She is very deaf, but examination of the ears shows no occlusion or deformity
of the external meatus. The drums show several patches of fibrous thickening.

In conclusion, it may be said that a survey of the literature seems
to support the contention that the separation of diffuse cranial hyper-
ostosis as an independent disease is not justified and that it is to be
regarded as a manifestation of the same process which is responsible
for the symptom complex of Paget 's disease. Further evidence in
favor of this view is furnished by a case recently reported by Bart-
lett,9 in which, as in that described by Koch, during life there was no
sign of the involvement of any bones except those of the skull. At
the autopsy, however, examination of the femur showed beginning
foci of disease.

"Bartlett : Yale Medical Journal, 1909, p. 367.

Fig. 5. — Radiograph of the pelvis and femur.

Fig. 6. — Radiograph of the tibiae.

THE PURIN CONTENT OF FOODSTUFFS.*
Karl M. Vogel, M.D.

The importance of considering the purin content of the diet in the
diagnosis and treatment of certain metabolic disorders has recently
been emphasized by numerous writers, for example, by Bessau and
Schmid,1 and by Brugsch and Hesse.3

The following determinations of the purin content of some of the
commoner foodstuffs were begun in the fall of 1908, in the II Medical
Clinic in Munich, at the instance of Prof. Fr. Miiller, and were con-
tinued in the laboratories of the College of Physicians and Surgeons
and of St. Luke's Hospital. In the meanwhile, the publication of
Bessau and Schmid 'a table made it seem unnecessary to continue in
this direction, but since then Hesse has reported the results of some
analyses made by him. His figures in general are higher than those
of Bessau and Schmid, and as mine correspond more closely with the
latter, it appears of some interest to record them also.

Hesse, in publishing his figures, calculated the presumptive amount
of purin bases corresponding to the nitrogen values found. In order to
make his results comparable to those of other authors who have fol-
lowed the practice of giving the nitrogen content of the purin precipi-
tates, I have calculated the nitrogen equivalent of his values, employ-
ing the customary factor 2.65. One column of the table, however,
contains his original figures. In the first four analyses of meat and
organs I used the method of Burian and Hall ;8 the other determina-
tions were made by means of the copper-bisulfite method.4 Of the
meats, 100 to 250 grams were taken, and of the other articles 250 to
500 grams.

♦Translated from the Munchener medizinische Wochenschrift, No. 46, 1911.
xBessau und Schmid. Therap. Monat, No. 3, 1910.
'Brugsch und Hesse. Med. Klinik, No. 16, 1910.
8Burian und Hall. Ztsehr. f. physiol. Chem., xxxviii, 336.
4Kruger und Schittenhelm. Ztsehr. f. physiol. Chem., xlv, 15.

175

176

ST. LUKE'S HOSPITAL REPORTS

Beef: Sirloin.

Liver

Sweetbread (thymus)
Spleen

Codfish

Wheat flour

Rye flour

Pea flour

Arrowroot

White bread.

Rye bread. . .

Hominy

Oatmeal

Rice

Potato

Spinach

Tomato

Milk

Swiss cheese.

■Percentage of purin N-

%of

Bessau

purins

Walker

and

Hall

Schmid

Vogel

Hesse

0.0522

0.037

0.059*

0.0666
0.0720

0.175
0.189

0.1101

0.093

0.099

0.142

0.372

0.4025

0.330

0.398
0.196

0.498

1.308

0.0233

0.038

0.040*

0.0499

0.131

0.001

0.0441

0.116

0.002

0.0365

0.096

0.0156

0.016
0.001

0.0411

0.108

0
trace

0.008
0.005*
0.014
0.004*

0.0211

0.030

0.0004*

0.0007

0.002

0.024

0.001*

0.022*

0.0072

0.019

0.0002

0
0

0.0002
0.0004

0.0038

0.010

trace

♦Refers to analyses made on American material.

ACUTE BICHLORIDE OF MERCURY POISONING— A REPORT
OF TWO CASES WITH RECOVERY.

Lepferts Hutton, M.D.

The following two cases are reported on account of the apparently
prevailing custom of keeping bichloride of mercury "Blue Tablets"
near the fountain syringe to prevent conception. Instead of using
a bichloride douche, the tablet (7y2 grains) was inserted into the
vagina. In looking over the literature on this subject, one is im-
pressed with the small number of cases of acute poisoning resulting
from this practice.

In Germany a law was passed in 1897, making all cases of acute
bichloride of mercury poisoning reportable. During the next 9 years,
101 cases of mercury poisoning, from the tablet form, were reported,
and no record of any case of poisoning from the insertion of the tablet
into the vagina. The official report for the past 5 years has not yet
been published, but probably the result will be the same as in the
preceding 9 years. The sale of mercury in any form is prohibited,
except on a physician's order.

In England and her colonies the writer was unable to find any
case of poisoning by this method. While in America, where any one
is able to buy the "Blue Tablets," 7 cases have been reported in the
past 10 years. To this collection of 7 cases the author wishes to add
2 more, as follows :

Patient.— Mrs. B.; 38 years old; born in the United States; occupation,
housework. Entered St. Luke's Hospital as a private patient of Dr. Henry
S. Patterson, on November 21, 1911, giving the following history:

On morning of admission, at about 2 A. M., patient inserted a 7%-grain
tablet of bichloride of mercury in her vagina to avoid conception. Soon
after she complained of intense burning sensation in that region. Later, the
patient attempted to douche herself, without much success. She then began
to realize the gravity of the situation and came to the hospital.

On entrance, she complained less of the pain in the vagina than of pe-
culiar paresthesia and cramp-like sensations in the hands and feet. She was

177

178 ST. LUKE'S HOSPITAL REPORTS

not salivated. There were no urinary or intestinal symptoms. Physical ex-
amination was negative, except for a good deal of redness of the vulva, with
some whitish slough and a sero-sanguinous discharge from the vagina.

Vaginal examination, with a bivalve speculum, showed the mucous mem-
brane to be covered with a whitish slough— cervix very red.

Treatment and Subsequent Course.— The treatment consisted of force
fluids, alkaline douche 3 times a day, and a colon irrigation 116° twice a day.

Blood.— W. B. B. 16,000. Poly. 73.5. Lymph 26.5. Hgb. 90 per cent. Her
urinary excretion ranged from 64 to 144 ounces a day, while her fluid intake
varied from 112 to 196 ounces.

Urine Examination.— Alkaline, sp. gr. 1006-1008, very faint trace of al-
bumen, no sugar, a very few hyaline casts.

Stools.— No blood; no increase in number.

Mouth. — No ulcerated areas ; no salivation.

The vagina, under the alkaline douches, cleared up very rapidly. She was
discharged cured, 7 days after onset.

Mrs. P., age 33, born in Italy, occupation factory hand, entered Dr. S. W.
Lambert's service at St. Luke's Hospital, on December 8, 1910, with the
following history:

Chief Complaint.— Pain in lower abdomen and a sore mouth.

Present Illness. — Three days ago was seized with sudden pain in lower
portion of abdomen. This pain was sharp, non-radiating, worse in daytime,
when at work in the shop. Vomited twice with onset. No chills, fever nor
cough. Mouth has been sore for the past 3 days, with increased salivation.
Teeth not loosened. Some difficulty in eating — no treatment during pres-
ent illness.

Past history was negative. Menstruated 2 weeks previously ; some leu-
corrhcea.

Physical Examination. — Breath fetid, foul-smelling. Lips dry and cracked.
Sordes on teeth and gums. Tongue badly coated — moderate salivation. No
evidence of any ulceration in mouth.

Heart normal. Lungs clear. Abdomen — no masses, no tenderness. Liver,
spleen, kidneys apparently normal. ♦

Vagina.— Yellow and dark brown sloughs on inner side of each labium
majus. Also yellow and white sloughs on both sides of the vaginal canal.
The cervix is swollen red, except the places which are covered by slough
whitish in appearance. A bimanual examination was not made.

Treatment consisted of bicarbonate of soda throat irrigation. Temper-
ation of 120° every 3 hours. Alkaline vaginal douche. Colon irrigation of
hot saline.

On cross-examination, patient confessed to having placed two bichloride of
mercury tablets in her vagina 3 days previous to admission and had not
taken any treatment previous to coming to hospital.

Subsequent History.— Her vaginal and cervical condition slowly healed.
Her urinary excretion ranged from 18-30 ounces a day, which, on repeated
examination, showed a high sp. gr. 1030. No albumen. No blood. No
sugar. No casts.

BICHLORIDE OF MERCURY POISONING 179

Three days after admission patient developed an ulcerative stomatitis,
which slowly healed.

On December 23d, 2 weeks after admission, the patient demanded her
discharge from the hospital. At this time she had some pyorrhoea along
the gums, otherwise her mouth had healed. Vaginally, her cervix was con-
gested and slightly eroded. Vagina congested. No ulcers seen. Although
not entirely cured, she insisted upon leaving the hospital, which was re-
luctantly granted.

A CASE OF LATENT DISSECTING ANEURISM OF THE
AORTA AND RUPTURED SACCIFORM ANEURISM.

Lefferts Hutton, M.D., and J. Gardner Hopkins, M.D.

The following case is presented on account of the unsuspected find-
ings at autopsy.

Mrs. E., married, age 52, born in the United States, occupation housework,
entered the hospital March 25, 1911, on the service of Dr. Samuel W. Lambert
She gave the following history :

Chief Complaint. — Cough, fever, and pain in the right side.

Present Illness. — Eight days ago the patient was suddenly seized with a
severe shaking chill, lasting about five minutes. This was followed by fever,
a dry, hacking cough, headache, and prostration. She also vomited several
times. Twenty-four hours later she had another chill, not so severe as the
first. This was followed by fever and a sharp, stabbing pain in the right side,
increased by coughing and deep breathing. Her abdomen felt somewhat sore,
and was distended. Since onset, the patient has been confined to bed, without
much change in her subjective symptoms.

Past History. — She had an attack of pneumonia twelve years ago, which
lasted eight weeks. She has had winter cough for several years, with some
shortness of breath on slight exertion, especially marked during past year.

Menstruation was regular up to four years ago, when menopause occurred.
One child was stillborn at term. No miscarriages. No children living. No
history of syphilis obtainable.

Habits. — Takes two cups of coffee daily. Does not use alcohol.

On physical examination, we found a well-nourished woman, who did not
appear acutely ill. She had moderate dyspnea, and was very slightly cyanotic.
Her cheeks were flushed. She had no herpes and no jaundice.

Eyes. — The pupils were equal, and reacted normally.

Tongue was clean and moist Throat clear. The mucous membranes were
normal. Teeth were in good condition.

Heart — The apex was palpable in the fifth space, 14 cm. to left of the mid-
line. The right border was beneath sternum. The first sound at the apex
was rough and impure ; second aortic louder than second pulmonic. No
murmurs were heard.

Pulse. — Regular, and of good force. There was a slight increase in tension,
and the vessel wall was palpable.

Lungs. — Many fine, crepitant and moist rales were heard all over chest,

180

HEALED DISSECTING ANEURISM

181

front and back. Posteriorly, on the right side, between the scapula and
vertebral column, there was a small area of slight dulness with bronchial
breathing, voice and whisper. There were many fine, moist rales.

Abdomen. — Slightly distended; no rigidity, masses, or tenderness made out.

Liver and spleen did not percuss large. The edges were not felt.

Extremities. — There was moderate edema of legs.

Fig. 1. — Diagram showing position of the aneurisms as seen from behind.
The sac of the false aneurism lies in front of the blind branch of the dis-
secting sac.

On admission, her temperature was 101.3° ; pulse 86 ; respiration 26.
"White blood cells 21,000; polymorphonuclears 76 per cent; lympho-
cytes 23 per cent; eosinophiles 1 per cent; hemoglobin 85 per cent.

182 ST. LUKE'S HOSPITAL REPORTS

Urine was acid, specific gravity 1.020. Very faint trace of albumin,
no sugar, no indican, and no casts found.

For the next six days her temperature slowly dropped from 102.3°
to 99.4°. Her pulse ranged from 96 to 100, and her respirations from
24 to 30. During this time the patient complained several times of
"pain as food entered the stomach," although she took fluids very
readily and in large quantities. On April 1, seven days after ad-
mission, the physical signs had perceptibly changed. The right up-
per lobe had almost entirely resolved; the right lower and left upper
were clear, while below the angle of the left scapula there was an
area of dulness with bronchial expiration and voice, and fine, sub-
crepitant rales over entire lower lobe, indicating a beginning con-
solidation of this lung. The leucocytes had risen to 25,000, the poly-
morphonuclears were 80 per cent. Her temperature was 102° ; pulse
96, and respiration 24.

During the next five days patient complained of lumbar pain,
which was relieved by either the hot-water bottle or codeine in moder-
ate doses, and was thought to be due to the pleurisy. The physical signs
of consolidation became more evident. The leucocytes ranged from
20,000 to 15,000, the polymorphonuclears from 80 to 71 per cent ; tem-
perature from 100° to 101°, pulse from 86 to 98, and respiration from
24 to 28. On April 7, seven days later, the physical signs consisted of
marked dulness, with diminished fremitus and distant bronchial
breathing, from angle to base. Above this was an area of increased
fremitus, bronchial breathing, and numerous rales. The possibility
of an empyema was discussed, but as the temperature was 100.2°, the
leucocytes only 11,000 with 68 per cent polynuclears, and the general
condition of the patient was considered good, the chest was not ex-
plored until thirty-six hours later, when a syringe full of clear fluid
was obtained near the angle of the scapula. The cytological exami-
nation showed polymorphonuclears 3 per cent, and lymphocytes 97
per cent.

From April 10 to 30, the physical signs of fluid remained the same.
The chest was explored at frequent intervals with the same result;
namely, a syringe full of clear fluid was obtained, but on substituting
a cannula and suction for the needle only a few cubic centimeters more
were obtained. The opinion prevailed that there were multiple small
cysts, which were aspirated dry at each exploration, surrounded by
an immensely thickened pleura.

Three days before her death, the patient began to regurgitate solids,

HEALED DISSECTING ANEURISM 183

but managed to retain fluids. This regurgitation remained unaltered.
The idea of an interlobar empyema still prevailing, the chest was
again explored with the same result: 2 e.c. of clear fluid.

Sixteen hours before death she complained of severe pain in the
left side, which was unrelieved by codeine or heat. During the early
evening she was restless and suffering from pain, which was relieved
by codeine. The patient then slept for about six hours, awakening
with severe pain between the ribs on the left side. This was not in-

Fig. 2. — Diagram showing the position of the aneurisms as seen in cross
section through the trunk. The diaphragm is represented by the double line
surrounding the liver.

fluenced by codeine. Thirty minutes later her pulse suddenly became
weak and irregular, and her skin cold and clammy. There was no
dyspnea, and no air-hunger, patient being conscious until the end.
On a hurried examination, breath sounds could not be heard over
left lower chest. Patient failed to respond to the usual hypodermic
stimulation, and died forty-five minutes after onset of pain.

The autopsy was performed the day after death. On opening the
thorax, the anterior portion of the left pleural cavity was found to be
filled with blood clot which extended about the root of the lung and

184 ST. LUKE'S HOSPITAL REPORTS

up over the apex, amounting to 600 c.e. in volume. From about the
mid-axillary line backward the lung was firmly bound down to the
chest wall with a mesh of fibrin 2 em. or more thick, which was satu-
rated with a turbid yellow fluid. No origin of the hemorrhage could
be found about the upper portion of the pleura, where the greater
part of the blood was collected. In the left upper quadrant of the
abdomen a large mass without definite boundaries was felt behind the
peritoneum and above the left kidney. On section, this mass was
found to lie behind the posterior portion of the diaphragm, and to
consist of a large false aneurism lying between the diaphragm and
the diaphragmatic pleura. The aneurism had ruptured upward into
the pleural cavity, and on account of the dense adhesions the blood
had been forced upward and forward around the root of the lung.
The aneurism opened laterally from the aorta by a huge gap measur-
ing 5 cm. vertically by 1 cm. antero-posteriorly. The remnants of the
arterial wall could be traced out for a distance of 3 or 4 cm. into the
wall of the aneurism. Beyond this point the sac consisted of dense
connective tissue, and for the most part was filled with firm thrombus.
It extended laterally 11 cm., practically to the lateral chest wall, and
measured 11 cm. vertically by 5 cm. antero-posteriorly.

The aorta also presented two other aneurisms. One of these was
a fusiform dilatation of the ascending aorta, occupying the region of
the fourth sinus. It was 5.5 cm. in diameter.

The lesion of greatest pathological interest was a healed dissecting
aneurism which involved the greater part of the descending thoracic
aorta. Eleven cm. below the origin of the left subclavian there was
a small opening in the left wall of the aorta through which a probe
could be passed into an elongated sac in the wall of the vessel. This
measured 2 cm. in average diameter, and extended about 2 cm. above
the opening into the main vessel. A short distance (3 cm.) below this
it branched, one branch communicating by a small opening with the
neck of the ruptured aneurism described above, the other lying pos-
terior to the neck of this aneurism and ending blindly a little below
the level of the celiac axis. The total length of the sac was 13 cm.
The lower portion of the blind sac was filled with a firm thrombus.
The upper part of the lumen was free. Some portions of the wall
were smooth and glistening, other portions showed atheromatous and
calcareous plaques. The caliber of the tube was irregular and the
wall showed nodules where it attained a thickness of 14 mm. It did
not block the orifices of the intercostal vessels, all of which opened

Fig. 3. — Photomicrograph showing cleft in the media of abdominal aorta.
Above is seen an atheromatous area in the intima and the linnen of the aorta.

50 diameters.

*•*£ - .«*?•-

Fig. 4. — Photomicrograph showing almost complete obliteration of one of
the vaso vasorum of the aorta. The vessel is surrounded by plasma cells
and lymphocytes. 2G0 diameters.

HEALED DISSECTING ANEURISM 185

posterior to it. The aorta itself showed most extreme endarteritis,
especially in the lower thoracic and abdominal portions. The changes
were much more marked than is usual in cases of aneurism. There
were many large calcareous plaques with sharp edges, between which
the surface was deeply ulcerated. The orifice of the celiac axis, which
lay a little below the main aneurism, was restricted to a diameter of
2.5 mm., while the superior mesenteric just below this was dilated,
measuring 7 mm. across. The right renal artery was very large, while
the left renal was much contracted, the suprarenal on this side being
unusually large, apparently in compensation. These vessels, beyond
their origin, showed little evidence of disease, and the atheroma was
confined chiefly to the aorta.

The other organs showed little of note. The heart was hypertro-
phied and the myocardium showed very slight evidence of fibrosis.
The aortic ring was thick and calcareous, but not appreciably dilated.
The valve leaflets were all slightly thickened, but appeared competent.
The coronary trunks were free. The lymph nodes about the aorta
were enlarged to a diameter of one to two centimeters. They were
soft and homogeneous on section. Many of them were closely attached
to the adventitia. The mesenteric nodes were also enlarged to a less
degree. The lungs showed edema and emphysema. There were evi-
dences of chronic passive congestion in the liver, spleen and kidneys.

Section through the dissecting aneurism showed that it lay in the
media of the aorta between the internal and external elastic lamella?.
The elastic fibers of both these lamellae were fragmented and partly
replaced by hyaline connective tissue. The adventitia was very thick.
The walls of the vaso vasorum were thickened by fibrous tissue, and
the endothelial cells were swollen. Some of the veins were entirely
occluded by masses of pus cells. The vessels were surrounded by col-
lections of plasma cells and lymphocytes. Large collections of these
round cells were found elsewhere in the adventitia, but none of the
foci contained giant cells or showed central necrosis. Spirochaetae
could not be demonstrated by Levaditi's method. The picture was
extremely suggestive of syphilis, but did not warrant an absolute
diagnosis. The intima of the aorta was greatly thickened by masses
of tissue staining faintly with eosin and containing few stainable
nuclei. There were areas of calcification. The inner wall of the dis-
secting aneurism showed similar degenerative changes. The lumen
was lined in part with a layer of flat cells resembling endothelium.

Similar lesions were found in the abdominal aorta. On cutting

186 ST. LUKE'S HOSPITAL REPORTS

this vessel after fixation splits were seen in the wall, apparently not
artifacts. In section these splits were seen to be in the media between
the two elastic lamellae. The clefts were traversed diagonally by
strands of unruptured fibers. There were smaller clefts in the intima.

Changes of this type were first referred to by Rokitansky, with
some reserve, as the possible cause of dissecting aneurisms. Recently
Babes and Mironescu described a very similar condition, which they
termed "dissecting aortitis," in two cases of dissecting aneurism. It
seems highly probable that the degeneration of the media in this case,
which led to the formation of large splits in the wall, either intra
vitam or, under very slight stress, post mortem, explains the formation
of a dissecting aneurism. The perforation of an atheromatous ulcer
in the intima would expose this weakened portion of the wall and the
blood would then force its way along this zone of the media with
very little resistance.

A healed dissecting aneurism is a rare lesion. In 1896, Adami was
able to collect thirty clearly described cases and five other probable
cases of this lesion. In the literature since that time we have found
six cases. There are doubtless many others which have not been re-
ported. Partial rupture of the aorta with the formation of a dissect-
ing aneurism is relatively not uncommon, especially in medico-legal
work, but the lesion usually terminates fatally within two or three
days. The most common point of rupture is in the neighborhood of
the aortic ring, and the sac may extend well down into the iliac ves-
sels. It may end blindly or may establish a secondary communication
with the aorta. If the patient survives the first shock, a blood flow
may be established through the aneurism. It may carry a fair pro-
portion of the blood stream and some of the large branches of the
aorta may originate from it. These healed aneurisms are usually lined
with a fairly well developed intima.

Their incidence is somewhat late in life, most cases being between
forty-five and fifty-five years of age, and they occur in females about
as often as in men. Three factors are concerned in their production,
probably in varying degree in different cases : trauma, arterial disease,
and hypertension. No one of these factors is constantly present.
Cases of rupture have been reported in arteries apparently normal in
very powerful individuals during exertion. On the other hand, cases
where the heart is small and shows brown atrophy, and where the
blood pressure could not have been excessive, may rupture if the
arterial disease is marked. Some cases have developed apparently

«<*

Fig. 5.— Photomicrograph showing endothelium lining the dissecting aneurism.

200 diameters.

HEALED DISSECTING ANEURISM 187

while the patient was in bed being treated for some other ailment, so
that trauma and exertion are not essential features. The arterial
changes are not usually so extreme as in this case. Degeneration of
the media is probably the essential feature. It is possible that the
"dissecting aortitis" mentioned above may be found to be the under-
lying cause in most cases.

References. — Adami, Montreal Medical Journal, 1896, xxiv, 945 ; and xxv, 23.
Babes and Mironescu, Beitrage f. path. Anat. (Ziegler), 1910, xlviii, 221.
Rokitansky, Lehrb. d. path. Anat, 1855, 3d edition.

REPORT OF A CASE OF CHRONIC ULCERATIVE COLITIS,
WITH SIGNS AND SYMPTOMS OF ADDISON'S DISEASE.

Edward N. Packard, M.D.

Service of Austin W. Hollis, M.D.

A. M. — Housemaid, German, aged 51, widow. Admitted August 9, 1911.
Died October 25, 1911.

History on Admission. — Chief Complaint: Vomiting, pains in legs, cramps
all over body, and loss of strength.

Family History. — Father died, aged 56, of rheumatism ; mother, at 57, dur-
ing menopause. Three brothers and one sister all living and well. Hus-
band was killed in an accident. No tuberculosis in family.

Past History.— Has had no children, no miscarriages. Has always been
healthy except for colds, etc. Diseases of childhood not remembered. Menses
irregular for 18 months.

Personal Habits.— Drinks about a cup of tea with a meal. No beer or
whiskey; always worked fairly hard until present illness.

Present Illness.— About 2 months ago, at time of her menses, patient was
very nauseated and vomited a great deal, and this has persisted until present
time. About 10 days later, patient began to have cramps in different parts
of the body. Then, lately, has been losing strength, and her head and body
feel as if they were too heavy for her legs. Her appetite has been very
poor all summer, and she has lost a good deal of weight. Patient complains
of nervousness, which has been growing more marked. About 3 weeks ago
a rash appeared on lower part of extremities; this has gradually extended
upward.

Physical Examination.— Patient is a large woman, who has evidently lost
some weight, the skin hanging loosely on body. Pt. does not appear acutely
ill. No dyspnoea, cyanosis, or jaundice. The skin is of fair color, except
following named spots, where skin appears darker than normal : eyelids, neck,
armpits, hands and wrists, nipples, navel, inguinal regions, external geni-
tals, and membrane of vagina. There is no pigmentation of mucous mem-
brane of throat or cheeks. On arms, chest and legs is a raised eruption
composed of small papules, in places confluent, and in other places partially
circinate. This eruption is of a slight reddish tinge and feels lumpy. The
eruption itches, and in places the top of the papule is scratched off.

Eyes.— Pupils equal and react.

188

ULCERATIVE COLITIS SIMULATING ADDISON'S DISEASE 189

Tongue.— Clean.

Throat— Negative.

Teeth and Gums.— In rather poor condition.

Chest— Good development, fair expansion.

Heart.— No localized apex impulse. Sounds heard best in 5th space,
Sy2 inches from m. 1. Left border 4 inches out. Sds. of good quality ; no mur-
murs or accentuations heard.

Pulse.— Regular, fair size and force; vessel wall not thickened.

Lungs. — At rt. post, base, there are a few sub-crepitant rales heard on
deep inspiration.

Abdomen.— Normal.

Extremities. — K. J. not obtained. Very slight edema. Some muscular
weakness. No paralysis or atrophy.

After the patient's admission to the hospital, she vomited daily for a
week. The test-meal showed a low total acid and no free Hcl. Her gastric symp-
toms gradually improved. Occasionally, throughout her sickness, she vomited
and complained of gastric distress. The patient had blood in the stool almost
constantly. The movements were never watery, but were of a brown fluid
character containing clots of blood. She never had more than 5 stools a
day. Often for days no blood was seen. She had periods of constipation.
Her weight for 2 months varied but little, averaging 125 pounds, but for
a few days before death, her weight fell to 110 pounds. The blood count
was normal, except for 5% eosinophiles. Parasites were not demonstrable.
Rectal examinations were negative, and no definite cause for probable ulcera-
tion could be found. The urine 1012, trace albumen, no sugar, few hyaline
and granular casts. On admission, a trace of indican. Wassermann reaction
negative. For 3 days preceding her death the temperature was 94°. The
autopsy revealed a chronic ulcerative colitis of an extent not appreciated while
she was under observation.

This case also presented the following interesting features: signs and
symptoms of Addison's disease, an extensive eruption, and a suppurative
skin lesion.

As noted in physical, there were fairly well marked areas of pigmen-
tation. These areas gradually paled out, except in axillae. The brown skin
of hands desquamated during skin eruption described below. The skin of
whole body was darker than the average normal individual's, but patient
said her skin had always been of dark hue. She had lowered vaso-motor
tone with blood pressure in 95 Hg. For a while she was able to sit in a chair,
but later her weakness increased rapidly until her death. The gastric
contents showed low total acid and no free Hcl, also absence of knee-jerks,
found in cases of Addison's disease. The autopsy showed no pathological
change in the suprarenals.

The eruption noted in physical gradually spread until the whole body, in-
cluding the face, was involved. The eruption gave a diffuse, dusky red,
slightly raised appearance. Margins indefinite. In places it was lumpy. It
itched. No vesicles or crusts formed. No exudation. It gradually faded,
the skin desquamating in fine particles.

190 ST. LUKE'S HOSPITAL REPORTS

At about the time the eruption was disappearing, small superficial, pain-
ful lumps appeared in axillae. These contained pus and were opened. The
suppuration became extensive and the patient was transferred to the surgical
ward. The count was 17,000, P. 87.5, L. 12.5, E. 1. Later, small punched-
out ulcers with irregular, overhanging edges, and bases covered with exuda-
tion, appeared in pubic region. Also numerous small pustules on eyelids,
end of nose, and anterior chest. At one time, 35 abscesses were counted.

Before her death, fine crackling rales were general over both lungs. The
blood count was 35,000, P. 92, which was explained at autopsy. The whole
suppurative process probably secondary to the ulcerative colitis.

Autopsy Findings : Body of middle-aged woman, appears somewhat emaci-
ated, cheeks sunken. In axillae are several ulcers y2 cm. in diameter, with
raised thickened edges and thick purulent exudate on granulating base. On
tip of nose and at inner canthus of left eye are pustules covered with crusts.
There are a number of healing ulcers similar to those in axilla? in pubic
region, and one or two more over anterior surface of chest. Also two scars
on chest of healed ulcers. There is a diffuse brownish pigmentation of the
skin most marked in the axillae.

Peritoneum.— Shows minute black flecks beneath the parietal surface and
the omentum is of dull grayish color.

Pleurae. — Following the line of several intercostal arteries are similar
streaks of pigment beneath the pleura. Dome of diaphragm reaches to 3d rib
on either side.

Lungs (390 gms., 450 gms.).— Voluminous and rather firm at bases. Apices
punctured with old scars but show no active tuberculosis. Bronchi inflamed
and contain creamy pus. Bronchial nodes enlarged and black.

On section right lung shows numerous miliary abscesses filled with creamy
pus scattered throughout lower lobe. The left shows a few similar abscesses
and numerous patches of gray granular consolidation. Except for these
patches, the lungs are moist, and considerable fluid is readily expressed from
the cut surface.

Heart (330 gms.).— Small, covered with thick layer of yellow fat. Muscle
brown. Cavities filled with chicken-fat clot. Valves normal. A ring of
atheromatous thickening about base of aorta, and numerous patches in the
coronary trunks. Coronaries tortuous.

Spleen (90 gms.).— Normal size, soft. Malpigian bodies distinct.

Kidneys (60 gms., 75 gms.).— Very small capsule strips readily leaving
smooth surface. Cortex thick, of pasty, very pale yellow color; markings
not well made out; medulla normal.

Suprarenals. — Left softened by post-mortem change. Right appears quite
normal.

Bladder.— Normal.

Uterus.— Cervix filled with mucus. Wall contains a few small fibroid
nodules.

Adnexa.— Normal.

Liver (1,096 gms.).— Normal size. Pale and mottled, with bright yellowish
areas. Gall bladder contains thin turbid bile. Wall not thickened. Small

ULCERATIVE COLITIS SIMULATING ADDISON'S DISEASE 191

stone impacted in mouth of cystic duct, but bile may be expressed into duode-
num.

Pancreas.— Largely replaced by fatty tissue. Islands of pancreatic tissue
appear normal.

Intestines. — Small bowel normal throughout. At ileo-caecal valve is ulcer
•with thickened base which throws it upward into the lumen, and along en-
tire ascending colon are similar ulcers about 2 or 4 cm. by 0.5 cm. with long
axis running around the gut. They do not appear to penetrate the muscu-
laris, which is greatly thickened so as to throw the ulcer into the lumen like
a fibrous ridge. A few thickened spots with beginning ulceration at the
center are found in the descending colon. The retroperitoneal nodes, near
the caecum and to right of vertebrae, are enlarged, soft, and uniform deep black
on section. The nodes in the mesentery are softened, semi-fluid and brownish.
The panniculus was well developed, 4-6 cm. thick, and composed of intensely
yellow fat.

Anatomical Diagnosis.— Chronic ulcerative colitis, chronic parenchymatous
nephritis, left broncho-pneumonia, miliary abscesses of both lungs, subacute
cholecystitis, multiple ulcers of skin.

Bacteriological. — Smears and cultures from lung abscesses showed Gram-
positive staphylococci in pure culture.

PNEUMOCOCCUS SEPTICEMIA.

A. E. Neergaard, M.D.
Service of Austin W. Hollis, M.D.

Miss M. D., domestic, age 21. Patient in Minturn III, from Novem-
ber 6, 1911, to November 7, 1911. Diagnosis — Pneumococcus septicemia ; con-
genital pulmonary stenosis. Result— Died.

Tbe patient was admitted at night, sent in with a diagnosis of typhoid
fever. She died a few hours later, before complete examination had been
made and before the clinical data could be collected. Hence the incom-
pleteness of the following records.

History on Admission.— The only facts obtained from the patient were,
that she had been suffering for 8 days with headache and backache, with a
fever varying from 101°-103°. She had coughed considerably, at times
raising blood.

Physical examination showed a fairly well-developed and well-nourished
young woman, acutely ill. Her respirations were rapid and she was mark-
edly cyanotic, but did not suffer from orthopnea.

Her pupils were equal and reacted normally. She had internal strabis-
mus. The tongue was coated. No cervical rigidity. Her chest was well
developed, with good expansion.

Heart. — Apex impulse in fifth space, about 5 inches out. No thrills. The
sounds were embryonic in character, the heart action irregular. Almost
masking the heart sounds, and heard all over the precordium, transmitted
to both chests anteriorly and posteriorly, was a loud, harsh systolic murmur,
heard with greatest intensity in the pulmonic area. The pulse was irregu-
lar, of fair size and poor force. The lungs showed no abnormality other
than a few rales at the bases posteriorly. Her abdomen and extremities
were normal.

The abnormal findings at the autopsy were as follows:

Pericardium.— Contained 170 c.c. clear yellow fluid. An irregular patch
of fibrin about 2 cm. in diameter was firmly adherent to the posterior sur-
face of the right ventricle.

Heart.— Weight 555 gms. The left auricle was very small, the right much
dilated, while the right ventricle was greatly hypertrophied, its wall measur-
ing 2.3 cm. in thickness. The tricuspid valve measured 11.5 cm. Its cusps
were normal. The pulmonary orifice barely admitted the tip of the little
finger, and measured 2% cm. One cusp showed 3 small areas, each about

192

PNEUMOCOCCUS SEPTICEMIA 193

3 mm. in diameter, of reddish color, with rough, irregular surface, due ap-
parently to a recent process. Otherwise, the cusps were normal. The left
auricle and ventricle were both small. The mitral valve measured 10 cm.,
the aortic 7 cm. Their cusps were normal. The left ventricular wall meas-
ured V/2 cm. in thickness. The coronaries were normal. Foramen ovale and
ductus arteriosus not patent.

Lungs. — Pleuritic adhesions and several small, hard, calcareous nodules
at the right apex. At the anterior portion of the right base was a small,
firm area (25 cm. in diameter), dark red, and raised above the surrounding
surface with fairly sharp demarcation from the adjoining tissue. A vessel
leading to this area was apparently occluded by a thrombus. In the upper
posterior portion of the right lower lobe and in the anterior portion of the
left lower lobe were similar areas, but no thrombosed vessels found.

Liver.— Weight 960 gms. Surface very irregular. Capsule thick. Liver
substance very firm on section, generally yellowish, with small red dots,
broken up by heavy bands of connective tissue.

Spleen.— Weight 240 gms. Fairly firm, deep red, trabecular prominent.

Kidneys. — Weight, right 157 gms., left 180 gms. Capsule stripped with
considerable difficulty, tearing away a portion of the tissue. Cut surface,
opaque white with red markings.

Uterus.— 11.5 x 5.5 x 3 cm. Cavity contained small amount of blood clot

Findings in other organs insignificant.

Anatomical Diagnosis.— Congenital pulmonary stenosis; acute endocarditis
of the pulmonary valve; cardiac hypertrophy and dilatation; hydropericar-
dium; infarction of the lungs; healed pulmonary tuberculosis; chronic primal
congestion of liver and spleen; chronic diffuse nephritis.

Bacteriological Diagnosis.— Smears from the pulmonary valves showed
Gram + diplococci ; smears from the uterus showed Gram + diplococci and
Gram + bacilli ; culture from the spleen was negative.

Children's Service

CHILDREN'S SERVICE FOR 1911

Results

DISEASES DUE TO MICRO-ORGANISMS

INFECTIVE DISEASES

•a

s
0

>
0
u
0.

>
0

d
P

■

"3
0
Eh

Cerebrospinal meningitis

1
1
1

Diphtheria

4
2
1
1
1
2
2

" i
l

4
1

-'*2

"i
2

3
1

2
1
2

1
1

Syphilis (congen.), mucous patches around anus.

Syphilis (congen.), secondary, circinate syphil-

1
2

Tuberculosis of lungs, indigestion, otitis media,

Tbc. meningitis, general miliary the, ruptured

1
1
4

10
1

"7
1

ALIMENTARY SYSTEM

INTESTINES

Colitis

"i
.. „

1
1

' i
1

45
2

1
5

1
1

1
2

4
1

' i

' i
1

1
1

PHARYNX

20
1

47
1

Retropharyngeal abscess, acute rhinitis, acute

1
1

2
1

197

198

ST. LUKE'S HOSPITAL REPORTS

ALIMENTARY SYSTEM — Continued

<1>

-a

STOMACH

1
2

' i

1
2

5
1

CARDIOVASCULAR SYSTEM

BLOOD

s 1

10
1

HEART

Mitral insufficiency and stenosis, tricuspid insuffi-

Pericarditis, mitral insufficiency, ascites

Pericarditis, mitral insufficiency, chorea, fibrinous

1
1

1
' "2

Rheumatic endocarditis, aortic and mitral insuffi-

1
2

LYMPH GLANDS

1
1

9
1

NERVOUS SYSTEM

BRAIN

1
1

DISEASES OF THE MIND

1
1

NERVOUS DISEASES OF UNKNOWN ORIGIN

2
4

SPINAL CORD

4
1

8
1

"i
1

OSSEOUS SYSTEM

BONES

1
1
2

Rickets

1
1

Rickets, tetany, laryngismus stridulus, gastro-

RESPIRATORY SYSTEM

BRONCHI

3
3

PEDIATRIC STATISTICS— 1911

199

RESPIRATORY SYSTEM— Continued

•a

Bronchi — Cont.
Bronchitis, eczema

1
""i

Bronchitis (acute), inguinal hernia, rickets....
Laryngitis, pertussis

1
1

Spasm of larynx, asphyxia, tetany

1
1

3
1

LUNGS

Abscess of lung

Atelectasis, prematurity

1
1
4

Pneumonia (broncho-)

Pneumonia (broncho-), ac. colitis

Pneumonia (broncho-), inguinal hernia

1
1

1
1
1
1

Pneumonia (broncho-), meningitis

Pneumonia (broncho), otitis media, conjunctivi-
tis, eczema, inflammation of Meibonian gland

Pneumonia (broncho-), pericarditis

1
1

Pneumonia (broncho-), pertussis

Pneumonia (broncho-), pertussis, otitis media...

PLEURA

Pleurisy with effusion

1
2

17
1

ORGANS OF SENSE

ORGAN OF HEARING

Otitis media, ac. mastoiditis, septic meningitis.. .
Otitis media, malnutrition

3
1

1
2

1
1

1
2

Otitis media, malnutrition, broncho-pneumonia. .

1
1

Otitis media, nephritis

Otitis media, scurvy, pertussis

1
2

TEGUMENTARY SYSTEM
Chronic ulcer of neck, malnutrition

1
1
1
1

2
1

' i

"i
1

1
1

6
1

URINARY SYSTEM

KIDNEY

5
1

"i
1

7
1

Pyelitis, chronic constipation

1
1

' i

CONGENITAL MALFORMATIONS

1
1

1
3

DEFORMITIES
Flat foot

3
1

4
1

200

ST. LUKE'S HOSPITAL REPORTS

INTOXICATIONS AND POISONS

INJURIES

MISCELLANEOUS CONDITIONS

1
1
1
4

i
l

2
6

1
1

Orthopedic Service

ORTHOPEDIC SERVICE

DISEASES OF THE SPINAL CORD

•a

£>

Paralysis (ant. tibial)

Poliomyelitis (anterior)

Poliomyelitis (ant.), paralysis.

DISEASES OF THE BONES

Fracture of femur (malunion) .......

Fracture of hip (ununited), nephritis.

Fracture of tibia

Rickets, bow-legs, knock-knees

Potts' disease

DISEASES OF THE JOINTS

Osteo-arthritis of ankles, knees, elbows, wrists and fingers.

Pneumococcus arthritis of hip

Pneumococcus epiphysitis

Septic arthritis of hip and knee

CONGENITAL MALFORMATIONS

Dislocation of hip

Malformation of femur.
Spondylolisthesis

DEFORMITIES

Genu varum

Genu valgum

Hallux valgus

Muscle-bound feet

Pes planus

Stiffness of elbow joint following fracture.

Talipes equino varus

Talipes equino valgus

Torticollis

Ingrowing toe-nail

DISEASES DUE TO MICRO-ORGANISMS

Tuberculous arthritis of hip

Tbc. arthritis of knee

Tbc. osteitis of hip

Tbc. osteitis of hip, pulmonary tbc

Tbc. osteitis of knee

Tbc. osteitis of spine

Tbc. osteitis of spine, hips and both knees.

203

4
1

2
1
1
1
2
1
1
1

4
1
7
1
2
2
1

AN OPERATION FOR SECURING MOTION IN ANKYLOSIS
OF THE ELBOW DESIGNED TO PREVENT THE SUB-
SEQUENT OCCURRENCE OF FLAIL JOINT.

T. Halsted Myers, M.D.

All the older surgeons insisted upon the removal of large amounts
of bone, both from the humerus and the ulna and radius if the ob-
ject was to secure a movable joint after resection of the elbow. One
and a half inches was about the distance that should separate the
ends of the bones. Since the introduction of the method of interpos-
ing between the bones, a flap of fascia and fat, or muscle, or animal
membrane, it has not been considered necessary to remove so much
bone. For instance :

Goldthwaite, Painter and Osgood, writing in 1909, advise as follows, page
248 : Open the joint by the posterior incision. Preserve the attachment of
the triceps to the fascial expansion over the upper part of the ulna. Subperios-
teal exposure of the condyles of humerus and the olecranon. Condylar sur-
faces removed by saw, elbow flexed and ends of radius and ulna pushed up
into the wound, where they can be reached easily. It is desirable to turn in
a flap of fascia or fat, obtained from the neighboring tissues. Arm put up in
internal angular splints for two or three weeks. Then gentle passive and active
motion permitted. In two months a fairly good functional result may be
expected. In some cases there will be too much lateral motion at the false
joint, rendering the articulation more or less unstable. To control this a
jointed leather splint, permitting flexion and extension, but holding the ends
of the humerus and ulna together so that they cannot slip past each other
laterally, has been employed.

Kocher, Operative Surgery, 1911, p. 317, pays considerable attention to
the conservation of the lateral ligaments. The external lateral ligament,
with the attachment of the extensor tendons, and the capsule attached to
the external condyle are separated subperiosteal^. If complete resection is
to be performed, after dislocating the joint, the internal lateral ligament is
separated subperiosteal^, along with the muscles, from the inner border of
the ulna and the internal condyle of the humerus, and the ends of the bones
are removed. In separating the lateral ligaments it is better to remove a
shell of bone along with them, so as to preserve their attachment to the
periosteum. The best results are obtained by interposing the supinator longus.

Binnie, Operative Surgery, 1912, p. 996, prefers operating as follows : With
osteotome, separate olecranon from humerus. Remove most of olecranon.
Divide bony tissue uniting humerus to ulna and radius. Completely divide

205

206

ST. LUKE'S HOSPITAL REPORTS

lateral ligaments. Flex elbow acutely. With Gigli saw remove small portion
of lower end of humerus. Remove articular surface of ulna, and model a
new sigmoid cavity. If necessary, remove part of head of radius. Divide any
bony tissue uniting radius to ulna, if possible preserving iinnular ligament.
Smooth and shape opposing surfaces of radius and ulna. Interpose flap of fat,
fascia and muscle. Trim edges of humerus. Cover its lower end and one
inch of both anterior and posterior surfaces with flap of fat, fascia and muscle
(anconeus, extens. carp. Ulnaris, etc.). Stitch this in place. Close wound
with drainage.

Fig. 1. — Tubby, Deformities, including Diseases of Bones and Joints, 1912,
removes rather more bone, including the epicondyle and epit.hrochlea, the olecra-
non and its articular surfaces, and part of the head of the radius, making a
gap of iy2 inches at least between ends in an adult. He interposes a strip
of the anconeus between humerus and radius and ulna, and winds a strip of
the extens. carpi rad. long, about radius, between it and the ulna.

As to the best material to interpose between the freshened ends
of the bones : While foreign bodies, such as plates of magnesium, ivory,
etc., seem to have been generally discarded, many surgeons are using
flaps of fat fascia and muscle from the neighboring parts.

Aponeurotic flaps are too feebly nourished with blood to undergo
transformation into bursal tissue, which is considered desirable (Hu-
guier, Paris, 1905). Baer, writing in the American Journal Ortho-
pedic Surgery, August, 1909, says :

"In a majority of cases the interposition of living tissues is followed by a
constant pain, due to pressure upon its nerve endings. While we may attain
a certain degree of motion by the interposition of muscle or fascia, the motion
is generally unnatural in character, and quite often results in an unstable joint
The membrane which I use is from the pig's bladder, and is chromicized, so as to
remain intact about forty days. This is thin and pliable enough to allow of

Fig. '2. — Skiagraph of right elbow taken a year after operati

Fig. 3. — Skiagraphs of left elbow taken a year after
operation.

ANKYLOSIS OPERATION WITHOUT FLAIL JOINT 207

easy adjustment within the joint, and will remain there beyond the period of
bone or fibrous formation."

Transplantation of living cartilage (Weglowski, Centralblatt fur
Chir. 1907, No. 17) in the treatment of ankylosis, and transplantation
of an entire living joint (Buehmann, Centralblatt fur Chir., 1908, No.
19) have not been done sufficiently often to enable one to estimate
their value.

The operation I wish to describe is in line with the tendency to
sacrifice as little bone as possible, by the interposition of animal mem-
brane, and to especially preserve the leverage of the muscles about the
elbow, and prevent too great relaxation of the joint.

In the early part of 1910 I saw a girl, fifteen years of age, most of whose
joints were partially or completely ankylosed by an infectious osteoarthritis,
which had attacked her ten years previously. The deformities resulting had
been corrected, and the joints manipulated, several times, under anaesthesia,
by different men, after the active stage of the disease had subsided; but the
ankyloses gradually recurred. Nothing had been done for the past five years.

As there were no signs of active disease, and both elbows were ankylosed
at 140°, but pronation and supination were fairly good, and as she had a little
motion in her fingers, and about half the normal amount in her shoulders, I
decided to try to mobilize her elbows, as that would enable her to feed and
dress herself.

May 21, 1910. Ether. After Esmarch bandage had been applied, the right
elbow was exposed by a vertical incision down to the bone, along the outer
edge of triceps tendon and olecranon process. The triceps tendon was freed
from the process for about an inch, but its periosteal attachment not divided.
All the soft tissues were then retracted en masse, with periosteum, to the outer
and inner sides of the joint, but only as far as the condyles. The ulna nerve
was displaced inward to the edge of the condyle. This dissection gave free
access to the posterior part of the joint, and a truncated wedge-shaped section
of the lower middle part of the humerus was removed easily with chisel. The
joint was then forced to a right angle position, and the rest of the bone
attached to head of radius and to ulna was removed with rongeurs, and all
surfaces made smooth. Cargile membrane was then placed in front, under
and behind the edges of the humerus. The ulna nerve was replaced, and the
wound closed without drainage. A plaster splint was applied from fingers
to neck, the elbow being held at 80°, in mid position between pronation and
supination.

Eighteen days later, first dressing. Primary union. Elbow passively flexed,
without pain, to 40°, and extended to 135°. Elbow then fixed at 40°. Ulna
anaesthesia noted at first is less marked. Two weeks later a sling was sub-
stituted for cast, and child encouraged to use the arm.

In September the anaesthesia had disappeared entirely, and the elbow had
a range of motion from 150° to 30°, and about 15° of both pronation and
supination.

208 ST. LUKE'S HOSPITAL REPORTS

October 3, 1910, the same operation was done on the left elbow, with
the exception that the incision was carried down the inner side of the olecra-
non, in order to make the approach to the ulna nerve more direct. This nerve
was not displaced at all, but was subjected to rather severe pressure by the
retractors, which may account for the anaesthesia In this case The joint was
found in about the same condition as the right had been, and was treated in
the same way, but instead of Cargile membrane, Johnson and Johnson's
chromicised pig's bladder (Baer's membrane)) was used to cover the edges
of the humerus. Wound then closed, without drainage, and elbow fixed at
80° by plaster splint extending from fingers to neck.

Nine days later cast was removed. Primary union. Cast reapplied. Oct.
20th, cast permanently removed. Extension to 120°, flexion to 60° possible, but
more pain and resistance than in previous case. Ulna anaesthesia. Sling ap-
plied ; massage and passive motion ordered daily. Position to be changed
each day.

Dec. 6, 1910. The child has very good use of the right elbow, and can feed
herself and reach all parts of her head. The left elbow can be extended to
140° and flexed to 40°, but is still somewhat tender, though each week less so.
The ulna anaesthesia is still present.

March, 1912. Report received from this child states that in the left arm
the range of motion is from 145° to 60°, with pronation and supination of 15°
each. In the right elbow the range of motion is from 135° to 40°, with an
equal amount of pronation and supination. There is still some ulna anaesthesia
in left hand. The child can dress herself without assistance.

The object of this method of remodeling the joint is to remove the
opposing bone surfaces a considerable distance from each other, and
yet not destroy the strength of the articulation, as is generally done
when the lateral ligaments are divided, and the condyles, the attach-
ments of the pronators and flexors on the inner side, and the extensors
on the outer side are removed. In the usual operation of excision,
the posterior support and leverage of the olecranon is also destroyed.
In this operation the ligaments on all sides of the joint are preserved.

The operation may not be suitable for tubercular cases which have
become ankylosed, but seems to meet the requirements in joints anky-
losed from any of the acute infections, or from the various forms of
atrophic or hypertrophic osteo-arthritis, and in some cases of ankylosis
after fracture about the joint with deformity and excessive callous
formation.

The enclosed sketch shows the amount of bone removed; that part
included by the heavy lines.

The skiagraphs taken Nov., 1910, show marked changes in the joints,
and also how little can be learned from such a picture about the
amount of motion possible in that joint.

Otological Division

THE RADICAL OPERATION WITH THE APPLICATION OF

THE PRIMARY SKIN-GRAFT, FOR THE RELIEF OF

CHRONIC MIDDLE-EAR SUPPURATION— WITH

REPORT OF CASES.

Edward Bradford Dench, M.D.

I have already written so fully, on previous occasions, upon this
subject, that an article of the same character, in the St. Luke's Hos-
pital Reports, may seem rather out of place. The fact, however, re-
mains that in spite of the excellent results obtained in cases of chronic
middle-ear suppuration by the radical operation, with the application
of a primary skin-graft, many surgeons still hesitate to resort to this
procedure.

I beg, therefore, to report two cases which I have operated upon
in St. Luke's Hospital during the last few months, which demonstrate
clearly the very excellent results which may be secured by this op-
eration :

The first patient was a boy, aged 11, who had suffered from a chronic
discharge from the right ear for 7 years. The boy was anaemic, his general
condition being much below normal, although no causes other than that of
the persistent aural suppuration could be found to account for the impaired
general health. An examination of the right ear showed an extensive de-
struction of the membrana tympani, with granulation tissue present. This
granulation tissue evidently had its origin in the tympanic vault. A por-
tion of the internal wall of the middle ear was dermatized. The low whisper,
upon the right side, was heard only at 4". There was no evidence of any
labyrinthine involvement. On October 24th the radical operation was per-
formed. The mastoid cells were well developed, and extensive caries was
found throughout the entire mastoid. This caries extended posteriorly to the
sinus groove, and the lateral sinus was exposed during the operation.

The complete radical operation was performed, all the mastoid cells were
obliterated, and the mastoid cells, middle ear and external auditory meatus
were thrown into one large cavity by the taking down of the posterior meatal
wall. Particular care was given to the obliteration of the hypotympanic
space by lowering the level of the floor of the external auditory meatus,
while the posterior tympanic space was obliterated by carefully removing

211

212 ST. LUKE'S HOSPITAL REPORTS

the posterior canal wall, as far backward as possible, without injury to the
facial nerve. The nerve was exposed by this procedure, but not injured.
The external auditory meatus was enlarged by cutting a tongue-shaped flap
from the concha. Cartilage and connective tissue were removed from this
flap, and the flap was then folded backward and upward and stitched to
the raw area on the posterior aspect of the auricle. The operation cavity
was then exsanguinated by firmly packing it with a strip of gauze saturated
in a solution of adrenalin chloride, of a strength of 1-1,000. All superficial
hemorrhage was controlled by ligatures. The entire cavity, formed by the
exenteration of the mastoid and middle ear, was then lined with two Thiersch
grafts.

Ordinarily, one graft is used to line this cavity, but it was impossible,
owing to the small thigh of the patient, to obtain a single graft large enough
for this purpose. The grafts were laid over the bone and made to apply
themselves exactly to the irregularities of the surface by introducing a
pipette beneath the grafts, and then exhausting the air. This procedure
permits the graft to adapt itself to the irregularities of the bony surface.
The grafts were held in position by small pledgets of sterile cotton packed
into the cavity. The posterior wound was then closed completely, and a
third graft was applied to the meato-conchal margin, the graft being held
in position by a light packing of sterile gauze. The operation was com-
pleted by the application of a sterile dressing. The sutures in the posterior
wound were taken out on the second day, and the pledgets holding the
graft in position were removed about 5 days after the operation. The
grafts adhered perfectly, and the ear was completely dry 3 weeks from the
time of operation. Two and a half months after the operation the whis-
pering distance on the right side was 3 feet.

The operation, in this case, was a perfect success, all discharge
from the ear having ceased 3 weeks after the operation, and the
hearing having been greatly improved.

The second case was that of a young man, 25 years of age. When 2
years old both ears discharged. There was no further aural trouble until
8 years before I saw the patient, when both ears again discharged. For
the past 8 years there had been an intermittent discharge from each ear
whenever the patient had a severe cold in the head. Two weeks before I
saw the patient, the left ear began to discharge rather profusely, and there
was some pain in the ear. Upon examination, a large perforation was found
in the right drum membrane, with partial dermatization of the mucous
membrane of the middle ear. The ear was perfectly dry. Examination of
the left side revealed some purulent discharge in the left auditory canal, a
large perforation involving the lower portion of the drum membrane and
the internal wall of the middle ear was swollen; there was slight sinking of
the upper and posterior wall of the external auditory meatus, close to the
drum membrane, and a sinus leading into the tympanic vault. The low
whisper was heard 23 feet upon the right side and 5 feet upon the left side.
The patient had a temperature of about 100° on the afternoon of the day

RADICAL OPERATION IN MIDDLE-EAR SUPPURATION 213

upon which I first saw him. There was no labyrinthine involvement demon-
strable, except that the left labyrinth was slightly hyperaesthetic to the
galvanic current. While the patient had no severe pain, there was a con-
tinued feeling of discomfort in the ear, and 5 days after I first saw him, the
radical operation was performed. The periosteum covering the mastoid was
considerably thickened, and there was considerable caries in the mastoid
cells. This caries was particularly well marked over the roof of the tym-
panum and mastoid, and it was necessary to expose the dura in this region
before all diseased bone was removed. The dura was slightly congested.
The radical cavity was formed in exactly the same manner as in the
previous case, the hypotympanic space being obliterated by removal of the
floor of the canal, while the posterior tympanic space was also effaced by
the careful removal of the posterior canal wall, close to the facial nerve.
The meatal flap was formed in the same manner as described in the first
case. The entire bony cavity was covered by a single Thiersch graft, held
in place by pledgets of sterile cotton. The posterior wound was closed and
a meatal graft applied. In 2 weeks' time the middle ear was perfectly dry,
and the low whisper was heard at a distance of 15 feet in the operated ear..

These two cases, operated upon within a period of six weeks, show"
the results that can be obtained in chronic middle-ear suppuration by"
operative interference. They are simply examples of a series of
nearly 200 cases, operated upon by the writer, in the same manner..
At the International Otological Congress, held at Bordeaux, in 1904,
the author reported 98 cases, operated upon by this method. Since
that time, I should say that an equal number of cases had been sub-
jected to operation. With the perfection of technique, the results in
later cases have naturally been better than in those cases operated
upon at an earlier period, and I believe that now we can promise any
patient suffering from a chronic middle-ear suppuration, not only a
perfectly satisfactory result, as far as the otorrhcea is concerned, but
also a satisfactory result as to the preservation of function of the
organ. The only exception which I would make to this latter state-
ment, is in those rare instances where, in spite of an aural discharge,
the hearing is exceptionally good. In these cases, the hearing may
become somewhat impaired as the result of the operation. In those
cases, however, in which, as the result of the suppurative process, the
hearing is greatly impaired, we can ordinarily promise the patient an
improvement in hearing if he will submit to the operation. This fact
is borne out in the two cases already reported.

In a short article of this character, it would hardly be wise for
me to discuss the dangers of chronic middle-ear suppuration. It may
be well, however, to repeat the statistics which I mentioned in my

214 ST. LUKE'S HOSPITAL REPORTS

paper, read at Bordeaux. These statistics were as follows: The
records of the New York Eye and Ear Infirmary, for 8 consecutive
years, showed that 19,323 cases of suppurative otitis media were
treated in that institution. During this time there were 218 cases of
severe intracranial complications. In other words, one patient out
of every 88 suffering from middle-ear suppuration, suffered also from
some severe intracranial complication demanding operative interfer-
ence.

These statistics are, I think, sufficient to show how frequently a
middle-ear suppuration causes some intracranial complication. The
radical operation naturally removes all danger of subsequent intra-
cranial involvement, and if, at the same time, we can promise the
patient that the function of the organ will not be seriously impaired
as the result of operative interference, we certainly are justified in
recommending this procedure in all cases of intractable middle-ear
suppuration.

Pathological Department

A NEW ERA IN MEDICINE IN NEW YORK.

F. C. Wood, M.D.

(Address given in Chicago, March, 1911, before the Alumni of
Columbia University.)

As most of you are aware, the educational problems before the
colleges of this country are many and complex. A growing appreci-
ation of the difficulties to be met is rapidly awakening, not only in the
teacher but also in the public, some doubt as to the perfection of
our methods and distrust as to the ultimate results as shown in the
finished product, the college graduate. The problems are not wholly
financial, as many seem to think; they lie far deeper in the innate
spiritual qualities of the American race. Never has a people so pa-
tiently tried to demonstrate that money will solve all problems of
politics, art, or education, as our own. Never has a failure been so
complete and absolute. We do not yet fully appreciate that money
will buy neither loyalty, scholarship, nor genius, but only industry,
no matter with how lavish a hand it be distributed. A faint glim-
mering of light has occasionally penetrated the darkness when some
incomprehensible foreigner has refused to abandon a comfortable
teaching position in his native land for twice the salary and one-tenth
of the appreciation he now enjoys. Because, with the expenditure
of a few millions, a model manufacturing plant can be created in a
year or two, people still seem surprised that the loyalty of a teaching
body to a university and that intangible thing called tradition may
be more valuable than much money; that the poorest paid and least
known of the professors within a college's walls may have a world-
wide reputation, while the specialist purchased at a high price from
a rival institution seems chiefly known to the readers of the illus-

217

218 ST. LUKE'S HOSPITAL REPORTS

trated editions of the Sunday newspapers, in which he publishes, in
popular form, the preliminary reports of investigations, the final
results of which rarely appear in print. It is not necessary to cite
examples before such an audience. But the fact must not be forgotten
that too often we think that a little more money would cure all
academic ills, while really a thorough organization of the work of an
already existing loyal and harmonious staff of teachers would accom-
plish quite as much.

But what of Columbia ? As graduates of the varied schools of that
institution, you may ask what message I bear? Have we mistaken
size for greatness or bartered a good name for newspaper notoriety?
I can honestly say, No. The growth of the University has been re-
markable, but, in general, wholesome, and its efficiency as a teaching
institution is in every way better than in the previous decade. The
most interesting changes of recent years in any department have
been in the Medical School, long famous as the College of Physicians
and Surgeons. The educational future of the institution has so re-
cently been assured by an unusual combination of circumstances,
coupled with a wise and generous gift of funds, that I shall confine
my remarks chiefly to this aspect of the University's growth.

As some of you may know, Columbia, on behalf of its Medical
Department, is about to enter into an agreement with the Presby-
terian Hospital, one of the largest private hospitals in New York, by
which a much closer relationship is to be consummated than has
hitherto existed between any of the New York schools and hospitals,
an arrangement which permits the nomination by the College of the
incumbents of the clinical and laboratory services of the Hospital.
In return for this permission, which carries with it the use of the
patients in the wards for the teaching of students, the College agrees
to care for the scientific work of the hospital, the various heads of the
purely laboratory departments becoming ex-officio responsible for the
hospital work in their special fields. How great a change this is, and
how much it means for the future of Columbia may not, at first sight,
be very obvious, but I may safely say it promises a new era in Amer-
ican medicine. It may seem a small thing as compared with the op-
portunities which have been enjoyed by the English and German
schools, by Johns Hopkins, and to a lesser extent by several of the
Philadelphia medical colleges. And yet, it is the beginning of what
may make New York City, as it should be, but is not, one of the great
medical centers in this country. A short statement of the past and

A NEW ERA IN MEDICINE IN NEW YORK 219

present position of the Medical School may bring more clearly before
you what the new arrangement means.

Up to the year 1891, the College of Physicians and Surgeons,
though nominally connected with Columbia University, was really a
proprietary institution, though, through the generosity of the Van-
derbilt family, it had been equipped with buildings which at that
time were ample for its needs. Even then, however, it was felt that
the school required a closer intellectual relationship with Columbia
University, then beginning that remarkable expansion which has cul-
minated in the great educational institution of some 7,000 students
now existing in New York. An agreement leading to closer union
was therefore carried out, and in 1901 the College was placed prac-
tically under the absolute control of Columbia. In the meantime,
much new construction had taken place, in order to bring the labora-
tories up to modern standards. Through the generosity of Mr. and
Mrs. W. D. Sloane, the Sloane Maternity Hospital was even then a
model institution for the teaching of obstetrics. It has since become,
in the past year, by the erection of a new pavilion, a complete Frauen-
klinik, to use an expressive German term ; that is, obstetrics and gyne-
cology are united in this hospital for women. In this phase of its
work the school has always had all that it could desire. The Vander-
bilt Clinic also has been a model for out-patient work, with a clientele
so enormous that it has been difficult even to care for the patients,
some 50,000 a year, much less to study each one carefully. Yet these
were the only sources of clinical material for instruction absolutely
under the school control.

These changes, begun 20 years ago, seemed to place the college in
a very strong position, especially as its faculty included most of the
abler clinicians visiting the large hospitals. The condition of the
scientific department has always been excellent, and the teachers in
those subjects are well known the world over. I have only to recall
the names of Prudden, Curtis, Cheesman, Hiss, Gies, Huntington,
Richards, Herter and MacCallum to your minds. But despite the pres-
ence of able men in the departments of medicine and surgery, the feel-
ing has been growing stronger in recent years that they have lacked
something that the laboratories possessed, that is a full control of their
teaching material. It is only too true that while the laboratory in-
vestigators of this generation are justly famous, the clinical teachers
in this country, as compared with those of Germany, have contributed
but little to the science of medicine. The surgeons, it is true, have

220 ST. LUKE'S HOSPITAL REPORTS

been ingenious, and have devised and perfected many operative
methods now generally employed; but surgery is spectacular; it at-
tracts endowments. Surgeons usually can obtain from hospital man-
agers equipment costing many thousands of dollars, when the medical
staff can hardly get a microscope, much less a polygraph. Surgery
is so definite, so positive, and, one may say, so simple a field, that the
surgeon has occupied the foreground in this country to the detriment
of the physician. American surgery to-day is technically the best
in the world, but medical research is still in its infancy.

The reasons for this are many : First, we do not obtain in medicine
the definite results that the surgeon does. We do not so evidently
save lives. The general public suspects, and quite justly so, that many
of the cures in medicine are due to fresh air, good nursing, and the
healing power of nature, and not so much to the drugs administered.
On the other hand, it is quite a simple matter for even a mediocre
operator to remove an inflamed kidney, or a diseased ovary, or a
tumor of the breast, and obtain satisfactory, even brilliant results.
The physician works under different conditions. No one can claim
to cure chronic Bright 's disease. Both kidneys are usually affected,
and before a diagnosis is possible and any treatment instituted the
organs have undergone serious and permanent changes. The treat-
ment of cardiac lesions is a palliative one. We help the heart to do
what it is trying to do naturally. We put the patient in bed and
give the hard-worked muscle a needed rest. We regulate the diet,
and, if need be, give cardiac stimulants. Nature does the rest. But
we do not effect the permanent cure of many forms of heart disease.
So, too, with many infectious diseases. Our powers are as yet ex-
tremely limited. I may merely mention, as examples, pneumonia and
tuberculosis. Our great victories over the latter are those of fresh
air, good food, and prevention of the distribution of the virus. This
brings us to the second reason why medical research in this country
has not prospered. For the investigation of disease in human beings,
a laboratory is necessary, and this laboratory is one in which the
scientifically trained physician can study patients. Much can be done
by means of animal experimentation, but dog medicine will never
replace human medicine. The ordinary laboratory animals do not
suffer spontaneously from the diseases in which we are most inter-
ested. In fact, many of the important conditions cannot be induced
in animals with any certainty. Therefore, while sufficient, and in
some instances, ample facilities have been given pathologists, chem-

A NEW ERA IN MEDICINE IN NEW YORK 221

ists, bacteriologists, and even surgeons, the physician has long strug-
gled with poor equipment, insufficient laboratory space, and lack of
access to patients whom he can control. In other words, the medical
school could offer no facilities for research in medicine, as it had no
laboratories for such study; that is, no hospital. A third reason is
that in general in this country there is no credit given and no financial
reward offered for even the best medical research; the prizes go to
the man with a large general practice.

Not a little criticism has been directed for years toward hospital
managers for closing the doors of hospitals to those who desired to
study disease in the wards as they are studying disease in the labora-
tory, and for giving appointments on the visiting staff to men who
are purely practitioners of medicine, and not investigators ; and many
comparisons have been made, to the disadvantage of this country,
with the great opportunities existing in Germany, which are open
not only to the Germans, but to any volunteer who is willing to give
a reasonable amount of time in the wards. It is possible for any
well equipped young American physician to go to Munich, for in-
stance, and, if he will spend six months, to enter the wards of the
great Fr. Miiller, and there study patients in a way which he cannot
hope to do in America. Even the Johns Hopkins Hospital is more
or less closed to outsiders, because of the necessity of using its ma-
terial for its own students. But the young man comes back from
Munich full of enthusiasm and scientific interest, and desirous of the
same facilities that he has enjoyed there, only to find the doors of
the hospitals closed against him. The great municipal hospitals can
offer no advantages to the student of scientific medicine; they are
poorly equipped, the scientific staff underpaid and overworked, and
the executive staff still too largely under political domination — so the
crowded ranks of the practitioners receive another recruit.

And yet there is another side to the question. The managers of
a private hospital are given money to be expended in the care of
patients. They are trustees of this money, and consequently cannot
spend it as freely as they could if the hospital were run on purely
business principles. They can try no experiment, risk no cent of their
funds. In consequence, the private hospital lags behind even the
municipal institution in advancing medical science, and falls far short
of what is and always can be accomplished by a private institution
not dependent for its future upon donations. Then, too, it is im-
possible to turn loose in the wards a large number of undergraduate

222 ST. LUKE'S HOSPITAL REPORTS

students. They are, in their enthusiasm, apt to over-examine and
annoy a patient. It is difficult, for example, to keep an interesting
ease of malaria in a ward ; every student and interne wishes to have
a blood slide for his own collection. The hospital has to protect these
people by limiting the number of students to each ward. It is difficult
to convince them that they gain weight and strength by repeated punc-
tures of their fingers. So, too, in gynecological work, it is impossible to
have a large number of men examine a woman patient. In acute ap-
pendicitis the fewer people who palpate the abdomen the better for
the patient. The course of a severe pneumonia is not improved by
having twenty men listen to the patient 's chest. So that the managers
have a great deal on their side, and yet, largely due to the agitation
and discussion which has been started by the alumni associations of
the large New York hospitals, composed as they are of the younger,
better trained physicians of the community, most of whom have
also studied abroad, one after another of the great New York
private hospitals has opened its wards to small numbers of selected
fourth-year students. The P. and S., for instance, to-day can send
fourth-year undergraduates into the wards of five of the large private
hospitals, where they remain for two months, enjoying all the facilities
offered to the residents, with the exception that they have no power
to administer drugs. Much to the astonishment of the managers,
not only has the death rate of the hospitals not increased by this
introduction, but it has been found that the attending physicians
are apt to give a great deal more time to their ward services than
they did under the old regime. The cases are more thoroughly ex-
amined, the patients are better satisfied, the histories are more care-
fully taken, the house staff is relieved of unnecessary routine, and it
is now the hospital which is beginning to ask for more teaching. This
is as it should be, and the first result of this experiment, begun at
St. Luke's Hospital, some three years ago, is the proposal of the
Presbyterian Hospital managers to join with the P. and S. as offering
the best results in the care of patients. To the managers, of course,
scientific study is of less immediate interest, though they also are be-
ginning to feel that the reputation that a hospital gets from the pub-
lications and scientific fame of its staff brings it glory, and in that
way, larger funds. In Germany — where, as any of you who have
studied there know — the patients have less to say about their treat-
ment than they have in this country; where autopsies are universal
instead of exceptional; and where the system exists of placing the

A NEW ERA IN MEDICINE IN NEW YORK 223

patient under the care of eminent men who have made advances in
chemistry or bacteriology or pathology, instead of those having merely
a large private practice — the conditions are far ahead of what they
can be in this country for some years to come. We may never reach
the same freedom in handling human beings that now exists in the
hospitals of Germany and France. Our attitude toward our patients
is quite different, our feeling of responsibility to them is much greater
here than it is there. All this makes more difficult the use of patients
for thorough scientific study. The semi-military discipline of a Eu-
ropean hospital cannot be imitated in America. Patients must vol-
untarily offer themselves for study. We must ask a patient's per-
mission before we can place him in a respiratory chamber; it is al-
most necessary to obtain his permission before he can be put upon
the somewhat irksome diet which is necessary for the complete chem-
ical investigation of his metabolic peculiarities. These are some of
the perfectly obvious and practical difficulties in medical investigation
in this country, and there are not a few others patent to every labora-
tory investigator. We cannot shut our eyes to them, and we must
meet them with all possible patience, while at the same time safe-
guarding our patients from annoyance and injury. This means a
far greater supervision by the resident and visiting physicians than
exists in Germany, but if such safeguards are offered, I think we
can accomplish just as good work here as there, even though at a
considerable disadvantage.

The union of the Presbyterian Hospital and the P. and S., the
close geographical relationship of the Rockefeller Institute, and the
presence of the enormous hospital material now being offered for
teaching purposes in New York City, therefore, opens up a new era
to the P. and S., which, in the past few years, has been in great
difficulties, both financial and clinical. The day of the old-fashioned
clinical lecture, when the students sat in an amphitheater and watched
the professors operate, or when the students made ward rounds and
saw fifty patients without being allowed to examine one, has long since
passed. Students must be taught in small numbers; no more than
four or six men can be allowed to study a case. It means a great in-
crease in the number of our teachers ; it means a great increase in our
clinical facilities, before we can reach the ideal. The Presbyterian
Hospital, in its new buildings, will construct ample laboratory fa-
cilities for such scientific work; it will probably be the center of a
large part of the undergraduate teaching of the school, and will offer

224 ST. LUKE'S HOSPITAL REPORTS

opportunities for the best type of medical and surgical research. But
that is not the limit of a great hospital school such as must develop in
New York, Chicago, and other large cities. For it is in the large
cities that opportunities for teaching medicine exist. It is impossible
to build a great medical school in a small town. A thousand hospital
beds must be available for teaching purposes, if the student is to be
thoroughly grounded, not only in medicine and surgery, but also in
the important specialties, and such a large material is easily available
if Columbia can further extend its hospital affiliations, even if the
relationship is not so intimate as that with the Presbyterian. These
are the conditions which we are now facing, and many problems must
still be solved.

A medical school must, primarily, teach undergraduates to be good
practitioners. That is what the public wants; that is what the coun-
try needs; well-rounded men who have seen a large series of cases,
who are trained in all the fundamental sciences ; men who have had at
least two years in college, more if possible, so that the curriculum need
not be crowded with elementary courses in fundamentals; men who
have had real training in biology and not merely a superficial course ;
men who know something of mathematics, something of experimental
physics, and a great deal of organic chemistry, and have a real read-
ing knowledge of German, not only the ability to pick out a few
sentences by the aid of a dictionary. Another function of a medical
school is said to be to train teachers. I think this is wrong. Teachers
are not made, they are born; only a small proportion of the men
who study medicine is in any way fitted to teach, and to adapt a
school for this special purpose is unnecessary. A still smaller pro-
portion of those obtaining a medical education is fitted for productive
research in medicine — the most complicated of all fields. Such men
must have all the preliminary training that the future practitioners
are given; they must also have opportunities to exert their natural
gifts. In other words, the school must offer research opportunities
for such undergraduates as show themselves fitted to do such research.

"We are too apt to be careless in the use of this term "research."
Much of the matter which is published from the foreign universities,
much from our own, is not worth the paper it is written on. It is
done by immature, poorly trained men, with limited horizon and per-
spective, and merely encumbers the field for those who come after.
Real research ability is very rare. It is well to give the practitioner a
chance to see what research means : that he cannot do research without

A NEW ERA IN MEDICINE IN NEW YORK 225

an enormous sacrifice of time, without giving up many of the rewards
that come to one who has many patients. He cannot obtain much
more than a living salary — in fact, as a laboratory investigator in
this country it is difficult to obtain even that. Research in medicine
is also the most expensive possible research, if we except astronomical
investigation. It requires not only patients to study, but the facilities
of large, well-equipped laboratories. The care of patients in New
York City costs over two dollars a day. This expense must be met
by the hospitals ; it cannot be added to the already overloaded budget
of the medical school.

There is also another function of the medical school, and that is the
offering to men the opportunity for post-graduate work in various sub-
jects, chiefly in the specialties, but also in the laboratory branches.
Most of these men will be practitioners who desire to fit themselves
for certain special branches, and this instruction must be disassociated,
more or less, from undergraduate teaching. "With the diminution
which is now going on in the number of men who take up medicine,
owing to the overcrowding of the profession, in the first place, and
owing to the greatly increased cost of medical education in time and
money — for it means a sacrifice of at least ten years' time to become
a physician — the number of undergraduate students in the college
will probably remain small. We do not desire more than one hundred
to one hundred and twenty-five students in a class. We now have
about eighty-five. The size of the school is not likely to be increased,
therefore, in the undergraduate department, in the near future.
Those who direct the future of the college are desirous of seeing
extensive development of advanced work and post-graduate teach-
ing— a great expansion of true investigation along the lines of
scientific medicine. For this we shall have to have other hos-
pitals than the Presbyterian; hospitals with ample laboratories,
with broadly trained clinical teachers in charge of the wards, men
who can appreciate the problems which are yet to be solved, and of-
fer the graduate in medicine a chance to develop his special powers
of clearing away the obscurities which still surround a large number
of the diseases which we so frequently try to treat.

The completion of this ideal scheme will probably require a good
many years of patient labor, and implies, primarily, an extensive
development of the hospital connections we now enjoy. The final
solution lies in the hands of the trustees of hospitals, both municipal
and private, and until they realize what is so obviously needed in

226 ST. LUKE'S HOSPITAL REPORTS

medical education, and appreciate the advantages of close union with
teaching institutions, it is difficult to see how any real progress can
be made, but there can be no question of the final outcome. The
hospitals and schools must finally come together to solve their com-
mon problems and so to obtain their highest possible development,
from both an educational and a philanthropic standpoint.

SELECTING LENSES FOR PHOTO-MICROGRAPHY.
F. C. Wood, M.D.

The drawing of tissues under the microscope is a difficult matter,
and but few physicians have the necessary ability or time to produce
satisfactory sketches. Even professional illustrators are rarely able
to reproduce such material properly without a great deal of super-
vision, and then only at considerable cost. On the other hand, the
production of commercial half-tone plates has now in the best hands
reached such a degree of perfection that there is but little loss of
detail in reproducing satisfactory prints of photo-micrographs if made
on a glossy surface solio or gaslight paper. These facts, together
with a desire to reproduce microscopic subjects as documents giving
evidence of the correctness of the text descriptions on which a thesis
may be based, lie at the bottom of the revival or, if preferred, the
more extensive use of photo-micrography in illustrating embryological
and histological publications.

The recent commercial introduction of color-sensitive plates and
suitable screens has made possible the use of three-color methods for
direct reproduction of microscopic objects, if expense of reproduction
does not have to be considered, in a beauty and accuracy not possible
in the old days of plate making. The employment of the Lumiere
direct color plate for projection purposes has also revived interest in
photo-micrographic methods.

During the last thirty years the elaboration of the mathematical the-
ory of the production of images by lenses, due to the genius of E. Abbe,
and the production of glass of special optical qualities by the Jena
Glass Works, have also enabled opticians to make many improve-
ments in lenses. The results have been most notable, perhaps, in the
production of photographic lenses for general purposes, but very re-
markable improvements have also been accomplished in the production
of microscopic lenses and oculars, though chiefly of the higher powers.

227

228 ST. LUKE'S HOSPITAL REPORTS

On the whole, however, these discoveries have not greatly improved
the objectives of low or medium magnifying power, from a purely
photo-micrographic point of view. Even in the most admirable
apochromatic objectives the curvature of the field of vision is often
very considerable; so much so that the remarkable 8 and 16 mm.
objectives of Zeiss are not especially satisfactory for photographic
purposes unless a very small field of view is all that is required.
"Within such a small field these objectives far surpass almost all lenses
hitherto constructed, but their chief value lies in visual use rather
than in photographic work, although the fact that they are apochro-
matic permits focusing them with white light and afterwards in-
serting a suitable color screen for photographic purposes without
danger of altering the focus. With achromatic objectives, on the
contrary, this is not a very safe process, and generally it is better to
focus with the light with which the photograph is to be taken, for
their correction is usually best at about wave length, 550, and is not
so good with other colors. Fortunately, this is the yellow-green color
most generally useful in the photo-micrography of ordinary stained
specimens.

"With the higher powers, that is, lenses of 4, 3, and 2 mm. focus,
this curvature of the field is less important, because the actual area
photographed under any circumstances is very small and the object
desired is usually a reproduction of fine details rather than a picture
giving extensive topography. Up to 50 diameters, photo-micrography
can be admirably done by any one of a considerable series of ob-
jectives of the photographic type without using an ocular. These
may be the Zeiss tessars or planars, or the well-known miniature
photo-objectives of Leitz, "Winkel, or Eeichert. Above this power the
most satisfactory lens is the micro-luminar of "Winkel of Gottingen,
of 16 mm. focus. This gives a sharp picture over a 6^ x 8!/^-inch
plate with a magnification of 75 diameters. "With care, it is possible
to go a little higher with this objective, but the results are not quite
so satisfactory. It is, of course, used without an eye-piece, though
with the special "Complanat" oculars of "Winkel slightly higher
powers can be obtained with some sacrifice of definition.

At this point the possibility of computing lenses of the ordinary
photographic type for use without an ocular ceases, and for higher
powers we must turn to a form of lens in which the field is never
perfectly flat, but in which the possible angular aperture, and conse-
quently the resolving power, rises rapidly with the diminution in

Fig. 1 (A). — Giant cell sarcoma of finger, taken with as large an aperture
as lens will bear, and showing a softer effect more closely resembling images
seen under the microscope, x 200.

Fig. 2 (B). — Scirrhus carcinoma. The cone of light is too small; hence,
the detraction images about the connective tissue. To be compared with A.

LENSES FOR PHOTO-MICROGRAPHY 229

focal length. The flatness of the field usually varies inversely with
the aperture; that is, the higher the aperture the smaller the area
which is in sharp focus at one time. With the eye this makes but
little difference, for we are constantly shifting the focus up and down
and fusing a succession of pictures. As Nelson says: "Curvature
of image is quite an unimportant error in a microscopic objective be-
cause all critical observations should be made in the central portion
of the field, the rest of the field being used merely as a finder. If it
is necessary to view large masses of an object a lower power should
be used. Sharp central definition is not always compatible with flat-
ness of field, and this sharp central definition should never be sacrificed
for what, at best, is only of small importance."1 The photographic
plate, unfortunately, sees only one plane of an object, and there is no
means of getting other planes into focus ; consequently, it is of the ut-
most importance to obtain lenses of sufficient angular aperture to give
all details combined with a field large enough to give topography.
Usually, extreme apertures should be avoided. Even if the resolution
of the details of the object over a small area is extremely sharp, it
must be remembered that the only reason for taking a photograph is
to produce a print which can be reproduced by a mechanical process.
In the last analysis, therefore, we should think chiefly of the method
of reproduction, and there is no need of having excessive detail on a
plate, because some of the finer points will be inevitably lost in the
print and much more in the half-tone by which the image is finally
transferred to paper. Of course, this does not mean that any hazy
print is sufficient, since the half-tone plate only adds more softness
and haze to the original, but it does mean that we must consider the
obtaining of a plate with harsh contrasts of light and shade and with
moderate sharpness, rather than a thin, exquisitely detailed, smaller
field, which, excellent as it may be for lantern slides, is totally in-
adequate for half-tone reproduction.

The most difficult magnifications to obtain with a sufficient size of
field to give topographic relations are those extending from about 100
diameters to 250 diameters. A large proportion of illustrative photo-
graphs are taken at about this magnification, lower powers than 75
diameters being employed chiefly for such topographic pictures as are
wanted for recording lesions of the spinal cord or the distribution of
glandular elements, such as in the endometrium. These, as has been

*E. M. Nelson: Jour. Roy. Mic. Soc, 1907, p. 656.

230 ST. LUKES HOSPITAL REPORTS

stated, can be taken easily with one of the photographic type of ob-
jectives. An example of such a photograph of 75 diameters (see
Fig. 4), taken with the TVinkel nricro-luminar, to show what that lens
can accomplish, is given. It will be noted that the field is perfectly flat,
covering a 6^0 x S^-inch plate, with sharp detail to the edges.

From 100 diameters on, the most usual combination is a 1-inch or
one-half inch objective. Many firms make two-thirds inch or 16 mm.
objectives. The older makers in England and America used to pro-
duce admirable high angle, four-tenths or one-half inch objectives,
sometimes with correction collar. One of these old achromatic one-
lialf or four-tenths inch objectives with the correction collar is a real
prize, which nowadays cannot be frequently picked up. Any one who
is doing photo-micrography should be on the lookout for such an
objective.

The writer, for example, has one such lens, made by Tolles, with a
focus of four-tenths of an inch and about 0.65 numerical aperture,
which was discarded as useless by the original owner, who did not
realize that the lens was corrected, of course, for the tube length in
general use at the time when the lens was made ; that is, a regular 10-
inch "English" tube. Consequently, he found that the lens was very
unsatisfactory when used on a short ' ' Continental ' ' stand. Of course,
the images are brilliant when used on a proper length tube, and when
the correction collar is screwed to its highest point the lens works
splendidly at 160 mm. tube length; the field is very flat, the color
correction is good. The lenses are as clear as on the day they were
made, and the whole objective is a testimonial to the magnificent
work that came from the hands of that great master of lens making.

It might not be uninteresting to note, in passing, that the writer
has been offered one hundred dollars for this supposedly worthless
lens by one who appreciates its optical qualities — a change in value
almost as remarkable as some stories told of finds of first editions
of old books.2

Such objectives, of course, are not frequently offered for sale at the
present time, because they are all made for the old long-tube micro-
scope stands now chiefly used in England, but they can usually be
obtained for a small sum when they do appear in the stock of second-
hand dealers.

'For similar records of a fine old Powell lens made in 1850, N.A. 0.385,
which is practically equal to a Zeiss 16 mm., N.A. 0.35, see paper by A. A.
C. Eliot Merlin, Jour. Roy. Mic. Soc., 1907, p. 646.

LENSES FOR PHOTO-MICROGRAPHY 231

METHODS OF TESTING LENSES.

The best method of testing the flatness of field and the optical
correction of low and medium-power objectives is, not by the eye,
which continually accommodates to focal differences, but by photo-
graphing a black and white object with very sharp edges to the black
lines. The most satisfactory way to obtain an object of sufficient
fineness and quality is to silver one side of a cover-glass of measured
thickness and then scratch fine lines through the silver coating. The
cover-glass is then mounted in balsam, silver side down, and if ex-
amined will be found to show clear spaces alternating with black
areas, the edges being perfectly clear cut. Such a grating for testing
objectives is sold by Zeiss under the name of Abbe test plate. The
ruling in this case is covered with a wedge-shaped piece of glass,
from 0.10 to 0.20 mm. in thickness, so that corrections for different
thicknesses of cover glasses can be obtained if the objective has a
correction collar. It is not, however, necessary to purchase such a
special testing apparatus, as one can easily be made as follows : A
number of cover-glasses of suitable thickness are first obtained. Most
dealers have measuring calipers and will select a set of cover-glasses
0.17 to 0.18 mm. thick. This is the usual thickness for which ob-
jectives are corrected. A series of such cover-glasses should be
cleaned by moistening them with strong ethyl alcohol, draining off the
surplus, and then pouring over the cover-glasses a few c.c. of strong
nitric acid. The beaker should be immediately placed in the open
air or under a fume hood, as a strong reaction will occur, very of-
fensive fumes of nitric peroxide being given from the acid. In a
few minutes, after the boiling of the acid has ceased, the surplus
should be poured off and the covers rinsed repeatedly in distilled
water until the water no longer reacts acid to the litmus paper. The
covers should then be lifted out of the water with clean forceps and
dried between two layers of filter paper, without touching them with
the fingers. After blowing off any lint, they should be dropped flat
on the surface of a silvering mixture so as to float. A convenient
solution for this purpose is the following:3

One gram of silver nitrate is dissolved in 20 c.c. distilled water,
and strong ammonia (0.880 sp. gr.) is added until the precipitate
formed is just redissolved. A solution of 1.5 grams potassium hy-

•Edser and Stansfield. Nature, lvi, 504, 1897.

232 ST. LUKE'S HOSPITAL REPORTS

droxide in 40 c.c. water, and again ammonia until the precipitate
redissolves; 80 c.c. distilled water are next added, and then silver
nitrate solution (any strength), until there is a faint permanent
precipitate. Make up to 300 c.c.

For the reducing solution, 1.8 grams of milk sugar are dissolved
with the aid of heat in 20 c.c. of distilled water. The two solutions
are mixed in a flat dish and the cover-glasses immediately dropped
on the surface of the fluid so that they fall flat and float. The dish
is covered and left quiet for an hour; at the end of that time, the
silver deposit is usually thick enough, the covers are lifted out, rinsed
in distilled water and dried.

Perfectly satisfactory rulings can be made by taking a fine sewing-
needle (No. 11), and, making a series of light scratches through the
silver in various directions, examining from time to time with a
hand-lens to see that a small area, about 2 or 3 mm., is thoroughly
scratched up. A more satisfactory preparation, which gives regularly
spaced rulings, can be made by the use of an ordinary rotating par-
affin microtome and a microscope with a mechanical stage. A strip
of stiff spring brass about 25 cm. long, 1 cm. wide, and about 2 mm.
thick is taken and a fine needle is fastened to the tip with a mass of
sealing wax. The needle should be perpendicular to the surface of
the metal. The strip is then clamped to the jaws of the holder ordi-
narily used for carrying the mounted paraffin blocks for cutting,
and the feed is adjusted to give any convenient number of microns.
The most satisfactory spacing is 50 microns, which in the ordinary
paraffin microtome requires two turns of the wheel. A silvered cover-
glass is fastened on a slide with some sealing wax, silver side up, and
clamped to the mechanical stage, and the microscope and microtome
are clamped to the table so that they do not move in relation to each
other, and are so arranged that the slide is movable at right angles
to the line of feed of the microtome. After the preliminary adjust-
ments have been made, the needle is lowered into contact with the
silvered surface, the springiness of the brass strip equalizing any
excess pressure, and a scratch about 10 mm. long is made in the silver
by moving one of the screws of the mechanical stage. The needle is
lifted by rotating the microtome slightly and the cover-glass is moved
out of the way; then the microtome is rotated completely, so as to
feed the needle forward 50 microns, the point of the needle is again
brought into contact with the silvered surface, and by moving the
microtome stage parallel to the first cut and 50 microns from it, an-

Fig. 4.— N<

.formal post-menstrual endometrium. Winkel 16-mm. micro-
luminar, with no eyepiece, x 75. The entire plate is sharp to the edges, but
as it was impossible to reproduce all. an area 15 x 13 cm. was selected.

LENSES FOR PHOTO-MICROGRAPHY 233

other scratch will be made in the silver. This is to be repeated until
a considerable ruled area is obtained. The slide is then turned at
right angles to its first position and a series of cross rulings made.
The cover-glass is then freed from the surface of the slide by softening
the sealing wax, and mounted in balsam. As soon as the balsam is
hard, the sealing wax is cleaned off with some strong alcohol and the
slide examined with a half-inch lens in order to see if the rulings are
satisfactory. This will usually be so, if a very fine needle has been
employed. The very finest sewing-needles (No. 11) are the best for
the purpose. In order to prevent bending, the needle should be set
a very short distance from its tip, in sealing wax. Not all needles
have a good point, so before using one, it should be examined with a
hand magnifying lens or under a low-power objective to see that the
point is not turned over, as is frequently the case in finer grade
needles.

If it is impossible to obtain a ruled test plate as described, an ex-
cellent object to determine the flatness of field of an objective, though
not its resolving powers, is a smear of normal blood, or, for short
focus immersion objectives, a slide of diphtheria or tubercle bacilli,
thinly spread and faintly stained. The spread of blood should be very
carefully made, if possible, on a carefully selected plate-glass slide,
though the ordinary cheap slides will do if one is picked out which
is flat and free from rough points on the surface. To test the flat-
ness, hold the slide so as to get a reflection of a window-frame on its
surface and see whether the lines are straight and do not become
curved when the slide is rotated. Several slides should be cleaned
by boiling in strong nitric acid, then washed in distilled water and
dried with a cloth or filter paper, free from grease. Normal blood
is then smeared over the surface of the slide, using any of the methods
regularly employed in preparing specimens for diagnostic work. The
smears should be thin and perfectly even, and the corpuscles sepa-
rated from each other by a space equal to about their own diameter.
The slide is dried and fixed in strong methyl alcohol and stained very
intensely with a 1/100 solution of water soluble eosin. If desired, the
leucocytes may be stained after pouring off most of the eosin by the
addition of a few drops of a 1/400 methylene azure. The blood should
be then mounted in balsam, using a measured cover. In order to get
photographs with a satisfactory contrast, it is necessary to use a
yellow-green screen and a color-sensitive plate, but as this is the light
which is necessarily used with all achromatic objectives when photo-

234 ST. LUKE'S HOSPITAL REPORTS

graphing stained tissues, it does not in the least interfere with the
test.

As soon as a suitable mount is obtained, the slide should be set up
in the microscope, the objective inserted with a suitable projection or
other eye-piece, and then the lines of the grating or the borders of
the red cells carefully focused on the ground glass of the camera by
the use of a hand-lens. It is necessary to see that the condenser is
in proper adjustment for the lens ; very few lenses will stand a cone
of light filling more than one-third to one-half of the aperture of
the back lens. This is best noted by focusing, then removing the eye-
piece and adjusting the condenser while looking down the tube. If
a Nernst light, or electric arc, or similar strong source of illumination
is employed, it is necessary to reduce the intensity of the light by a
piece of dark glass or a fragment of a photographic dry plate which
has been exposed to daylight for a second and then developed and
fixed. This will usually give a neutral tint film sufficiently opaque
to prevent injury to the eye. "With a Zeiss photographic apparatus
such a dark glass is provided in a cap which fits into the end of the
draw tube. If the photographer is fortunate enough to possess one of
the old-fashioned four-tenths or one-half inch achromatic objectives
made by Powell & Lealand, Tolles, H. R. Spencer, or "Wales, which
are provided with a correction collar, great care should be taken in
seeing that this collar is turned until the best correction is obtained
for spherical and chromatic aberration. The colored fringes seen at
the edge of the black lines are present, to some extent, with all achro-
matic objectives, especially at the periphery of the field, and their
complete removal, except at the center, is not so important as the
perfect correction of the spherical aberration, as is shown by the
perfect sharpness of the edges of the silver bands or the blood cells.
Most objectives are now corrected for a shorter tube length, usually
either 160 or 170 mm., and marked, as a rule, with the proper length
for the draw tube. It is necessary, if the objective is not screwed
directly into the nose-piece, to allow for either 10 mm., in case of a
revolving nose-piece, or 22 mm., in the case of the Zeiss sliding ob-
jective changers. The old-fashioned achromatic objectives with cor-
rection collar, even when computed for the long tube, often work
admirably on the modern short tube-stand if there is a sufficient
range of collar adjustment.

As it is not always easy to judge the point at which definition be-
gins to fall off, it is usually better to make a photograph rather than

07 0.7

0.8 0.8

1.2

1.3

.1.8

0.9 0.9

0 1.0

I 1.3

Fig. 5. — I. Tolles % inch, showing sharp Held over
0.0 mm. x 200.
II. Tolles 4-10 inch, showing sharp field over
0.7 mm.
III. Spencer 1 inch, eomplanat eyepiece No. 1.
showing sharp field over nearly 0.!) mm.

LENSES FOR PHOTO-MICROGRAPHY 235

to rely entirely upon the eye. The most suitable plate for this pur-
pose is the Cramer isochromatie double-coated plate, which has great
latitude of exposure and stands prolonged development without fog-
ging, and yet is sensitive to the yellow-green color used in tissue
photography.4 The exposure should be short and the development
prolonged in order to bring up all possible contrast. When the nega-
tive is dry a print can be made from it if desired, and the quality of
the image judged from the print, but to any one who is experienced
in looking at negatives, it will be easy to determine the approximate
point at which the sharpness of image ceases, and that, of course, is
the size of the useful field of the objective. It is generally somewhat
easier to tell the exact point from a blood smear photograph than it is
from the photograph of the ruled screen. The screen, however, af-
fords a better test of the optical qualities of the objective than the
corpuscles, because the edges of the silver bands are extremely sharp
and the slightest haziness or color is shown in the photograph as a
lack of sharpness to the edge. Another definite way of getting the
diameter of the field, though it is not a satisfactory one for the re-
solving power of the objective, is to photograph a stage micrometer.-
If the lines are black or the micrometer used is one of the photo-
graphic reproductions, the diameter of the useful field can be fairly
easily told ; but, as just stated, it is not a satisfactory test for resolu-
tion, because by varying the time of exposure, the screen and the de-
velopment, the apparent sharpness of the lines can be varied and a
poor objective will give, on a thoroughly developed plate, a much
better picture than a good objective on a thin plate.

In order to get the best definition the lens should be used with an
achromatic condenser of approximately the same focus as the ob-
jective. If such a condenser is not available, a lens of about the
same aperture and focus can be used in the substage as a condenser
with the most satisfactory results. On looking down the tube of the
microscope, the illuminated area of the condenser diaphragm should
be central, and the maximum amount of light used which the objective
will bear without the image becoming hazy. If the light is not cen-
tered or if the diaphragm is reduced to too low a point, the diffraction
lines will appear at the borders of the red corpuscles or at the edges
of the rulings of the Abbe test plate. It is, unfortunately, only too

4It is not necessary to go into further details concerning plates or de-
veloper here ; possibly in a subsequent number of this report the subject of
plates, screens, developers, etc., will be fully treated.

236 ST. LUKE'S HOSPITAL REPORTS

common to see photo-micrographs in which the diameter of the sharp
field of the objective has been increased by the process of reducing
the cone of light thrown by the condenser to a very small diameter.
The result is that, while the field covered by the objective is slightly
larger, diffraction lines are present about the borders of the nuclei,
and the bodies of the cells and all finer details are lost. The ad-
vantage of the use of lenses of large aperture is that they stand a
good deal of light without the image becoming hazy, and therefore
the exposure may be shortened with equal or better definition. In-
fluenced, perhaps, by the constant habit of looking at or making
drawings of histological material with a pen, the average person
thinks that a photo-micrograph showing diffraction lines represents
more accurately the appearances usually present under the micro-
scope than a much softer picture obtained by the use of a high-angle
immersion lens, but a little study of stained sections under the micro-
scope with high-grade lenses and a suitable condenser and light will
show that, on the contrary, few cells have a sharp outline, and that in
well preserved material each shades into the next contiguous cell
without any great contrast. The routine fixation and hasty paraffin
embedding of much of the material ordinarily examined has also con-
tributed not a little to the sharp outline attitude, for the inevitable
shrinkage following such procedures tends to isolate cells or groups
of cells and thus leave clear spaces about them.

AREA OF USEFUL FIELD.

The results of the examination of photographs of ruled silvered
plates, of blood slides, and of stage micrometers is shown in the ap-
pended table. The magnification chosen was a constant one ; that is,
200 diameters, this being the maximum magnification likely to be used
with medium power objectives; above that point, 6 or 4 mm. lenses
are to be preferred, though an exceptional 8, 10, or 12 mm. lens
may permit a useful magnification of 250 to 300. This is much
lower than the theoretical "useful magnification," which is usually
given as 100 times the numerical aperture; in other words, a lens of
N.A. 0.20 should give a good image at 200 diameters, one of 0.30 at
300 diameters, one of 0.65 at 650 diameters; but in practice but few
objectives will give more than half this, and the ordinary cheap
commercial achromats not more than a third or even a fourth. The
test is therefore much more severe on the 16 to 25 mm. lenses than
on those of shorter focus. Possibly all that can be expected of inch

Fig. 6. — Zeiss s-inm. apochroniat, with No. '■> pro-
jection eyepiece, x 200. The ink ring shows the
limit of the sharp field.

LENSES FOR PHOTO-MICROGRAPHY 237

objectives is a maximum of 125 to 150. A few lenses, even though
their aperture is relatively low, will give good pictures at 200 di-
ameters, the best example the writer has seen being the Winkel apo-
chromat of 25 mm. focus with a N.A. of 0.22. This exceptional lens
stands 200 diameters better than many of much shorter focus and
larger aperture, with a sharp field covering a 6y2 x 8y2 plate.

The objectives, concerning which further details are given in Table
II, fall naturally into two groups ; the first 8 of 12 mm. or less in focus,
the last 5 of between 16 and 25 mm. focus. Of the half-inch lenses,
the Tolles one-half is the superior though its low aperture of 0.42
requires more careful handling of the illumination than the three
which follow. The Spencer Lens Company's 8 mm. apochromat is
one of the best for photography now being made. The Watson lens
is only fair. The Powell and Lealand, though still made, is not to be
recommended. The particular type of Bausch and Lomb half-inch
is no longer listed by that firm, but is a very fine lens. Last of all
comes the 8 mm. Zeiss, with so small a field that its usefulness is
much restricted, though within that field it gives the best and sharp-
est images of any objective examined. In the second group, the
maker of the Spencer lens is long since dead, but the lens is a re-
markable one. Close to it is the Winkel apochromat, which is the
best lens now obtainable for low-power photography ; that is, between
75 and 200 diameters. The Zeiss and Leitz 16 mm. are very good for
within the sharp field, but this is much too limited for photographic
purposes.

A long series of tests have also been made with low-power achro-
matic lenses of both foreign and domestic makers, but though, with
patience and great care, fair results can be obtained, they are not
wholly satisfactory. The optical requirements for photographic work
are much more severe than for purely visual effects, for which these
lenses are intended. In the higher powers, however, some excellent
lenses are obtainable, especially the "flourite" objectives of Leitz and
Reichert, but better work can be done with the 4 and 6 mm. dry
apochromats of Zeiss, and still better with Powell and Lealand 's
quarter-inch apochromatic immersion. For the highest magnifications,
such as are required for photographing bacteria, the improved achro-
matic 1/12-inch oil immersions are very satisfactory, though nothing
quite equals the Zeiss 3 mm., N.A. 1.40.

238

ST. LUKE'S HOSPITAL REPORTS

I.— TABLE OF LENSES ARRANGED ACCORDING TO DIAMETER OF USEFUL
FLAT FIELD AT A MAGNIFICATION OF 200 DIAMETERS.

of Field in Millimeters with Zeiss II. Projec-
Lens tion Eye-piece

Tolles % inch. 110 mm. Definition satisfactory.

o«^ii 4, •„ », (100 mm. Used with 160 mm. tube.

/"> 1D 85 mm. Used with 250 mm. tube. Definition about the

same, but better than the % inch.
Wales 4/10 inch.
Powell and Lealand % inch

achromatic immersion.
Spencer Lens Co. 8 mm. apo-

chromat.
Watson % inch holostigmat.
Powell and Lealand % inch

apochromat 160 mm. tube.
Bausch and Lomb % inch,

Series III.
Zeiss 8 mm. apochromat.

Leitz 8 mm. apochromat.

H. R. Spencer 1 inch 250 mm.

tube.
Winkel 25 mm. apochromat.

Zeiss 17 mm. achromat AA.
Watson 24 mm.

Zeiss 16 mm. apochromat.
Leitz 16 mm. apochromat.

Diameter

110
100

mm.
mm.
mm.

mm.

75
70
75

mm.
mm.
mm.

60
60

mm.
mm.

mm.

115

mm.

160

mm.

180
170

mm.
mm.

70
75

mm.
mm.

Very good definition.

Fair definition ; much better than would be
expected from resolution tests.

Very good definition.

Definition better over this area than any of the

above lenses, except the immersion P. & L.
Definition even better than the Zeiss in the lens

examined, but not equal to the immersion.
With Winkel Complanat Eye-piece No. 1 field

is 200 mm., with excellent definition.
With Complanat Eye-piece No. 2, 180 mm. and

very good definition.
Very fair definition.
Field, but very poor definition all over ; will

not give good picture at over 150 diameters.
Good definition.
Good definition.

II. — TABLE OF RESOLUTIONS OF SERIES OF LENSES.

The diatoms employed were Nitschia scalaris (abbreviated N.S.), 26,000 lines to the

inch, mounted in styrax, and Pleurosigma angulatum (abbreviated P. A),

44,000 lines to the inch, mounted in realgar.

Grade Lens

100 Tolles achromatic 4/io inch or

10 mm. N.A.=0.65 for 250

mm. tube.
100 Zeiss or Leitz 8 mm. apochro-

matic. N.A.=0.65 for 160

mm. tube.
90 Wales achromatic Vio incn or

10 mm. N.A.=0.60 for 160

mm. tube.
75 Spencer Lens Co. 8 mm. apo-

chromatic. N. A. =0.60 for

160 mm. tube.
70 Watson holostigmat 12 mm.

N.A.=0.45 for 170 mm.

tube.
70 Bausch and Lomb, Series III,

12 mm. N.A.=0.54 for 210

mm. tube.
65 Tolles % inch. N.A.=0.42 for

250 mm. tube achromat.

65 Powell and Lealand % inch
or 12 mm. apochromatic.
N.A.=0.64 for 250 mm. tube.

60 Herbert R. Spencer 1 inch or
25 mm. N.A.=0.35 achro-
mat.

60 Zeiss 16 mm. N.A.=0.30 apo-
chromatic for 160 mm. tube.

50 Zeiss 17 mm. A. A. achromat.
N.A.=0.30.

45 Watson 24 mm. N.A.=0.24
holostigmat.

45 Winkel 25 mm. N.A.=0.22
apochromat.

Resolution Central

Resolution Oblique

Objecl

Light

N.S.

Easily into dots, even

Very easily into

better than Zeiss 8 mm.

dots.

P.A.

Easily into dots.

N.S.

Easily into dots.

P.A.

Easily into dots.

N.S.

Dots.

P.A.

Easily into dots.

N.S.

Dots.

Dots poorly.

P.A.

Dots.

N.S.

Good resolution, but
only lines.

Fairly into dots.

P.A.

Not resolved.

Fairly into dots.

N.S.

Fairly into lines.

Fairly into dots.

P.A.

Fairly into dots.

N.S.

Easily into lines.

Fairly into dots.

P.A.

Not resolved.

Poor resolution in
dots.

N.S.

Lines only.

Dots poorly.

P.A.

Not resolved.

N.S.

Lines only.

P.A.

Not resolved.

N.S.

Lines only.

P.A.

Not resolved.

N.S.

Lines only.

P.A.

Not resolved.

N.S.

Just shows lines.

P.A.

Not resolved.

N.S.

Barely shows lines.

P.A.

Not resolved.

SWv ^A* \? . *. .v

Fig. r. — Powell and Lealand ^-inch apochromat x 200. The ink ring
shows the limit of the sharp field.

LENSES FOR PHOTO-MICROGRAPHY 239

The resolution, or ability to reproduce fine details, also varies di-
rectly with the numerical aperture of the lens, but a lens of high aper-
ture may not be so satisfactory as one of slightly smaller opening if
its spherical and chromatic corrections are not also perfect.

An example of this is seen in the Powell and Lealand half-inch
apochromatic, which will be discussed later. Theoretically, this lens
should be an excellent one, but practically it is worthless.

Resolution being equal, the best lens in every respect is the one
giving the largest field. With the low powers it is possible that the
entire field may not be employed for reproduction, but it is very con-
venient to have a little leeway so that the exact centering of the
image to be obtained is not necessarily carried out under the micro-
scope, but a general field selected from which a suitable part may be
cut for final use as an illustration. The selecting and absolute center-
ing of an exact field on the ground glass of the camera focus is time-
consuming, and it is difficult, without a great deal of experience, to
judge the final effect of a tissue photograph, either in the camera or
from a negative; the print is the best criterion.

The most accurate means of testing the resolution alone, because
the mere marking of the angular aperture on the objective does not
guarantee that the measurement is correct, is to use a diatom, suitably
mounted. The objectives under consideration range from 25 to 8 mm.,
with a numerical aperture of from 0.22 to 0.65. There are two di-
atoms which offer convenient standards. These are the Pleurosigma
angulatum and the Nitschia scalaris. They should be mounted in a
highly refracting medium, such as realgar, or, if such preparations
cannot be obtained, dry. The light used must be intense ; direct sun-
light, if properly screened, is good ; or the direct light from a Nernst
filament or miniature arc lamp, or even a flat-wick kerosene lamp is
preferable to daylight. The condenser must focus the light on the
object. Under such conditions it is remarkable what a good lens will
do. For instance, the writer has been able to resolve Amphipleura
pellucida in realgar with the Zeiss 4 mm. short-tube apochromatic
lens and a dry Watson parachromatic condenser, using a suitable blue
screen. Usually, nothing but an immersion lens will show the lines
on this most difficult object.

The table on page 238 shows the results of the examination of a
series of lenses in the possession of the writer — a rough estimate in
percentage is given to aid in classification, but has no claim to ac-
curacy. It will be seen that the resolution of Pleurosigma in dots by

240 ST. LUKE'S HOSPITAL REPORTS

central light immediately divides the objectives into two classes, those
above N.A. 0.50 and those below, though a Powell and Lealand one-
half N.A. 0.64, falls, for some unknown reason, into the lower class.
The Nitschia scalaris gives another dividing line when resolved into
dots by oblique light at N.A. 0.40. All of the objectives thus tested re-
spond pretty closely to the theoretical limits, those usually set being
a numerical aperture of at least 0.65 for the resolution of the dots
of P. angulatum with an axial light, slightly less for lines, and at
least 0.30 for N. scalaris in styrax; the only exception being the
Powell and Lealand half-inch, N.A. 0.64, which falls way below its
class, being surpassed by the Watson and Bausch and Lomb half -inch
objectives of considerably lower aperture and equalled by a Tolles
half-inch achromatic, N.A. 0.42. The flat field of this lens is almost
twice that of the Powell and Lealand, and for photographic work the
objective is much superior, though made some 40 years ago, before
the discovery of the Jena glasses and the computations of Abbe, per-
mitting apochromatic lens construction.

In the same way the Tolles 4/10-inch is equal to, and possibly
surpasses in resolving power, the best modern product of Zeiss, the
8 mm. apochromat, while its field is much larger. Close behind is an
old achromatic 4/10-ineh Wales, with slightly lower aperture, but
with a large, flat field and exquisite definition. Either of these old
lenses are much superior to the modern achromatic lenses of any
maker for the purposes of photography, if we except a Powell and
Lealand half-inch immersion, specially made for the writer, with a
numerical aperture of 1.30. This has a flat field of 90 mm. and gives
better definition and greater resolution than any dry lens. It is,
however, purely a photographic objective, and not useful for other
purposes.

Some improvement in the flattening of the field can no doubt be
obtained by improvement in the eye-pieces employed in photographic
work. A step in this direction has been taken by Winkel, whose so-
called "complanat" eye-piece gives a somewhat flatter field with his
objectives than with the projection type of eye-piece made by Zeiss,
and, in fact, the performance of the old achromatic objectives is often
better with a complanat than with a projection eye-piece.

CONCLUSIONS.

A complete outfit of lenses suitable for the highest class of photo-
micrography is expensive, and, though fair results can be obtained by

LENSES FOR PHOTO-MICROGRAPHY 241

the use of the cheaper grades of achromatic lenses generally fitted to
microscopes, quite satisfactory for ordinary visual work as they may
be, yet good photographs can only be made with the finest lenses, for
defects which the eye will entirely overlook will become most apparent
when a lens is used for photography. An ideal outfit would be the
following :

1. Zeiss planar 75 mm. focus for very low powers.

2. Winkel micro-luminar, 16 mm. focus, for magnification from 25 to 75
diameters.

3. Winkel 25 mm. apochromat with complanat eye-pieces I and II, for
75 to 150 diameters.

4. Tolles, Spencer, or Wales 710 or y2-inch for from 150 to 200 diameters.
In lieu of these a Spencer Lens Company's 8 mm. apochromat is the best
now on the market as regards flatness of field. The Zeiss or Leitz 8 mm.
apochromat is more expensive and has a smaller field, though giving su-
perior definition.

5. A Powell and Lealand %-inch apochromatic immersion, N.A. 1.30, for
200 to 500 diameters. As this lens is expensive, a dry apochromat 4 or 6 mm.
of Zeiss, or any other standard make, such as Winkel, Leitz, or Reichert,
may be substituted, but the flat field is smaller than in the immersion and
the lenses more difficult to handle because of the necessity for careful ad-
justment of the light and their sensitiveness to varying thicknesses of cover-
glass. The Powell and Lealand immersion is the most satisfactory lens made
for medium powers.

6. A Zeiss 3 mm. apochromat, N.A. 1.40, for the long tube. This is one
of the most remarkable lenses made. It gives a range of from 500 to 1,400
diameters with the Zeiss III and VI projection eye-pieces, which are also
to be employed with lenses IV and V. It is less easily injured than the 2
mm. Zeiss apochromat, N.A. 1.40, the front lens of which may be dismounted
by the slightest touch to a cover-glass, and has a larger field. The long
tube, 3 mm., is a shade better than the short tube lens of the same aperture
and focus. In fact, all of the long tube objectives give better results than
the short tube ones, as the same magnification can be obtained with a lower
eye-piece.

CASE OF INCOMPLETE RUPTURE OF THE HEART DUE TO
CORONARY HEMORRHAGE.

J. Gardner Hopkins, M.D.

The patient was a woman of fifty years, a designer by occupation.
Except for the diseases of childhood, she had always been well up to
four days before admission to the hospital, when she was suddenly
seized with a feeling of suffocation while at work and had to be taken
home. This attack was followed by rather severe constant pain in the
precordium, which increased on deep breathing. She had no other
symptoms. As the pain continued, she came to the hospital and was
admitted on Dr. Janeway's service. On examination, the apex beat
was not made out. The heart dulness was apparently increased ; the
sounds were distant but normal ; no murmurs were heard. . The pulse
was regular and of good force. After rest in bed, the pain disap-
peared, and on the third day the patient was allowed to sit up, with
the expectation of discharge in a few days. While being wheeled to
her bed after defecation, she became deeply cyanotic, fell forward
in her chair, and apparently died instantly.

At autopsy, the pericardium contained coagulated blood which
formed a thick layer about the anterior, posterior, and right surfaces
of the ventricles and extended up about the aorta and pulmonary
artery. The clot was thickest at the apex posteriorly, where it meas-
ured 2.5 cm. The ventricles and right auricle were in systole and
left auricle in diastole (Fig. 1). The leaflets of all the valves were
thickened and those of the mitral showed atheromatous plaques.
There was no evidence of endocarditis. In the apex of the left ven-
tricle was a blood clot about 2 cm. in diameter, and in the anterior
wall near the septum was a cleft filled with blood clot continuous with
that in the ventricle (Fig. 2). This cleft extended downward and to
the left, following the course of the muscle fibers. At the left border
of the heart it reached the subpericardial fat and extended through
the fat, communicating with the pericardium apparently at the apex
posteriorly, though the precise point of communication was not made

242

RIGHT AURICLE

LETT AURICLE

PULMONARY ARTERY

AORTA

Fig. 1. — Section through base of heart, viewed from above, showing compres-
sion of right auricle and dilatation of left auricle.

B
8

a
s

O
•J

►J
m

APEX OF LEFT VENTRICLE

RUPTURE

Fig. 2. — Section through heart, near apex, viewed from below, showing

rupture in the wall.

INCOMPLETE RUPTURE OF THE HEART 243

out. There was also hemorrhage in the fat below and about the apex
of the right ventricle. The blood clot in the ventricle was covered
by a delicate membrane, which, on section, consisted of a fibro-cellular
membrane covered with endothelium, and was evidently the remains
of the endocardium, showing that the blood had lain beneath the
endocardium and not actually in the ventricular cavity. The coro-
naries showed extensive sclerosis, and the descending branch of the
left coronary was much thickened and diffusely calcareous. The ex-
ternal diameter of this vessel was about 4 mm., but its lumen was
very small. About 4 cm. from its origin the lumen was practically
occluded by the thickening ; but could be traced, on section, 1 cm. or
more below this point (Fig. 3). The anterior wall of the left ven-
tricle in the region supplied by this artery was pale yellow and glisten-
ing and translucent on section. There were other smaller tears in the
muscle, also filled with thrombi, which did not extend to the pericar-
dium. Microscopically, the muscle cells in this area were shrunken
and hyaline in appearance. In some areas they showed no nuclei ; in
others they had small, deeply staining nuclei. Between the necrotic
cells there were rows of polymorphonuclear leucocytes, among which
were a few small, round cells. In places the leucocytes were collected
in masses resembling small abscesses (Fig. 4), in which a few partly
calcified fragments of muscle cells could be seen. No bacteria were
seen in these areas. There were also many leucocytes about the tears
in the muscular wall. The small arteries in the wall were thickened
and some were filled with organized thrombi (Fig. 5). The pericar-
dium was thickened, due chiefly to infiltration with small round cells
and large cells of endothelial type.

The aorta showed extensive arteriosclerosis with calcification, and
there was marked interstitial nephritis.

The anatomical diagnosis was: Arteriosclerosis of aorta and coro-
nary arteries. Myomalacia of anterior wall of left ventricle. Incom-
plete rupture of the heart due to hemorrhage from a coronary vessel.
Hemopericardium. Chronic interstitial nephritis. Adenoma of renal
cortex. Chronic passive congestion and fatty degeneration of liver.
Emphysema, congestion, edema, and healed tuberculosis of lungs.

Rupture of the heart is among the rarer causes of sudden death
and has aroused much interest since the first case described by Har-
vey. Morgagni described a number of cases from his own experience,
but the lesion appears to be much less frequent in recent times. El-
leaume collected sixty-one cases, thirty-seven of which were in men

244 ST. LUKE'S HOSPITAL REPORTS

and twenty-four in women. The rupture is usually very minute, as
in this case, and usually larger externally than internally. The cleft,
as a rule, follows the course of the muscle fibers. Occasionally there
is a long tear, in one case from the base to the apex ; and from three
to five multiple tears have been reported. Forty-three of fifty-five
cases involved the left ventricle, and the usual point is in the an-
terior wall, near the apex. The rupture may follow embolic or
sclerotic occlusion of the coronary artery with subsequent softening
of the wall. Abscesses in the myocardium, gummata, and tumors have
also led to rupture. Ten of Elleaume's cases were due to rupture of
an aneurism of the heart, which is a relatively frequent cause. Quain
suggested that diffuse fatty change might lead to rupture, but this
seems unlikely as it lessens the force of the heart action and would
rather tend to prevent rupture.

Rupture of the heart occurs in old age and usually after severe
exertion. It sometimes occurs without any apparent occasion, and
even while the patient is asleep. In other cases it may follow psy-
chical excitement, as in the case of Philip the Second of Spain, who
died of rupture of the heart when told of the defeat of his armies.

In the case reported here, rupture was evidently due to degenera-
tion of the myocardium in the region supplied by the descending
branch of the right coronary artery. The sections of the heart muscle
present a typical picture of acute suppurative myocarditis, but the
history of the case is very much against the supposition that the
process was infectious. There was no evidence of endocarditis and
pericarditis, or any other condition which would account for the origin
of an infectious myocarditis. It is probable that the collections of
leucocytes were not due to bacterial infection, but to reaction about
the necrotic tissue. These collections of leucocytes are commonly
found in softening of the myocardium. The fact that the inner
blood clot lay beneath apparently intact endocardium makes it seem
probable that the rupture was due to hemorrhage from some coro-
nary vessel which penetrated internally beneath the endocardium
and externally into the pericardial sac. There was no escape
of blood from the ventricle. From the amount of reaction about the
clot, the first hemorrhage into the wall probably occurred when the
patient had the first attack of dyspnea, and the terminal event was
rupture of this intramural hematoma into the pericardium.

The most interesting feature of the ease is the condition of the
auricles. In a section through the base of the heart (Fig. 1) the left

.-/?*:*-..

,>..

■

Fig. 3. — Photomicrograph showing cross section of the descending branch
of the left coronary artery. The lumen is obliterated, except for two narrow
slits at the right. To the left is a calcified area. 20 diameters.

^*&3>Zt\\ ■&**£■ -.it-

§1 : 'ftSlliHiiil

iii: ill

/■

Fig. 4. — Photomicrograph showing collection of leucocytes in necrotic heart

muscle. 45 diameters.

Fig.

-Photomicrograph showing remains of endocardium covering the blood
clot in the ventricle. 22."> diameters.

Fig. 6. — Photomicrograph of the necrotic heart muscle, showing small throm-
bosed vessel, surrounded by leucocytes. 200 diameters.

INCOMPLETE RUPTURE OF THE HEART 245

auricle is seen to be in diastole, while the right auricle is compressed
to a mere slit. This illustrates clearly the theory of Cohnheim that
death in hemopericardium is due to compression of the right auricle,
the chamber in which the blood pressure is the lowest. He injected
fluid into the pericardial sacs of dogs and showed that the sudden in-
jection of 150 c.c. to 200 c.c. was sufficient to cause death, whereas,
a much larger amount of fluid might accumulate gradually in the
pericardium without a fatal result. The effect depends upon the
tension of the fluid rather than upon its amount. As the pericardial
pressure approaches the pressure in the right auricle it interferes with
the entry of the blood into the heart from the systemic veins, causing
a rise in venous pressure and a fall in arterial pressure. The pres-
sure in the left auricle is considerably greater than in the right, and
consequently the entry of blood from the lungs is not interfered with
until the pericardial pressure is increased considerably above the point
necessary to compress the right auricle.

References. — Cohnheim, Allegemeine Pathologie. Trans, by McKee, vol. i»
p. 30. Elleaume, Essai sur les ruptures de cceur. These de Paris, 1857. Fried-
reich, Virchow's Handbuch f. spezielle Pathologie u. Therapie, vol. v, sec. 2,
p. 183. Morgagni, De sedibus et causis morborum, book ii, letter 27. Quain,
Medical and Chirurgical Transactions, London, vol. xxxiii.

REPORT OF THE WASSERMANN REACTIONS DONE BY THE
PATHOLOGICAL DEPARTMENT DURING THE YEAR 1911.*

C. H. Bailey, M.D.

During the past year 597 "Wassermann reactions have been done
by the Pathological Department. The results of the reaction on the
423 cases whose histories were accessible were as shown in the fol-
lowing table:

Positive
Syphilis :

Primary 6

Secondary, untreated 20

Secondary, treated 7

Tertiary 54

Latent 24

Congenital 2

General paresis 1

Tabes 5

Diseases possibly of syphilitic origin :

Aneurism 6

Aortic insufficiency 9

Facial paralysis 1

Chronic inflammations of the eye 7

Diseases not diagnosed clinically as

syphilitic 1 2 3 177

Those cases are classed as positive which gave complete inhibition
in the tube containing 0.2 c.c. of the patient's serum and antigen, with
complete hemolysis in the control tube containing 0.4 c.c. of the pa-
tient's serum without antigen. Those in which there was a slight
trace of hemolysis in the tube with antigen and complete hemolysis
in the control, and those which, with complete inhibition in the tube
with antigen, showed a trace of inhibition in the control, are classed
as doubtful positive. Those with partial hemolysis with antigen or

*A portion of this article appeared in the Archives of Internal Medicine,
May, 1912.

246

Doubtful

positive

negative

Negative

REPORT OF WASSERMANN REACTIONS 247

partial inhibition in the control are classed as doubtful negative; all
others as negative.

The three cases classed under "Diseases not diagnosed clinically
as syphilitic" which gave positive or doubtful positive reactions re-
quire special mention.

Rheumatoid Arthritis. — Wassermann positive. No history of syphilis ob-
tainable. Patient complained of pain and swelling in her right great toe of
three weeks' duration. Pain in right ankle and left arm for one week. On
entrance, toe was swollen, somewhat red, and tender. Slight tenderness over
inner aspect of left tibia. Temperature normal. During her five weeks in
hospital both elbows and several phalangeal joints were involved. Patient
was on mixed treatment eleven days, potassium iodide being continued nine-
teen days longer, without improvement.

Gelatinous Carcinoma of Rectum. — Wassermann doubtful positive. The
patient denied lues, and the past history was not suggestive. Diagnosis was
made from section of excised portion of tumor.

Lymphosarcoma of Tonsil. — Wassermann doubtful positive. This woman
gave a history of one miscarriage, one child born dead at term, one child dead
at 22 months (cause not known). She had two living children. Otherwise,
there was nothing suggestive in the past history. Diagnosis was made from
section of excised portion of tumor.

The cases on which Wassermann reactions have been done subse-
quent to the injection of Ehrlich's 606 are but fourteen in number.
These cases are, however, of sufficient interest to report individually.

Case 1. — Oct. 25, 1910. Chancre of lip. Spirocheta pallida present. Wasser-
mann positive.
Intramuscular injection of 0.6 gm. 606.
Roseola present.

Intramuscular injection of 0.6 gm. 606.
Spirocheta pallida present. Wassermann positive.
Wassermann positive.
Wassermann positive.
1, 1911. Wassermann positive.
Case 2. — Primary lesion six years ago. Came in for stricture of urethra, one
month duration.
July 1, 1911. Intravenous injection 606.
July 12. Wassermann negative.

Case 3. — Primary lesion four months previously, followed by secondaries.
Dec. 4, 1910. Intramuscular injection 0.5 gm. 606.
Jan. 4, 1911. Wassermann positive.
Case 4. — Secondaries in February, 1911. Then six months pregnant.

Mar. 8, 1911. Wassermann positive. Intramuscular injection of

606, followed by mixed treatment.
June 28. Wassermann negative. Baby said to be well.

Oct.

26.

Nov.

15.

Nov.

19.

Dec.

21.

Feb.

248

ST. LUKE'S HOSPITAL REPORTS

Case 5. — Primary lesion April, 1910. Secondaries about one month later.
From August up to the time of admission to hospital had numer-
ous ulcerating lesions on various parts of body. Treated continu-
ously, since primary lesion, with mercury, by inunction and injec-
tion, without effect.

Nov. 26, 1910. Entered hospital. Condition : multiple gummata and
serpiginous syphilides. Wassermann positive.

Nov. 27. Intramuscular injection of 0.4 gm. 606.

Jan. 4, 1911. Wassermann positive. Lesions healing rapidly.

Apr. 26. Wassermann negative. Lesions healed.

Case 6. — Infant, age two months.
Oct. 16.

Oct. 18.

Oct. 25.

Nov. 2.

Case 7. — June 7,

June 10.
June 24.
June 26.
July 29.
Aug. 30.
Nov. 15.

General eruption, snuffles, hoarseness. Large liver
and spleen. Wassermann positive. 0.025 gm.
606 administered subcutaneously.
Wassermann positive.
Wassermann positive.

Wassermann positive. Condition much improved.
1911. Fading roseola, and mucous patches. Wassermann
positive.
0.6 gm. 606 intravenously.
0.6 gm. 606 intravenously.
Wassermann positive.
0.6 gm. 606 intravenously.
Wassermann positive.
Wassermann positive.
Has had no symptoms since first injection.
Case 8. — Jan. — , 1910. Primary lesion, followed by secondaries. Treated

with mercury.
Sept. 15, 1911. Wassermann positive. Has no symptoms.
Sept. 22. 0.5 gm. 606 intravenously.

Oct. 17. Wassermann positive.

27. 0.5 gm. 606 intravenously.

28. Wassermann doubtful positive.
7. 0.6 gm. 606 intravenously.

27. Wassermann doubtful positive.

15, 1912. Wassermann negative.

— , 1909. Primary lesion. Treated ten months with mercury.

29. 1911. Wassermann positive. No symptoms at present.
2, 1912. Wassermann negative.

Had two doses of 606 in the interval.
Primary lesion six months ago ; 606 four months ago.
June 21, 1910. No symptoms at present. Wassermann negative.
Primary lesion six years ago.

Dec. 7, 1910. Orchitis, dactylitis. Wassermann positive.
Dec. 8. 0.9 gm. 606 intramuscularly.

Dec. 18. Wassermann positive.

Mar. 2, 1911. Wassermann positive.

Oct.
Nov.
Dec.
Dec.
Feb.
Case 9. — Mar.
Mar.
Jan.

Case 10.
Case 11.

Mar. 15.

Sept. 20.

Case

12.— Sept— , 1910.

July — , 1911.

Oct. 18.

Case

13.— Sept. — , 1910.

Mar. — , 1911.

Mar. 26.

May 27.

June 28.

Case

14. — Denies syphilis.

Oct. 16, 1911.

REPORT OF WASSERMANN REACTIONS 249

Wassermann positive.

Wassermann doubtful positive.

Primary. Treated with mercury for seven months.

606.

Wassermann negative.

Primary lesion.

Mixed treatment.

606 subcutaneously.

606 intravenously.

Wassermann negative.
Had yaws thirty-five years ago.

Wassermann positive. Palpable tumor of liver.
Diagnosis : Gumma of liver.

0.5 gm. 606 intravenously, followed by mixed treat-
ment.
Jan. 23, 1912. Tumor not felt. General condition greatly improved.
Wassermann positive.

Four of the above cases, on whom no test was done before injection,
gave a negative reaction after injection. Four, on whom the reaction
was positive before injection, gave a negative reaction after an interval
of three and one-half to nine months. Six cases gave a positive or
doubtful positive reaction after an interval of seventeen days to nine
months.

It is conceded by most observers that in working with a hemolytic
system it is advisable to use known amounts of both amboceptor and
cells. Wassermann 's original method for the diagnosis of syphilis
makes use of 1 c.c. of a 5 per cent suspension of sheep corpuscles with
just twice the amount of amboceptor necessary to hemolyze these
cells. Since the discovery of the existence of an anti-sheep ambo-
ceptor in some human sera it has been a question whether this ad-
ditional amount of amboceptor might not be sufficient to produce
hemolysis in conjunction with a small residue of complement not
fixed in the first stage of the reaction. If this should occur, negative
results would thus be obtained in syphilitic cases.

The recognition of this possibility has given rise to several modifi-
cations of the Wassermann reaction. The best known of these is
probably that of Noguchi. He claimed1 that: " Wassermann 's origi-
nal method is subject to an error arising from the presence in human
serum of a varying amount of natural amboceptor capable of being
reactivated by guinea-pig's complement." He found experimentally

Noguchi. Jour. Exp. Med., 1909, xi, 392.

250 ST. LUKE'S HOSPITAL REPORTS

that four units of anti-sheep amboceptor prevent entirely the detec-
tion of one unit of syphilitic antibody. The modification of the Was-
sermann technique devised by him has, among other advantages, that
of avoiding this danger by the use of a hemolytic system consisting
of human blood cells and the serum of a rabbit immunized against
them.

Several other methods of obviating this source of error have been
suggested which still make use of sheep corpuscles as in the original
Wassermann method. That of Bauer2, in which each serum is tested
for anti-sheep amboceptor and artificial immune serum added only to
those which show an insufficient amount of natural anti-sheep ambo-
ceptor to give complete hemolysis with the amounts of sheep cells
and complement used in the Wassermann reaction, will of course be
efficient in those cases in which the human serum contains just enough
amboceptor to give complete hemolysis. As, however, some sera con-
tain many times this amount of natural amboceptor, with these the
source of error still remains.

Jacobaeus3 proposed absorbing the sheep amboceptor from human
serum by incubating the serum, after the addition of sheep cells, at
37° for one-half hour; then centrifuging off the cells and proceeding
with the Wassermann reaction according to the regular technique.
In a series of 257 cases he obtained about 10 per cent more positives
by this method than without absorption. He claims that complemen-
toid is also removed by this method, thus giving it the advantage of a
modification introduced by Wechselmann,4 in which complementoid
is removed by digesting the inactivated human serum with barium
sulphate. Bauer5 had previously tried the same procedure which
Jacobaeus employed, but discarded it on account of its making the
serum anti-hemolytic. He claimed that this property was much in-
creased by the addition of liver extract, thus causing negative sera
to give positive reactions.

S. Mintz8, using this method in a series of 38 cases, obtained 30
positive reactions against 25 without absorption. The sera which
reacted positively were all syphilitic.

This method of amboceptor absorption has been tried by the author

2Bauer. Sem. meo\, 1908, xxviii, 429.

'Jacobaeus. Ztschr. f. Immunitatsforsch., Orig., 1911, viii, 615.

4Wechselmann. Ztschr. f. Immunitatsforsch., Orig., 1909, iii, 525.

'Bauer. Berlin klin. Woch., 1908, xiv, 834.

6S. Mintz. Ztschr. f. Immunitatsforsch., Orig., 1911, ix, 29.

REPORT OF WASSERMANN REACTIONS 251

on 305 sera, regardless of the amount of natural anti-sheep ambo-
ceptor present. The result of the Wassermann reaction on each of
these sera has been compared with the result of the reaction on the
same serum with the natural anti-sheep amboceptor present.

Only 53 of the 305 sera contained one or more units of natural anti-
sheep amboceptor in 0.2 c.c, i.e., sufficient to hemolyze completely 1
c.c. of a 5 per cent suspension of sheep corpuscles in the presence of
one unit of complement. In 70 sera there was no trace of anti-sheep
amboceptor in 0.2 c.c. In the remaining 182, anti-sheep amboceptor
was present, but in a quantity not sufficient to produce complete
hemolysis.

The technique employed to remove the anti-sheep amboceptor from
the human serum was as follows: To 0.5 c.c. of the patient's serum,
after inactivation, was added 2 c.c. of 0.85 per cent salt solution and
0.1 c.c. of sheep cells. After shaking, the mixture was incubated at
37° for 20 minutes. The cells were then centrifuged off and the
supernatant fluid used in the Wassermann reaction, 0.5 c.c. of the
diluted serum being used in the tube with antigen and 1 c.c. in the
control tube without antigen, the amount of antigen, complement, etc.,
being correspondingly reduced to one-half the usual quantity. The
remainder of the fluid was used to test the completeness of the ambo-
ceptor absorption. In about one-quarter of the cases a sufficient
amount of the patient's serum was used to test for remaining sheep
amboceptor in a full c.c.

In all but three of the 305 sera, removal of the sheep amboceptor
was complete. 0.2 c.c. of each of these showed a faint trace of hemoly-
tic power for sheep cells still present. One additional serum showed
very slight hemolytic power remaining in a full c.c, but none was
demonstrated in 0.2 c.c.

So far as the removal of anti-sheep amboceptor from human serum
is concerned, we may conclude that the method is practically always
efficient. The objection to the method is that inhibitory bodies are
in some way produced by this process ("Sachs-Friedberger phenom-
enon") which considerably slow hemolysis, there sometimes being a
trace of inhibition at the end of an hour in the control tubes and in
negative sera. The difference in reaction between positive and nega-
tive sera is, however, clear-cut, the inhibitory action not being suffi-
ciently marked to render the method impracticable as a means of
avoiding any error which may be due to the presence of natural anti-
sheep amboceptor.

252 ST. LUKE'S HOSPITAL REPORTS

Rossi7 claims that incubation at 0° for 20 minutes is as efficient in
absorbing the amboceptor as incubation at 37°, while by this method
the inhibitory phenomenon does not appear. His method is to add
0.5 c.c. of sheep red blood corpuscles to 1.5 c.c. of the patient's serum,
both having been previously cooled to 0°. The mixture is kept at
this temperature for 20 to 30 minutes, then rapidly centrifuged, and
the serum drawn off with a pipette. In a series of 60 syphilitic cases
he obtained 50 positives by the Wassermann reaction and 56 positives
after absorption.

This method of absorption, as well as that at 37°, was tried on
195 of the above 305 sera. In a portion of these the Rossi technique
was followed in detail. With the remainder, the technique was the
same, except that serum and cells were mixed in the proportions used
for absorption at 37°. This method was found equally efficient in
absorbing the anti-sheep amboceptor. So far, however, as the avoid-
ance of inhibitory action is concerned, it was unsuccessful, there
being little if any difference in this regard between the two methods.

The results of the Wassermann reactions on the 305 sera with
natural anti-sheep amboceptor still present and on the same sera
after the amboceptor has been completely removed, are shown in the
following table. The results of the Wassermann reaction, following
absorption at 0° did not differ in any particular from those following
absorption at 37°.

Doubtful Doubtful
Wassermann reaction Positive positive negative Negative
On sera with natural anti-sheep ambocep-
tor present 103 16 2 184

On sera after removal of anti-sheep ambo-
ceptor 104 18 1 182

As is shown by the above table, there was a difference in results
in but three of the 305 cases. The cases in which the reaction differed
were as follows:

1. Diagnosis : Pyorrhea Alveolaris. No history of syphilis obtainable.
The serum contained five units of anti-sheep amboceptor. Wassermann reac-
tion : with anti-sheep amboceptor present, negative ; after removal of anti-sheep
amboceptor, doubtful positive.

2. Diagnosis : Syphilitic Laryngitis. Primary lesion fourteen years ago.
Treatment previous to Wassermann reaction not known. The serum contained
over three units of anti-sheep amboceptor, the exact amount not being de-

7Rossi. Ztschr. f. Immunitatsforsch.. Orig., 1911, x, 321.

REPORT OF WASSERMANN REACTIONS 253

termined. Wassermann reaction : with anti-sheep amboceptor present, doubtful
negative; after removal of anti-sheep amboceptor, positive.

3. Diagnosis : Tabes Dorsalis. No history of syphilis. Serum contained
two units of anti-sheep amboceptor. Wassermann reaction : with anti-sheep
amboceptor present, negative ; after removal of anti-sheep amboceptor, doubtful
positive.

It will be noted that in none of these cases was the difference in
results a difference between a frank negative and a frank positive
reaction.

In reporting results of the Wassermann reaction it is unnecessary
to give in detail the technique employed, the method being so well
known. There are, however, certain points which it seems to us
should be mentioned. In the reactions reported here, the guinea-pig
serum was always titrated and care taken never to use as much as two
units, as will frequently be done if 0.1 c.c. is used. The antigen used
in nearly all of the 305 cases was an acetone-insoluble fraction of
beef heart, prepared as recommended by Noguchi8. The quantity
used in the reaction was 0.01 c.c. This antigen was not hemolytic or
anti-complementary in four times this amount, and had high anti-
genic properties. Titrated against four positive sera it gave with
one complete inhibition in one-tenth the quantity used ; with a second,
complete inhibition in one-thirteenth, and with the other two com-
plete inhibition in one-twentieth the quantity used.

As the results obtained by the amboceptor absorption methods vary
considerably from those reported by Wechselmann and other ob-
servers, experiments were done to test the effect of the introduction
of artificial amboceptor on the Wassermann reaction done with the
above antigen.

Three sera were selected which were frankly positive with this
antigen and Wassermann reactions done on each of these after the
addition of five, ten, and fifteen units of artificial anti-sheep ambo-
ceptor. Reactions were also done on the same sera without the ad-
dition of artificial amboceptor and after the addition of five, ten, and
fifteen units, using an amount of antigen which by titration with each
serum contained two units of antigen for that serum. Each serum
contained natural anti-sheep amboceptor, but in an amount less than
one unit. This was not removed.

Serum 1. — Contained two units of syphilitic antibody. Wassermann reac-
tions were positive with both strong and weak antigens. With the addition of

"Noguchi. Serum Diagnosis of Syphilis, 2d Edition.

254 ST. LUKE'S HOSPITAL REPORTS

five, ten and fifteen units of amboceptor, the reactions were doubtful or nega-
tive with both antigens, but the inhibition was greater with the stronger
antigen.

Serum 2.— Contained eighteen units of syphilitic antibody. Wassermann
reactions were frankly positive with the strong antigen, even with the addition
of five, ten and fifteen units of amboceptor. With the weak antigen the serum
gave a frankly positive reaction when artificial amboceptor was not added.
With five units of amboceptor the reaction was doubtful ; with ten and fifteen
units, negative.

Serum 3. — Contained more than twenty-five units of syphilitic antibody.
Wassermann reactions were frankly positive with both antigens, with fifteen
units of anti-sheep amboceptor present.

CONCLUSIONS.

From the above cases and experiments, we conclude that it is pos-
sible for anti-sheep amboceptor in human serum to affect the Wasser-
mann reaction, but that when an antigen of high titer is used this
is possible only with sera of very low antibody content and several
units of anti-sheep amboceptor. As these two conditions, in our ex-
perience, occur but rarely in practical work, we feel that, when a
strong antigen is used, the importance of anti-sheep amboceptor in
human serum as a cause of negative reactions in syphilitic cases is
not great. As a routine procedure, the absorption of amboceptor is
unnecessary. Its removal is advisable, however, from sera which
give a negative or doubtful reaction, and which contain a large
amount of anti-sheep amboceptor. This is easily accomplished by
digestion with sheep cells. It is immaterial whether this is done at
0°, 37°, or room temperature.

COMPLEMENT IN HUMAN SERUM.*
C. H. Bailey, M.D.

C. C. Bass1, in "A New Conception of Immunity," draws inter-
esting conclusions from several statements, the experimental proof
of which, unfortunately, he does not give. The broad application
made of the principles stated, and the fact that, as stated, they are
contrary to generally accepted ideas, encouraged the following brief
experiments.

The statements referred to are as follows:

"Human complement capable of acting with human amboceptor to
produce lysis ... is destroyed by any temperature above normal
body temperature. ... A temperature of 40° C. (104° F.)
destroys complement in human serum in from fifteen to thirty min-
utes and prevents lysis regardless of the amount of amboceptor em-
ployed. ' '

"Freshly drawn human blood contains little or no complement
capable of acting with human amboceptors. . . . No human spe-
cific complement develops at ordinary fever heat, 38° to 40° C. (101° to
104° F.), such as obtains locally and often generally in most in-
flammations. ' '

"In the event that human complement has developed in a blood
... it again disappears in from thirty to seventy-two hours. ..."

EXPERIMENTS.

Experiment 1. — Five human serums, all of which had been on the clot for
over seventy-two hours, were withdrawn, and tested for complement, before
and after heating at 40.5° C. for thirty minutes.

To tubes, each of which contained 0.25 c.c. of a 2 per cent suspension of
washed calf-cells and 0.25 c.c. (two units) of a 1-600 dilution of inactivated
serum of a rabbit immunized to calf -cells, was added the human serum in the
following amounts : 0.8, 0.4, 0.2, 0.05 and 0 c.c. A similar series was set up for

♦Reprinted from the Journal of the American Medical Assn., 1911, lvii,
Dec. 23.

^ass, O. C. : Jour. A. M. A., Nov. 4, 1911, p. 1534.

255

256 ST. LUKE'S HOSPITAL REPORTS

each patient, with like amounts of serum, heated for thirty minutes at
40.5° C.

Patients A and B gave no hemolysis with either heated or unheated serum.
Patient C gave complete hemolysis with 0.4 c.c. of serum, both heated and
unheated. Patient D gave slight hemolysis with 0.8 c.c. of serum, heated and
unheated. Patient E gave complete hemolysis with 0.8 c.c. of serum, and almost
complete with 0.4 c.c, heated and unheated.

This experiment shows that complement may still be present in
serums over seventy-two hours old, capable of completing a lytic sys-
tem, and that such complement is not destroyed by thirty minutes'
heating at 40.5° C. It would be remarkable if human complement
capable of acting with a calf -immune system were not destroyed by
thirty minutes' heating at 40° C, while "human complement capable
of acting with human amboceptor to produce lysis" were thus de-
stroyed. As, however, the article in question specifies the latter, the
following experiment was performed to determine this point, as well
as the truth of the statement that "freshly drawn human blood con-
tains little or no complement capable of acting with human ambo-
ceptors. ' '

Experiment 2. — A normal individual was bled directly into an equal amount
of citrate solution in a water bath at 41° C. The cells were immediately cen-
trifuged off, and varying amounts of the supernatant fluid added to a 5 per
cent suspension of sheep cells, previously sensitized with human serum con-
taining natural sheep amboceptor, and set up in the bath at 41° C. Incubation
was at 41° to 43° C, for thirty minutes.

The remainder of the supernatant fluid was retained in the bath at 41° to
43° C, for thirty minutes, and then added to sensitized cells.

To tubes, each of which contained 0.25 c.c. of a 5 per cent suspension of
washed sheep-cells and 0.125 c.c. (=2 units) of human serum containing anti-
sheep amboceptor, inactivated one-half hour at 56° C, was added the citrated
plasma, prepared as above described, in the amounts given in Table I.

TABLE I. COMPLEMENT CONTENT OF PLASMA OF NOEMAL INDIVIDUAL.

-Result-

With plasma heated

With fresh plasma 30 min. at 41° C.

Citrated plasma Hemolysis Hemolysis

0.6 Complete Complete

0.3 Complete Complete

0.15 Almost complete Almost complete

0.075 Partial Partial

0.0375 Slight Slight

.0 None None

COMPLEMENT IN HUMAN SERUM 257

Experiment 3. — Two patients, one with a temperature of 104° F., the other
104.5° F., were bled directly into equal amounts of citrate solution, in a water
bath, at a temperature of 42° C. The cells were at once centrifuged off, and
the plasma, thus diluted, added to sheep cells sensitized with human serum,
as in Experiment 2, already in the bath at 42° C. Incubation was at 42° C,
for thirty minutes.

TABLE II. — COMPLEMENT CONTENT OF PLASMA OF FEBEXLE PATIENT.

Fresh citrated , Result *

plasma from Patient A Patient B

febrile patients Hemolysis Hemolysis

0.6 Complete Complete

0.3 Complete Complete

0.15 Complete Almost complete

0.075 Partial Partial

0.0375 Slight Slight

.0 None None

From the above experiments the following conclusions seem jus-
tified :

1. Human complement capable of acting with human amboceptor
to produce hemolysis is not destroyed by a temperature of 41° C. for
thirty minutes.

2. Freshly drawn human blood contains a considerable amount of
complement capable of acting with human hemolytic amboceptor, and
such* complement is not destroyed by heating at 41° C. for thirty
minutes.

3. The blood of a patient with a temperature of 40° C. contains
complement capable of acting with human hemolytic amboceptor.

4. Complement does not necessarily disappear from human serums
in seventy-two hours after withdrawal from the body.

EFFECTS ON TITRATIONS OF INEQUALITY OF SENSITI-
ZATION OF CORPUSCLES.*

C. H. Bailey, M. D.

It is well known that corpuscles will absorb many times the amount
of specific amboceptor necessary to produce hemolysis, and that such
absorption takes place with considerable rapidity. We believe, how-
ever, that the importance of these facts in quantitative serum work,
as titrations for lytic or complementary power, has not yet been
recognized. The author has frequently noted that duplicate titrations
of the same serum gave results that differed beyond reasonable limits
of experimental error, and that the reading obtained from a serum
titration could be influenced considerably by slight variations in the
method of activating the corpuscles. These results appear to be due
to the fact that when corpuscles are added to an amboceptor dilution
they are not at once evenly distributed through the fluid, and thus,
owing to the rapidity with which amboceptor is absorbed, an oppor-
tunity is afforded for certain corpuscles to take up more of the ambo-
ceptor than others, and unequal sensitization results. If this be the
case, it will be seen that slight variations in the method of activating
the corpuscles will produce variations in the distribution of ambo-
ceptor and consequently in the hemolysis obtained.

The following complement titrations illustrate the difference in
results which are produced by different methods of activating the
corpuscles :

Experiment I. — The tubes contained a 1-10 dilution of guinea-pig serum,
in the amounts shown below, with sufficient salt solution to make the final total
in each tube 1.25 c.c.

A. To each tube was added 0.25 c.c. of a 1-2000 dilution of amboceptor
(= 1 unit) and 0.25 c.c. of a 5 per cent suspension of sheep corpuscles, sep-
arately.

B. Into 4 c.c. of a 1-2000 dilution of amboceptor were dropped, rapidly, but
one drop at a time, 4 c.c. of a 5 per cent suspension of sheep corpuscles, the

♦Reprinted from the Journal of Experimental Medicine, May, 1912, xv.

258

SENSITIZATION OF CORPUSCLES 259

receptacle being shaken in the meantime. Of this mixture, 0.5 c.c. was added
to each tube.

C. Like B, except that the process was reversed, the amboceptor being
added to the corpuscles ; 0.5 c.c. was added to each tube.

D. Into 4 c.c. of the 5 per cent suspension of corpuscles was quickly poured
4 c.c. of the amboceptor dilution, and the mixture immediately shaken ; 0.5 c.c.
was added to each tuba

The results, after incubation for one hour at 37°, were as follows :

Guinea-pig serum,

1-10 dilution... .375.3 .25 .225.2 .175.15 .125.1 .075.05 .025 0

A C C C C C AC AC AC P P YS YS 0

B VS VS VS VS VS VS VS VS VS VS VS VS 0

C C C C C C C C AC AC P VS VS 0

D C C C C C C C C ACP VSVS 0

Note. — In this and the following experiments C = complete hemolysis,
AC = almost complete hemolysis, P = partial hemolysis, S = slight hemolysis,
VS = very slight hemolysis, and 0 = no hemolysis.

It is to be noted that although the amounts of amboceptor, com-
plement, and cells, and the dilutions, are the same in corresponding
tubes of the different series, the results differ considerably. B and C
are methods of activation which would hardly be used in practical
work. They serve, however, to illustrate the extreme variation in
results which may be obtained. It is evident in B that practically
the entire amount of amboceptor was taken up by the first few
corpuscles added, consequently they were the only ones to hemolyze ;
and there is little difference in the amount of hemolysis resulting
between the highest and lowest tubes. C, on the other hand, as might
be expected, approaches closely to an even sensitization. A and D are
methods which are often used in complement titration, as for the
Wassermann reaction, A probably more commonly than D. When
a cell suspension is added to small tubes containing amboceptor, as
was done in A, it may be noted that frequently a few cells will be
distributed through the liquid, the greater bulk, however, remaining
on the surface, along the side of the tube, or sinking to the bottom,
thus affording an opportunity for a few cells to absorb more than
their share of the amboceptor, the amount depending, of course, on the
interval elapsing between the introduction of the cells and the shaking
of the tube.

It is evident that to cause this inequality, the absorption of ambo-
ceptor by corpuscles must be very rapid. The following experiment
was done to obtain some idea of the amount of amboceptor absorbed
by corpuscles in a given time :

260 ST. LUKE'S HOSPITAL REPORTS

Experiment II. — Amboceptor absorption in A, with a 5 per cent suspension
of sheep corpuscles, and corresponding immune rabbit serum ; in B, with a
2 per cent suspension of sheep corpuscles and corresponding immune rabbit
serum. The amboceptor was so diluted as to contain 1, 2 and 5 units of
amboceptor for equal quantities of the 5 per cent and 2 per cent suspension
of cells.

a. To 4 c.c. of diluted amboceptor, in a centrifuge tube, was added 4 c.c.
of corpuscle suspension, and the mixture immediately centrifuged, at a speed
of about 2,000 revolutions.

b. Like a, except centrifuged after an interval of 2 minutes.

c. Like a, except centrifuged after an interval of 5 minutes.

From each was taken 0.5, 1, 1.5 and 2 c.c. of the diluted amboceptor, 0.5
being approximately equivalent to 0.25 of the original amboceptor dilution, and
to each of these amounts was added 0.2 c.c. of a 1-10 dilution of guinea-pig
serum (= 1 unit by previous titration) and 0.25 c.c. of corpuscle suspension,
each tube being immediately shaken after the addition of the corpuscles. For
the control tubes the amboceptor was diluted with equal parts of salt solution.
After incubation at 37° for one hour the results were as follows :

Amboceptor 0.5 1 1.5 2

A. Five per cent suspension of sheep corpuscle

1 unit of amboceptor

Control C

a 0

b 0

c 0

2 units of amboceptor

a VS

b 0

c 0

5 units of amboceptor

a C

b P

c S

B. Two per cent suspension of sheep corpuscle

1 unit of amboceptor

Control C

a 0

b 0

c 0

2 units of amboceptor

a P

b 0

c 0

5 units of amboceptor

a C

b C

c P

SENSITIZATION OF CORPUSCLES 261

It appears from the above experiment that a 5 per cent suspension
of corpuscles almost completely absorbed one unit of amboceptor in
the brief time necessary to centrifuge off the cells. About three-
quarters of the 2 units of amboceptor appear to have been absorbed
in the same length of time, while of the 5 unit amboceptor 1 unit at
least remained. Absorption by the 2 per cent suspension was ap-
parently not so rapid. About three-quarters of the 1 unit and about
one-half of the 2 unit amboceptor were absorbed in the time taken
to centrifuge, while of the 5 units at least 1 unit remained even after
absorption for 2 minutes plus the time taken to centrifuge.

Definite conclusions, however, cannot be drawn from such an
experiment as to the exact amount of amboceptor absorbed or the
relative speed of absorption by the 5 per cent and 2 per cent suspen-
sion of corpuscles, as it is not known to what extent the failure of
hemolysis may be due to inhibitory bodies produced by the addition
of corpuscles for the purpose of amboceptor absorption ("Sachs-
Friedberger phenomenon"). Such inhibitory bodies probably do not
greatly influence the results obtained in this experiment, but if pres-
ent it is natural to suppose that they are in larger amount after
absorption with a 5 per cent suspension of corpuscles than after
absorption with a 2 per cent suspension of corpuscles.

Though the cells were centrifuged from the fluid as quickly as
possible, an interval of between 1 and 2 minutes probably elapsed
before their complete removal. The following experiment was done
to show that an appreciable amount of amboceptor is absorbed in a
considerably shorter time than this.

Experiment III. — A 1-10 dilution of guinea-pig serum was used in the
amounts given below, with sufficient salt solution in each tube to make the
final total 1.25 c.c. A 5 per cent and a 2 per cent suspension of sheep corpus-
cles, and a 5 per cent and a 2 per cent suspension of calf corpuscles were used
with one unit of the respective amboceptor ; 0.5 c.c. of the corpuscle suspension,
activated as follows, was added in series :

A. 3 c.c. of the corpuscle suspension was poured into 3 c.c. of amboceptor
dilution, and quickly shaken.

B. 0.5 c.c. of the corpuscle suspension was poured into 3 c.c. of ambo-
ceptor dilution, shaken, and, 15 seconds later, 2.5 c.c. of the corpuscle suspen-
sion added.

C. Like B, except with 50 seconds interval.

D. Like B, except with 1 minute interval.

E. Like B, except with 2 minutes interval.

After incubation at 37° for one hour the results were as follows :

262 ST. LUKE'S HOSPITAL REPORTS

Guinea-pig serum diluted 1-10 5 .4 .3 .25 .2 .125.062.031.015

5% suspension of sheep corpuscles

A C C C C C C AC S VS

B C C C C AC AC P S 0

C C C C AC AC P S VS 0

D AC AC AC P P P S VS 0

2% suspension of sheep corpuscles

A C C C C C AC VS 0 0

B CCCCCPVSO 0

C C C C C AC P VS 0 0

D .' C C AC AC P S VS 0 0

E AC P P S S VS VS 0 0

5% suspension of calf corpuscles

A C C C C C C AC VS 0

B C C C C C AC P VS 0

C C C AC AC AC AC P VS 0

D C C AC AC AC P VS VS 0

E AC AC P P S S VS VS 0

2% suspension of calf corpuscles

A C C C C AC P VS VS 0

B C C C C AC P VS 0 0

C C C C AC P VS VS 0 0

D C C AC P VS VS VS 0 0

E AC AC AC P VS VS VS 0 0

It will be seen by the foregoing experiment that a considerable
effect is produced on the degree of hemolysis obtained by a contact of
even 15 seconds of a portion of the corpuscles with the amboceptor
before the introduction of the remainder. The effect is somewhat less
marked with the 2 per cent than with the 5 per cent suspension. This,
we believe, is what takes place in greater or less degree in any serum
titration when an even distribution of the corpuscles throughout
the amboceptor dilution is not at once obtained. It is probably im-
possible to obtain an absolutely even sensitization. The nearest ap-
proach to this is produced by quickly pouring the diluted immune
serum into an equal volume of the corpuscle suspension, which is
shaken during and for a short period after the mixing (Exp. I, D).
If the corpuscles are poured slowly into the amboceptor or intro-
duced in separate lots, as with a 5 or 10 c.c. pipette, unequal sensitiza-
tion will result. This is illustrated in an extreme degree by the
method of sensitization used in Exp. I, B, that of dropping the cells
into the amboceptor. It is to be noted that the reading is not only
higher with an even sensitization, but is also sharper; that is, the

SENSITIZATION OF CORPUSCLES 263

change from complete hemolysis to entire lack of hemolysis, instead
of being gradual, is quite sudden (Exp. I, A and D).

The importance in practical work of obtaining as uniform a dis-
tribution of amboceptor as possible is obvious, as well as the necessity
in any comparative titration of using suspensions of activated cells
in the various titrations which are exactly alike as to the distribution
of amboceptor. The importance of complement titration for the
Wassermann or other complement absorption tests is rightly empha-
sized. If, however, the same method of sensitization is not used in
this titration as is used in the final stage of the Wassermann reaction,
the titration is of little value as an index of the activity of the serum.
It is a common practice to introduce amboceptor and corpuscles sep-
arately in a complement titration (Exp. I, A), while corpuscles
previously sensitized in bulk are used in the Wassermann reaction.
By the latter method it is much easier to approximate an even sen-
sitization (Exp. I, D). Thus the reading obtained in a complement
titration in which amboceptor and corpuscles are added separately
would lead one to use an excess of complement in performing the
reaction.

In an amboceptor titration, the immune rabbit serum and cor-
puscles are usually introduced separately — to employ separate lots
of corpuscles previously activated with each dilution would be an
exceedingly tedious task — yet if one accepts the highest dilution with
which complete hemolysis is obtained as the titer of the serum, and
with this dilution titrates the same complement as was used in the
amboceptor titration, hemolysis will be obtained, provided more evenly
sensitized corpuscles are here used, with considerably less complement
than was used in the amboceptor titration. This may be illustrated
by reference to Experiment III. It is stated in this experiment that
one unit of amboceptor was used. Both the anti-sheep and the anti-
calf amboceptor were titrated before this experiment, using 0.25 c.c.
of the same dilution of guinea-pig serum as was used in the experi-
ment. The anti-sheep serum was found to give complete hemolysis of
the 5 per cent corpuscles in a dilution of 1 to 800, incomplete in 1
to 1,000 ; the anti-calf gave complete hemolysis of the 5 per cent cor-
puscles in a dilution of 1 to 400, incomplete in 1 to 600. In the ex-
periment, however, in which they were used in dilutions of 1 to 800
and 1 to 400, respectively, we find that they both give complete hem-
olysis when previously sensitized corpuscles are used (Exp. Ill, A)
with one-half the amount of complement (0.125 c.c.) with which they

264 ST. LUKE'S HOSPITAL REPORTS

were titrated. A retitration of the anti-sheep serum with 0.25 c.c. of
the complement dilution, using 0.5 c.c. of corpuscle suspension previ-
ously activated for each dilution by rapidly mixing 5 c.c. of a 5 per
cent suspension of corpuscles with an equal amount of the proper
amboceptor dilution, gave complete hemolysis in a dilution of 1 to
1,200. We must conclude, then, that an amboceptor as well as a
complement titration is influenced by the evenness of the sensitization
of the corpuscles.

CONCLUSIONS.

The absorption of amboceptor by corpuscles is rapid, a consider-
able amount being absorbed in as short a period as 15 seconds. In the
sensitization of corpuscles, the amount of amboceptor absorbed by
the different corpuscles is not uniform, the inequality depending on
the time taken in obtaining an even distribution of the corpuscles
through the diluted immune serum. Amboceptor absorption is ap-
parently influenced by the concentration of the corpuscles, being more
rapid with a 5 per cent than with a 2 per cent suspension, and thus
the stronger concentration is more susceptible to inequality of sen-
sitization from variations in the method of activation.

In experimental work it is of importance to obtain as equal a
sensitization as possible. It is essential that in comparative titrations
the same method of activation be employed in the several titrations,
and where possible, it is advisable that all the cells to be used be
sensitized together in bulk.

The results obtained in titrating hemolytic sera and complement
depend to a considerable extent on the evenness of sensitization of the
corpuscles.

THE DETERMINATION OF COPPER— A MODIFICATION OF
THE IODIDE METHOD.*

E. C. Kendall, Ph.D.

For the determination of copper the most important methods are
the electrolytic, the iodide, and the cyanide. As the determination by
means of the electrolytic method requires a considerable amount of
time and apparatus, the only methods for the rapid estimation of
copper are the iodide and the cyanide.

Upon an examination of the two volumetric methods mentioned it
is apparent that in respect to the amount of time and attention re-
quired for a determination the cyanide has a great advantage over
the iodide method. However, in respect to the accuracy of the results
obtained the iodide method is conceded to be by far the more accurate
of the two. As every consideration would be in favor of the iodide
method if it could be modified in such a way as to make it as rapid
and easy of manipulation as the cyanide method, an attempt was made
to make such a modification.

In the determination of copper by the iodide method the copper
may be originally present as copper, copper oxide, or sulfide. The
first step is to obtain the copper in solution. Practically the only way
to do this is to dissolve it in nitric acid. The solution of the copper
with nitric acid produces nitrous acid in the solution, and it is the
removal of this which causes the delay in the estimation of the copper.
As the method is described in the literature, the nitrous acid is de-
stroyed with bromine, the excess of bromine being removed by boiling ;
or the nitrous acid is removed by evaporating to dryness.

The modification of the iodide method as described in this paper
consists in the destruction of the nitrous acid without boiling. This
is accomplished by the addition of a small amount of sodium hypo-
chlorite. The addition of sodium hypochlorite to a nitric acid solution
produces hypochlorous acid. The interaction of hypochlorous acid

♦From the Journal of the American Chemical Society, vol. xxxiii, No. 12,
December, 1911.

265

266 ST. LUKE'S HOSPITAL REPORTS

and nitrous acid results in the oxidation of the nitrous acid and the
formation of hydrochloric acid, and the reaction between hypochlorous
and hydrochloric acid results in the destruction of the hypochlorous
acid and the formation of free chlorine and water. As the solution
of sodium hypochlorite contains small amounts of chlorides, hydro-
chloric acid will always be present when the solution is acidified, thus
insuring the destruction of the hypochlorous acid and the formation
of free chlorine. We thus see that the effect of adding sodium hypo-
chlorite to the solution is the complete destruction of the nitrous acid
and the formation of free chlorine.

To remove the free chlorine in solution some compound must be
added which will take up the chlorine, but will not affect subsequent
operations. Such a compound is found in phenol. Under the condi-
tions of the determination, phenol will add chlorine directly to the
benzene ring, but is not affected by iodine or any of the other com-
pounds in the solution. Chlorophenol not being ionized removes all
traces of free chlorine.

This modification of the method greatly reduces the time and at-
tention required for a determination, and, in addition, the copper
solution is prepared in such a way that iodine can be liberated by
copper alone.

In the determination, the copper, copper oxide, or sulfide is dis-
solved in nitric acid. After the addition of the sodium hypochlorite
and phenol, which requires but a moment, the solution is made slightly
alkaline with sodium hydroxide, and is then made acid with acetic acid,
when the solution is ready for titration. Potassium iodide and starch
are added, and the titration is made to the disappearance of the starch
iodide color. There is never any fear of the blue color "flashing
back," and the solutions will remain colorless indefinitely after the
titration. As the ionization constant for acetic acid is too low to
allow nitrates to liberate iodine, the amount of nitric acid in solution
is immaterial. Even 20 c.c. of concentrated nitric acid will not affect
the titration. However, too great an acidity is to be avoided, as
nitrophenol will be formed. The presence of nitrophenol prevents
the determination of copper, but there is no danger of its formation
even in the presence of a large amount of acid if the solution is neu-
tralized soon after the addition of the phenol. If a large amount of
nitric acid is used to dissolve the copper, it should therefore be partly
neutralized before addition of the phenol.

As chlorine easily oxidizes phenol to compounds which prevent the

THE DETERMINATION OF COPPER 267

determination of copper, it is essential that all of the phenol be added
quickly to the solution. Under these conditions the chlorine adds
directly to the benzene ring, but if the phenol is added drop by drop
the chlorine will oxidize it, producing colored compounds in solution.

In order to add the phenol quickly enough to the solution it may be
poured in from a beaker, or, a more convenient way, from a pipette
from which the tip has been removed so that the delivery is from an
opening which is of the same bore as the rest of the tube. By forcing
the phenol out of such a pipette with the breath, the entire volume is
added very quickly and at the same time the phenol is well mixed with
the contents of the flask.

After addition of the phenol the chlorine gas which is in the flask
above the liquid is removed by blowing it out with the breath, and
the sides of the flask are washed with a jet of water from a wash
bottle. There should be no odor of chlorine just before the solution,
is made alkaline.

It should be remembered that the end point of the titration is not
pure white. Cuprous iodide has a cream color, and when a large
amount of copper is present the cuprous iodide gives a decided tint
to the solution. When the end point is nearly reached a drop of the
thiosulfate is allowed to fall into the center of the flask. If a change
of color occurs the solution is given a slight rotary motion and after
the solution is again quiet another drop of the thiosulfate is added.
This "spot test" is easily recognized and gives a very accurate end
point.

The speed of reaction of the copper with potassium iodide varies
with the volume. In a small volume the action is rapid and all of the
iodine is liberated at once, but in a large volume an appreciable time
may be required for all of the copper to react. This is especially
noticeable when a small amount of copper is present. A high con-
centration of potassium iodide greatly assists the liberation of the
iodine. Accurate results cannot be obtained unless at least 3 grams
of potassium iodide are added, irrespective of the amount of copper
present, up to 500 mg. of copper.

The solutions required are:1

A. The Sodium Hypochlorite solution is made by boiling together
a mixture of 112 grams of calcium hypochlorite and 100 grams of
anhydrous sodium carbonate in 1,200 c.c. of water. After the calcium

'The weights given here are for calcium hypochlorite having 35 per cent or
more available chlorine.

268 ST. LUKE'S HOSPITAL REPORTS

is precipitated as carbonate, the solution is filtered and its strength
found as follows : 5 c.c. of the hypochlorite solution are added to 100
c.c. of water containing 5 c.c. of 30 per cent potassium iodide solution,
and a few c.c. of dilute hydrochloric acid are added. The liberated
iodine is titrated with 0.1 N sodium thiosulfate. The volume of the
solution is now adjusted so that 5 c.c. of the hypochlorite solution are
equivalent to 30 c.c. of 0.1 N sodium thiosulfate.

B. Phenol — A 5 per cent colorless solution of phenol.

C. Sodium Hydroxide — A 20 per cent solution.

D. Acetic Acid, 50 per cent.

E. Potassium Iodide — A convenient way to use this is to prepare
a solution which contains 30 grams per 100 c.c. of solution. Then
10 c.c. will contain 3 grams, which is the amount needed for a de-
termination.

F. Sodium Thiosulfate — For the accurate titration of the liberated
iodine two solutions are used. One strong solution, 1 c.c. of which
equals 6 mg. of copper, and a weak solution, 1 c.c. of which equals
1 mg. of copper. The strong solution is run in until the iodine liber-
ated by the copper gives a light straw color to the solution. Starch
is then added and the titration is finished with the weak solution.

As a thiosulfate solution loses strength, it should be restandardized
from time to time. A convenient way to do this is as follows : A solu-
tion of sodium thiosulfate, approximately 0.1 N, is made by dissolving
24 grams of the crystallized salt per liter of water. After the solution
has stood at least 24 hours it is standardized against copper by the
method described below. Pure electrolytic copper which has been
cleaned with emery paper should be used. After dissolving 150 to
200 mg. of the copper in 6 to 8 c.c. of 50 per cent nitric acid the so-
lution is treated as described below and the thiosulfate is then stand-
ardized with this known weight of copper. The most convenient
means of restandardizing the thiosulfate is to use a solution of acid
potassium iodate. Acid potassium iodate has the formula KI03.HI03,
so that a normal solution has one-twelfth the molecular weight in
grams per liter. A 0.1 N solution is prepared by dissolving 3.249
grams of the salt in 1 liter of water, and it is standardized against
a known strength of thiosulfate as follows: Add 10 c.c. of the acid
iodate solution to 150 c.c. of water containing 0.5 to 1 c.c. of hydro-
chloric acid. Upon the addition of potassium iodide, iodine will be
liberated according to the equation

HIO.3 + 5HI = + 3H20 + 61.

THE DETERMINATION OF COPPER 209

Starch is added and the titration is made to a colorless solution. From
this titration the weight of copper to which 20 c.c. of this solution are
equivalent is accurately determined. A 20 c.c. pipette is passed through
a one-hole stopper and is allowed to remain in the acid iodate bottle.
The end of the pipette is closed with a small rubber stopper. The ex-
act copper equivalent of a thiosulfate solution is now easily found by
titrating 20 c.c. of the acid iodate solution whose copper equivalent is
known with the thiosulfate as described above. The acid iodate re-
mains constant indefinitely.

G. Starch for Indicator — The best preparation for this purpose is
a 0.5 per cent solution of Kahlbaum's soluble starch. This is prepared
as ordinary starch, but gives a perfectly clear solution which is very
sensitive with iodine. If ordinary starch must be used it should be
free from all cloudiness.

DETAILED DESCRIPTION OF THE METHOD.

If the copper to be determined is present as metallic copper, 200-
300 mg. are placed in a 300 c.c. flask and dissolved in 5-10 c.c. of 50
per cent nitric acid.

If the copper is present as cuprous oxide, it is filtered on a Gooch
crucible through asbestos. The cuprous oxide is then dissolved
through the Gooch crucible with 10-15 c.c. of 30 per cent nitric acid
into a 300 c.c. Erlenmeyer flask.

If the copper is in the form of sulfide, it is filtered on a Gooch
crucible which has a layer of asbestos one-eighth inch in thickness.
The crucible is then placed in a small beaker of 50 c.c. capacity, and
10 c.c. of 50 per cent nitric acid are added. The beaker is placed on
a hot plate, and the nitric acid allowed to boil until all the black sul-
fide has gone into solution. The crucible is then washed off, and the
solution transferred to a 300 c.c. Erlenmeyer flask. The presence of
the asbestos in the solution does not interfere with the titration of
the copper.

If the copper to be determined is already in solution as sulfate,
chloride, or other salt, sufficient solution is taken to give 100 to 300
mg. of copper.

Having obtained the copper in solution, preferably in a 300 c.c.
Erlenmeyer flask, the volume being between 50 and 60 c.c, the acidity
is adjusted to equal 4 to 5 c.c. of concentrated nitric acid. A greater
volume of acidity is to be avoided. The temperature should not be
above 25°. Five c.c. of the hypochlorite solution are now added to
the copper solution, which is well mixed with a rotary motion. As

270 ST. LUKE'S HOSPITAL REPORTS

soon as the color of the copper solution changes from a clear blue to
a greenish tint, sufficient hypochlorite has been added. Another in-
dication of a sufficient amount of hypochlorite is the liberation of
chlorine. For weights of copper up to 200 mg., 2-3 c.c. of the hypo-
chlorite are sufficient. For larger amounts of copper more hypo-
chlorite may be needed, but 5 c.c. will be sufficient for any amount
of copper which would be determined by this method. The reactions
between the hypochlorous and nitrous acid require an appreciable time
and the best results are obtained by allowing the solution to stand
about 2 minutes before the addition of the phenol. This, however,
is not essential. Ten c.c. of the phenol solution are now added as
quickly as possible, by blowing the solution from a pipette from which
the tip has been removed.

The chlorine gas which remains in the flask above the liquid is re-
moved by blowing into the flask and the sides are washed down with
a jet of water. If the solution is allowed to stand at this point, nitro-
phenol will slowly form. Sodium hydroxide is therefore added until
a very slight precipitate is obtained. The solution is now made acid
with acetic acid ; only a few drops should be required to dissolve the
precipitate. Ten c.c. of the potassium iodide are added and the ti-
tration made with the standardized thiosulfate. If great accuracy is
required the titration is finished with a weak solution of thiosulfate.

The following are some results obtained by the method described
above. The milligrams found and the error are calculated only to a
point which is within the degree of accuracy of the apparatus used.

DETERMINATION OF COPPER

Copper taken

Copper found

Error

Mg.

20.00

20.01

+ 0.01

20.00

19.99

—0.01

20.00

0.00

30.00

29.99

—0.01

30.00

0.00

40.00

39.98

—0.02

40.00

39.96

—0.04

60.00

60.01

+ 0.01

60.00

60.01

+ 0.01

80.00

80.12

+ 0.12

80.00

80.03

+ 0.03

80.00

79.98

—0.02

80.00

79.98

—0.02

Error
Per cent.
+ 0.05
—0.05

0.00
—0.03

0.00
—0.05
—0.10
+ 0.02
+ 0.02
+ 0.15
+ 0.04
—0.02
—0.02

THE DETERMINATION OF COPPER

271

Copper taken

Coppei* found

Error

Mg.

Per cent.

100.00

0.00

100.00

99.99

—0.01

120.00

119.95

—0.05

—O.04

140.00

0.00

160.00

0.00

160.00

0.00

180.00

0.00

180.00

0.00

200.00

0.00

200.00

199.9

—0.1

—0.05

203.2

0.00

220.2

220.1

-o.l

—0.05

240.0

0.00

240.0

240.2

+ 0.2

+ 0.08

261.6

0.00

280.0

0.00

280.0

280.3

+ 0.3

+0.10

300.0

300.1

+ 0.1

+ 0.03

320.0

319.9

—0.1

—0.03

320.0

319.9

—0.1

—0.03

340.0

0.00

Note. — The sum of the + and — errors very nearly equals zero.

For the opportunity of carrying out this work I wish to thank Dr.
N. B. Foster and for assistance with the analytical work Mr. A. W.
Thomas.

THE DETERMINATION OF IODINE IN THE PRESENCE OF
OTHER HALOGENS AND ORGANIC MATTER.

E. C. Kendall, Ph.D.

During an investigation of the iodine bearing compound of the
thyroid gland a method for the determination of small amounts of
iodine in organic combination was worked out in this laboratory. As
the reactions involved in this method are quantitative when larger
amounts of iodine are present, conditions have been established which
furnish a rapid and accurate method for the determination of iodine
in the presence of bromides, chlorides, and organic matter.

For the determination of iodine when present as an iodide or in
the uncombined condition, Andrews1 has proposed a volumetric
method in which the iodine is oxidized to iodine chloride by means
of iodic acid. The titration by Andrews' method is done in the
presence of a large excess of hydrochloric acid, the end point being the
disappearance of iodine. As the oxidation of the iodine is limited by
the acid to the formation of I CI, one molecular weight of iodine re-
acts with but two molecular weights of chlorine.
El + Cl2 = KC1 + IC1.

If the oxidation of the iodine is carried out under conditions which
permit the quantitative formation of iodic acid, one molecular weight
of iodine requires six molecular weights of chlorine, as shown by the
equation

Kl + 3C12 + 3H20 = KC1 + HI03 + 5HC1.
Dupre's method for the determination of iodine is based upon this re-
action, weak chlorine water being used for the oxidation. In a recent
paper by Hunter2 a method is proposed in which the iodine is oxidized
to iodic acid with sodium hypochlorite, and after the removal of the
excess of hypochlorite the weight of iodic acid is determined by the
further addition of potassium iodide. Iodic acid and potassium iodide
react as follows:

HI03 + SHI = 31, + 3H20.

'Jour. Amer. Chem. Soe, 25, 756.

sJour. Biological Chem. (1910), vol. vii, p. 321.

272

THE DETERMINATION OF IODINE 273

The liberated iodine is titrated with sodium thiosulfate, the weight
of iodine titrated being six times the weight originally present.

The method described in this paper is based upon the oxidation of
the iodine to iodic acid and the subsequent determination of the
amount of iodic acid formed.

DETERMINATION OF IODINE WHEN PRESENT AS AN IODIDE OR FREE IODINE.

For the determination of iodine when present as an iodide or in the
uncombined condition, it is necessary to have a solution of the iodine
which is free from organic matter or oxidizing agents, such as arsenic,
antimony, copper, nitrites, and all compounds which liberate iodine
from potassium iodide. If bromine or any compounds which inter-
fere are present, the method is modified as described below.

The solution containing the iodine is placed in a 500 c.c. flask, the
total volume of the solution being between 200 and 250 c.c. The
solution3 should have a neutral or very slightly alkaline reaction.
Five c.c. of phosphoric acid (85 per cent diluted with an equal volume
of water) are added to the solution. A solution of sodium hypo-
chlorite4 is now added, while the solution is shaken with a rotary
motion. If an iodide is present iodine will be liberated, but the fur-
ther addition of hypochlorite will oxidize this to iodic acid. The
hypochlorite should be added slowly, and care should be taken to
avoid adding more than is necessary to give a colorless solution. The
solution is allowed to stand 2 to 3 minutes after becoming colorless and
then 10 c.c. of a colorless 5 per cent solution of phenol are added.
The phenol combines with the free chlorine in solution, forming
chlorophenol. This compound being unionized, removes all traces of
chlorine from the sphere of reaction. When a solution of phenol is
slowly added to a solution containing free chlorine the phenol is
partially oxidized, producing colored compounds, but if the phenol is

•To prevent loss of iodine at this point the solution must be cold, and when
more than 100 mg. of iodine are present the solution in the flask should be
covered with a few c.c. of benzol.

*A convenient means of preparing this reagent in a proper concentration is
to add 112 gm. of calcium hypochloride whose available chlorine is approximately
35% to 1,200 c.c. of water. Stir the mixture, to break up any lumps, and heat
to boiling. One hundred grams of anhydrous sodium carbonate are now
added, and the solution boiled 10 to 12 minutes. After cooling, the precipitate
of calcium carbonate is filtered off and the solution of sodium hypochlorite is
kept in a black-colored bottle.

274 ST. LUKE'S HOSPITAL REPORTS

all added at once the chlorine adds to the benzol ring without oxida-
tion of the phenol. For this reason the phenol is added to the flask
as rapidly as possible. This is accomplished by forcing the phenol
with "the breath from a 10 c.c. pipet from which the tip has been
removed, so that the delivery is from an opening which is the same
bore as the rest of the tube. A few drops of phenolphthalein are
added and the solution is made slightly alkaline with 30 per cent so-
dium hydroxide which is free from nitrites. The solution is now made
acid with 10 c.c. of 50 per cent phosphoric acid. Upon the addition
of potassium iodide the iodic acid in solution will liberate iodine
which is titrated with sodium thiosulfate. The amount of potassium
iodide added should be sufficient to leave an excess after reacting with
the iodic acid. The weight of potassium iodide required is, roughly,
eight times the weight of the iodine originally present.

The effect of the presence of small amounts of oxidizing compounds
is considerably lessened if the solution is made alkaline and is then
acidified again. This step is necessary to secure satisfactory results.

The most satisfactory method for standardizing the sodium thio-
sulfate which is used to titrate the iodine liberated by the iodic
acid is as follows : Ten grams of freshly resublimed iodine are weighed
out in a weighing bottle. This is placed in a large Erlenmeyer flask
containing 5 grams of sodium hydroxide dissolved in 400-500 c.c. of
water. The cover is removed from the bottle and the iodine is dis-
solved in the alkali. The solution is now diluted to two liters; 1 c.c.
will contain 5 mgms. of iodine. For standardizing, the iodine solution
is measured into a flask, the volume is made between 200-250 c.c. and
then the acid and hypochlorite are added as described above. The
number of c.c. of thiosulfate divided into the weight of iodine
measured into the flasks is the standard of the sodium thiosulfate
for the iodine originally present.5 If more than 100 mgms. of iodine
are present there is danger of loss of iodine by volatilization during
the titration. A satisfactory means of preventing this is to add a
few c.c. of benzol to the flask. This will float on the surface and
prevent loss of iodine. Care should be taken to finish the titration
with starch and to shake the solution vigorously when near the end
point.

By the method described above the following results were obtained.

The "original iodine" equivalent of sodium thiosulfate in this titration
is one-sixth the amount found by the titration. Hence, if N/10 thiosulfate is
used, the standard will be approximately 2.115 mg. of original iodine per c.c.

THE DETERMINATION OF IODINE 275

The iodine was present in the form of potassium iodide, which was
prepared by dissolving a known weight of pure iodine in potassium
hydroxide and reducing with metallic aluminium.

Iodine

Error

taken

found

Mg.

Per cent

5.079

5.077

—.002

.04

5.079

5.040

—.039

.76

7.618

7.619

.001

.01

7.618

7.630

.012

.15

10.158

10.136

—.022

.22

10.158

10.150

—.008

.08

12.698

12.717

.019

.15

12.698

12.707

.009

.07

15.237

15.166

—.071

.46

15.237

15.213

—.024

.16

17.776

17.742

—.034

.19

17.776

17.756

—.020

.11

20.316

20.337

.021

.10

20.316

20.394

.078

.38

22.855

22.820

—.035

.15

22.855

22.871

.016

.07

25.395

25.434

.039

.15

25.395

25.340

—.055

.22

30.06

30.13

.07

.23

30.06

30.13

.07

.23

40.08

40.10

.02

.05

40.08

40.10

.02

.05

50.10

50.17

.07

.13

50.10

50.30

.20

.39

60.12

60.07

—.05

.09

60.12

60.26

.14

.23

70.14

70.18

.04

.05

70.14

70.27

.14

.20

80.16

80.19

.03

.04

80.16

80.11

—.05

.06

90.18

90.20

.02

90.18

90.39

.21

.23

100.20

100.12

—.08

.08

100.20

99.74*

— .46a

.46

125.45

125.65

.20

.16

125.45

.00

150.57

150.62

.05

.03

150.57

150.54

—.03

.02

150.57

150.54

—.03

.02

175.66

175.80

.14

.08

"Iodine was lost, as no benzol covering was used in this determination.

276 ST. LUKE'S HOSPITAL REPORTS

Iodine

Error

taken

found

Mg.

Per cent

200.71

175.59

—.07

.04

200.71

200.80

.09

.04

200.71

200.76

.05

.02

225.85

225.53

—.32

.15

225.85

226.00

.15

.07

250.95

250.91

—.04

.02

250.95

250.91

—.04

.02

276.04

275.88

—.16

.06

276.04

276.12

.08

.03

301.15

301.45

.31

.10

301.14

301.05

—.09

.03

326.23

326.02

—.21

.07

326.23

326.02

—.21

.07

361.33

350.78

—.55

.15

DETERMINATION OP IODINE IN THE PRESENCE OP BROMIDES AND CHLORIDES.

When bromine or a bromide is present in a solution to which hypo-
chlorite is added there is no oxidation of the bromine similar to the
oxidation of iodine. Furthermore, the presence of the bromine does
not interfere with the oxidation of the iodine. Hydrobromic acid,
when present in large amount, will reduce iodic acid, but all hydro-
bromic acid may be removed by the addition of sufficient sodium
hypochlorite.

The method for the determination of iodine in the presence of
bromine is as follows: The iodine (in the form of iodide or uncom-
bined) is dissolved in 200-250 c.c. of water having a neutral or slightly
alkaline solution. Five c.c. of phosphoric acid (85 per cent diluted
with an equal volume of water) and 10 c.c. of benzol are added.
Sufficient sodium hypochlorite is now added to liberate all of the
bromine and oxidize the iodine. Iodine will be liberated at first, but
this will be further oxidized to iodic acid. It is imperative that all
the bromine be liberated. A small amount of powdered pumice is
added and the solution boiled. The benzol reacts with the hypo-
bromite and hypochlorite, forming brom- and chlor-benzol. The free
bromine boils out of solution. A precipitate of brom-benzol may form,
but this does not affect subsequent operations. After a few minutes'
boiling, all traces of bromine are removed. The solution is now re-
moved from the flame and cooled. Under these conditions, it is not
necessary to neutralize and acidify, but the potassium iodide is added

THE DETERMINATION OF IODINE

277

' 0.1 g.

' 0.5 g.

' 1.0 g.

100

' no

100

• 0.1 g.

100

' 0.5 g.

100

' 1.0 g.

250

' nQ

250

' 0.1 g.

250

' 0.5 g.

250

' 1.0 g.

directly to the cold solution. A cover of benzol should be used for
weights of iodine over 100 mg.

The following results show that there is no appreciable interfer-
ence of the bromine in the determination of iodine by this method :

50 mgms. iodine and no potassium bromide required, 26.38 c.c. sod. thiosulfate

26.38
26.30
26.30
20.50
20.48
20.50
20.48
46.10
46.00
46.15
45.88

In standardizing the sodium thiosulfate to be used when bromine
is present, more satisfactory results are obtained by establishing the
standard with a known weight of the iodine solution as prepared
above, under the conditions which are described for the determination,
of iodine in the presence of bromine.

The presence of chlorides has no effect upon the determination of
iodine by this method and there is no need of boiling the solution.
The following results bear on this point:

50 mgms. iodine and no sodium chloride required, 26.50 c.c. thiosulfate

50 ' 1.0 g. " " " 26.50 "

50 ' 5.0 g. " " " 26.51 "

50 " " " 10.0 g. " " " 26.50 "

These results were obtained by the method outlined under the
heading, Determination of Iodine When Present as Iodide or Free
Iodine.

When iodine is to be determined in the presence of organic matter,
or nitrites, copper, iron, lead, mercury, and silver, it is necessary to
remove these interfering substances and prepare the iodine as an
iodide for the determination.

DETERMINATION OF IODINE IN THE PRESENCE OF ORGANIC MATTER AND
INTERFERING ELEMENTS.

The most satisfactory means of removing the above-mentioned sub-
stances is by a fusion which will destroy organic matter, retain the
iodine as an iodide, and by forming insoluble compounds, remove
interfering elements.

Many fusion mixtures have been proposed for the destruction of

278 ST. LUKE'S HOSPITAL REPORTS

organic matter, but when tried did not give entirely satisfactory re-
sults for the peculiar needs of this method. The determination of
iodine in the presence of organic material, as worked out in this
laboratory, is as follows:

DETAILED DESCRIPTION OF METHOD.

The Fusion.* — The fusion takes place in two stages: first, the oxida-
tion of the organic matter ; second, the reduction of all oxidizing com-
pounds. The destruction of the organic matter is accomplished by
fusion with a mixture of sodium potassium carbonate and potassium
chlorate. The mixture is made by grinding together and passing
through a 20-mesh sieve:

138 grams of potassium carbonate (anhydrous)
106 " " sodium carbonate (anhydrous)
100 " " potassium chlorate (anhydrous)

One gram or less of the organic material is placed in the bottom
of a 2%-inch nickel crucible. This is dissolved in a few c.c. of 30
per cent sodium hydroxide. The water is evaporated by placing the
crucible in a hot air oven at a temperature of 150-200°. Fifteen grams
of the fusion mixture are now added, the cover is placed on the
crucible and the crucible is heated strongly by a large Bunsen or,
preferably, a Meker burner. The fusion begins before the crucible is
red hot and proceeds quietly and quickly. The crucible should be sup-
ported on a triangle and surrounded by a collar of sheet asbestos.
The one used in this laboratory was 3 inches in diameter, 3 inches
deep, and one-quarter inch thick. The top of the collar was notched
by cutting away small rectangles about 1 inch long by one-half inch
deep. "When a cover of sheet asbestos was placed over the collar these
notches permitted the hot gases from the burner to escape after pass-
ing around the crucible. By heating in this manner the sides as well
as the bottom of the crucible were heated to a red heat. After three
minutes' heating with an 8-inch Meker burner, in a collar, as above
described, all but a trace of the chlorate is destroyed, and the melt has
ceased to liberate bubbles of oxygen. If the carbon content of the

♦Since sending this article for publication this method of fusion has been
found unreliable under certain conditions. In the Journal of the American
Chemical Society another method of fusion will be described which can be
relied upon under all conditions. With the exception of the fusion, the
method is not changed.

THE DETERMINATION OF IODINE 279

added material is low, or if insufficient heat is applied, the fusion
may require a longer time.

During the destruction of the organic matter, the nitrogen con-
tained in the protein material is in part oxidized to a nitrate. The
action of heat on the nitrate formed results in the production of ni-
trites in the fusion mass. If the fusion mass containing nitrites
should be dissolved in water and acidified, the nitrous acid would
oxidize the iodide, liberating iodine, which would be carried out of
solution by the escaping carbon dioxide. It is therefore necessary to
destroy the nitrites and the trace of chlorate before solution of the
fusion mass. The most satisfactory reagent for this purpose was
found to be metallic zinc, in granular form. The zinc must be free
from arsenic. The size of the granules is unimportant, satisfactory
results being obtained with both zinc dust and 20-mesh granules,
but in order to facilitate subsequent operations, 20-mesh zinc gran-
ules were found most convenient.

After the first heating for 3 minutes, during which time the or-
ganic matter is destroyed and the chlorate decomposed, 2 grams of
the zinc are added to the crucible without removing from the flame,
the cover is replaced, and the crucible heated in the flame for an ad-
ditional 2 minutes. The zinc reduces all traces of chlorate and ni-
trites. The crucible is removed from the flame and the melt is al-
lowed to cool on the sides of the crucible. When cold, the crucible
is nearly filled with water and placed on a hot plate. After the fusion
mass has dissolved (this requires about 10 to 15 minutes), the solution
is transferred to a beaker, and is then filtered to remove the excess
of zinc and zinc oxide, and any interfering element, as lead, mercury,
silver, copper, etc.

In order to avoid thorough washing of the filter paper, the solution
may be placed in a 250 c.e. flask, diluted to the mark, well mixed
and then filtered into a 200 c.c. flask, washing out the 200 c.c. flask
with the first 15-20 c.c. of the filtrate. The most rapid filtration we
have found is by using a fluted filter, Carl Schleicher & Schiill, No.
597. If no interfering element is present, filtering the solution may
be omitted, if care is taken to decant the solution from the beaker
into the 250 c.c. flask, leaving the granules of zinc in the beaker. The
beaker and zinc are washed repeatedly with small amounts of water.
The presence of zinc oxide or carbonate is not objectionable. The
solution in the 250 c.c. flask is now adjusted to the mark of gradu-
ation and well mixed with a rotary motion. The zinc oxide settles

280 ST. LUKE'S HOSPITAL REPORTS

rapidly, and after a few minutes' standing, a solution comparatively
free from the precipitate may be decanted from the flask. The 200
c.c. flask is washed out twice with a few cubic centimeters of this
solution and is then filled to the mark by decanting the solution from
the 250 c.c. flask. The iodine is now present as an iodide, free from
interfering compounds. A few drops of methyl orange are added,
and the solution is made very slightly acid7 with 50 per cent sul-
furic acid. The acidity should not be less than 2-3 c.c. (or more than
5 c.c. ) of the 50 per cent sulfuric acid. Sodium hypochlorite is added
until the iodine is oxidized to iodic acid. Phenol is added and the
solution made slightly alkaline to phenolphthalein. Five c.c. of 50
per cent phosphoric acid are now added and the iodic acid is deter-
mined by addition of potassium iodide and titration with sodium
thiosulfate. If bromine is present the method is varied by acidifying
with 20 c.c. of syrupy 85 per cent phosphoric acid and adding suffi-
cient hypochlorite to liberate all the bromine and oxidize the iodine.
Ten c.c. of benzol are added, and the solution is boiled (with powdered
pumice) until all bromine is expelled. Under these conditions it is
not necessary to neutralize, but the potassium iodide is added to the
cold solution. A cover of benzol should be used for more than 100
mg. of iodine.

Sulfuric acid is used to acidify the solution so that the neutraliza-
tion will not form a salt with an ion in common with the acid used
to acidify in the final titration. The presence of sodium phosphate
greatly reduces the acidity from the phosphoric acid, but sodium sul-
fate has no such action. The methyl orange being destroyed by the
hypochlorite does not interfere with subsequent operations. If the
color from the methyl orange is destroyed upon acidification, or if
there is any trace of iodine liberated, the fusion was not carried out
properly. In this case, either heating to a higher temperature or for
a longer time will be necessary to secure accurate results.

"When the organic matter and fusion mixture are wet with water
and evaporated to dryness before fusion, the action of water makes
too intimate contact between the organic matter and the chlorate, and
a violent explosion may result. By evaporating to dryness with so-
dium hydroxide and adding the fusion mixture to this, there is no
danger of explosion. If some particles of carbon remain unoxidized,

7The presence of a few c.c. of chloroform materially decreases the foaming
from the escaping carbon dioxide.

THE DETERMINATION OF IODINE 281

it does not affect the result, as all the iodine will be retained as
iodide.

THE DETERMINATION OF SMALL QUANTITIES OF IODINE IN ORGANIC

COMBINATION.

In 1910, Hunter8 published a method for the determination of small
quantities of iodine in organic combination, which may be briefly
stated as follows: The compound is fused with a mixture of sodium
potassium carbonate and potassium nitrate. This fusion destroys the
organic matter and fixes the iodine as an iodide. The fusion mass is
dissolved in water and sodium hypochlorite is added. Upon acidifi-
cation with phosphoric acid, the sodium hypochlorite oxidizes the
nitrous acid formed during the fusion to nitric acid and the iodide
is oxidized to iodic acid. The excess of free chlorine formed from
the sodium hypochlorite is removed by boiling. After all free chlorine
has been removed and the solution is cold, potassium iodide is added.
The iodic acid in solution, which was obtained from the iodine orig-
inally in organic combination, reacts with the added potassium iodide,
each weight of iodine present as iodic acid liberating six times its
weight of iodine. The weight of iodine finally titrated, therefore, ifl
equivalent to six times the amount of iodine originally present.

During the past 18 months I have had occasion to make determi-
nations of iodine in thyroid preparations, and the method outlined
above was used for this work. As the results obtained were not en-
tirely satisfactory, a careful study of the chemical reactions involved
was undertaken, with the hope of finding a reliable method for the
determination of iodine. The one serious and unavoidable objection
to Hunter's method is the fact that simply boiling a solution contain-
ing a large amount of sodium hypochlorite, to which phosphoric acid
has been added, will not always completely remove compounds which
liberate iodine from potassium iodide.9

Foerster and Jorre10 have pointed out that when a solution of

8Hunter : Jour. Bio. Chem., 1910, vii, 321.

•In this connection, Hunter says : "The reagent that gives most frequent
trouble is the hypochloric solution. It must be reasonably fresh. If this con-
dition be fulfilled, the commercial product often gives excellent results. Some-
times, however, it is impossible to get a commercial solution that does not
give values too high."

10 J. Pr. Chem., 1899 [2], 59, 53.

282 ST. LUKE'S HOSPITAL REPORTS

sodium hypochlorite is acidified, oxy-chlorine compounds, among
which may be chloric acid, are produced. The amount of chloric acid
formed appears to depend upon the rate of acidification, the tempera-
ture, and concentration of the acid used.

In Hunter's method it is necessary to add the phosphoric acid to
the solution containing a comparatively large amount of sodium hypo-
chlorite. This results in the formation of oxychlorine acids, which, for
a series of determinations, may vary between wide limits, depending
upon the conditions of fusion. When the solution is boiled for 15 to 20
minutes, these acids are broken down and expelled, but rarely are they
entirely removed from solution. As the amount of oxidizing com-
pounds formed in the solution is uncertain, and as a variable amount
may be removed by boiling, no constant correction can be applied to
the results. For large amounts of iodine this correction is inappreci-
able, but when only a few one-hundredths of a milligram are present it
is a serious objection. The chemical properties of chloric acid are closely
analogous to those of iodic acid, and while some compounds will reduce
one more easily and completely than the other, no single compound
was found which could be satisfactorily used in a quantitative method
to destroy chloric and leave the iodic acid unchanged. Another ob-
jection, though less serious, is the presence of a large amount of nitrate
in the solution of the fusion mass. Nitrates in acid solution liberate
iodine from potassium iodide. This reaction is slow in a solution
slightly acid with phosphoric acid, but the titration of the iodic acid
has to be made immediately after the addition of the potassium iodide
as iodine is slowly liberated by the nitrates. Although many attempts
were made to modify Hunter's method by removing all oxidizing
compounds except iodic acid, no satisfactory modification was found.

Further investigation, however, has resulted in the following method
for the determination of iodine, which has proved reliable* in this
laboratory.

The method for small amounts of iodine is carried out as for larger
amounts described above, with the following modifications: If the
thyroid substance is in solution the equivalent of 1 gram of organic
substance is placed in the 2%-inch nickel crucible and the water is

THE DETERMINATION OF IODINE 283

evaporated by placing the crucible in a hot-air oven at 150-200°. The
15 grams of fusion mixture are now added and the fusion carried out
as described.

If the substance is in powder form, 1.2 grams are intimately mixed
with 15 grams of the fusion mixture, and no water is added, but the
fusion is carried out under the same conditions of heating and reduc-
tion with 20-mesh zinc granules. The zinc granules are separated
from the fusion mass by filtering or decanting as described above.
To the solution of the fusion mass 20 c.c. of syrupy 85 per cent phos-
phoric acid are added by allowing the acid to run from the pipet di-
rectly into the flask. There should be no liberation of iodine at this
point. A few drops of bromine are added to the flask and the so-
lution is shaken with a rotary motion until the bromine imparts a
distinct yellow color. The solution is now boiled for 7-8 minutes.
This will expel all but a trace of bromine. To the boiling so-
lution, which should be colorless, 15-20 drops of 5 per cent sodium
salicylate11 are added. The salicylic acid produced in solution will
remove all traces of bromine, but will not affect the iodic acid. After
boiling 1 to 2 minutes after the addition of the salicylate, the solution
is removed from the flame, cooled, potassium iodide is added, and the
liberated iodine titrated12 with thiosulfate.13 For small amounts of

"This is best prepared by dissolving pure salicylic acid in sodium hydroxide.

"Hunter recommends a clear 0.5 per cent solution of arrowroot starch for
an indicator in finishing the titration. A 0.5 per cent, solution of Kahlbaum's
soluble starch also furnishes a sensitive indicator for this work.

I3The most convenient strength of sodium thiosulfate for amounts of iodine
ranging from 0.5 to 5.0 gm. is n/200. This is not a stable solution, and must be
frequently restandardized. A convenient method is to prepare a solution of
potassium acid iodate which is equivalent to a known weight of iodine. The
strength of any sample of thiosulfate is readily found by titrating the iodine
liberated by the acid iodate solution, which retains its strength indefinitely.
The iodine equivalent of the potassium iodate is found as follows: Prepare
an N/10 solution of potassium acid iodate KIO3.HIO3 by dissolving 3.249 gm. of
the salt in 1 liter of water. This solution, diluted 20 times, will be approxi-
mately N/„00. Dissolve a known weight of pure iodine (approximately 1 gm.)
in 1 liter of water containing 1 to 2 gm. of sodium hydroxide. Dilute this ten
times. 1 c.c. of this solution will contain 1 mg. of iodine. Measure 25 c.c. of this
solution into a 500 c.c. flask, and dilute to 200 c.c. ; add 5 c.c. of 50 per cent
phosphoric acid and a few drops of bromine ; boil out the bromine ; add 15 to
20 drops of 5 per cent sodium salicylate, cool, add potassium iodide, and titrate
the liberated iodine with approximately n/,00 thiosulfate. This will establish
the relation between "original iodine" and the N/„00 thiosulfate, and from this

284 ST. LUKE'S HOSPITAL REPORTS

iodine, from 0 to 2-3 mg., this method will furnish very satis-
factory results. It is imperative to have reagents of known purity.
Potassium chlorate, as purchased in the open market, is often con-
taminated with a small amount of iodide. For our work Merck's
reagent potassium chlorate gave no traces of iodine, but all of the ordi-
nary grades of this salt contained a small amount. The zinc must be
free from arsenic and antimony. A blank should be made, using some
organic substance, free from iodine. If there is no iodine in any of
the reagents used, there should result a perfect blank. As little as
.005 mg. of original iodine can be detected by this method.

Some results showing that there is no loss of iodine by this method
of fusion are as follows: 1.5 mg. of iodine, in the form of potassium
iodide, was added to 15 gm. of the fusion mixture containing 1 gram
of organic matter (Witte peptone). The fusions were carried out
with a flame from an 8-inch Meker burner maintained as hot as pos-
sible, the crucible being surrounded with an asbestos collar, as de-
scribed above. The length of time of heating, after addition of the
zinc, was 2 minutes.

After the fusion the iodine was determined as above.

Time of c.e. sodium

heating thiosulfate used Iodine found

3 minutes 12.71 1.50 mgm.

6 " 12.75 1.51 mgm.

9 " 12.70 1.50 mgm.

12 " 12.75 1.51 mgm.

15 " 12.72 1.50 mgm.

Some other results obtained by heating in the first stage of the
fusion for 3 minutes and after addition of the zinc for the indicated
times, are:

the iodine equivalent of the potassium acid iodate can be found by adding
a known volume of the acid iodate to 150 c.c. of water containing potassium
iodide and 5 c.c. of 50 per cent phosphoric acid. When a small amount of
iodic acid is in a solution wbich contains but a small amount of salts, the
reaction with potassium iodide is retarded, and the end point of the titration
with thiosulfate is uncertain. The addition of 5 to 10 gm. of sodium chloride
to such a solution accelerates the liberation of iodine and makes the end point
sharp and accurate.

THE DETERMINATION OF IODINE 285

Lgth. of heating

after addition c.c. sodium

of zinc thiosulfate used Iodine found

2 minutes 12.71 1.50 mgm.

4 " 12.80 1.51 mgm.

6 " 12.68 1.50 mgm.

8 " 12.80 1.51 mgm.

10 " 12.58 1.49 mgm.

These results show that there is no appreciable loss of iodine even
when the length of time of the fusion is prolonged to 15 minutes.

In the determination of iodine by this method, where more than
3-4 mg. are present, the best results are obtained by acidify-
ing with 20 c.c. of 85 per cent phosphoric and then oxidizing with
sodium hypochlorite. After boiling for 10-12 minutes, the sodium
salicylate is added, as described above for bromine.

When the hypochlorite is added to the acid solution the conditions
are as unfavorable as possible for the formation of chloric acid, and
with a comparatively large amount of iodine present, no appreciable
error results from this source. However, the addition of an excess of
hypochlorite should be avoided. Bromine and sodium hypochlorite
should not be added together, as traces of iodine are liberated by such
a solution even after prolonged boiling.

Hunter showed that iodine in organic combination, as well as in
inorganic combination, is retained and converted into an iodide with-
out loss by an alkaline fusion mixture. The original form of com-
bination does not appear to affect the accuracy of the determination.

The following results were obtained by measuring a solution con-
taining the indicated weights of iodine into nickel crucibles. The
water was evaporated off, 15 gm. of the fusion mixture containing 1
gm. of Witte peptone were added, and the determination made as de-
scribed above. The iodine solutions were made by dissolving pure
iodine in sodium hydroxide, and diluting the solution to convenient
strength for measuring the iodine.

Iodine taken c.c. thiosul- Iodine found Error Error

Mg.

fate used

Mg.

Per cent

4.079

39.85

4.072

—.007

—0.17

4.079

39.65

4.052

—.027

—0.66

3.059

29.88

3.054

—.005

—0.16

3.059

29.85

3.05

—.009

—0.29

2.039

35.1

2.029

—.01

—0.49

2.039

35.1

2.029

—.01

—0.49

286

ST. LUKE'S HOSPITAL REPORTS

Iodine taken

c.c. thiosul-

Iodine found

Error

Mg.

fate used

Mg.

Per cent

1.02

17.5

1.011

—.009

—0.89

1.02

17.35

1.003

—.017

—1.66

0.714

24.40

0.717

+ .003

+ 0.42

0.714

24.80

0.729

+ .015

+ 2.10

0.510

17.27

0.510

17.85

0.525

+ .015

+ 2.9

0.306

8.45

0.301

—.005

—1.6

0.306

8.51

0.303

—.003

—0.98

0.102

2.60

0.093

—.009

—0.88

0.102

2.60

0.093

—.009

—0.88

0.051

4.20

0.044

—.007

—13.00

0.051

3.90

0.041

—.010

—20.00

0.031

2.90

0.030

—.001

—3.2

0.031

2.80

0.029

—.002

—6.6

These results show that the method is accurate to within .02 mg.
up to 3 or 4 mg. When used for a qualitative test for the presence
of iodine, the method is especially valuable, as the use of bromine and
salicylic acid assures a perfect blank in the absence of iodine.

Three samples of desiccated thyroid gland, kindly furnished by
Parke, Davis & Company, when analyzed by this method, gave the

following results:

Iodine found per

c.c. thiosul- gram of substance

fate used Mg.

Sample 1 19.25 1.813

19.28 1.816

Sample 2 19.77 1.862

19.77 1.862

Sample 3 18.00 1.696

18.25 1.719

18.35 1.728

I wish to express my appreciation to Mr. A. W. Thomas for assist-
ance during the course of this investigation.

SUMMARY.

This paper on the determination of iodine establishes the conditions
for the determination of iodine —

First. — "When present as a soluble iodide or in the uncombined
form.

THE DETERMINATION OF IODINE 287

Second. — When present with bromine, bromides and chlorides.

Third. — When present with interfering compounds, as copper, sil-
ver, mercury, nitrites, etc.

Fourth. — When in organic combination.

Fifth. — When present in small amounts, special reference being
given to the determination of the iodine content of the thyroid gland.

A NEW METHOD FOR THE DETERMINATION OF THE
REDUCING SUGARS.*

E. C. Kendall, Ph.D.

In the study of velocity of amylolytie action it became desirable
to determine with the greatest possible accuracy the reducing sugars
resulting from the digestion of starch. This led to the following study
of some modifications of Fehling's reagent with a view to establishing
the optimum medium and conditions for a gravimetric method of de-
termining reducing power.

Benedict1 and others have pointed out the fact that glucose is more
readily destroyed with sodium hydroxide than with sodium carbonate,
and that larger amounts of copper are reduced by the same weight of
sugar if sodium carbonate is used in place of sodium hydroxide. A
comparison of the results obtained with three of the more common
methods and a copper solution where the sodium hydroxide is replaced
with sodium carbonate follows.

50 mg. of glucose reduces according to :

Munson and Na2CO, solution

Defren's method Allihn's method Walker's method replacing NaOH

89.8 mg. Cu. 98.2 mg. Cu. 102.0 mg. Cu. 147 mg.

We thus see that the use of sodium hydroxide gives only about
two-thirds of the amount of copper reduced which may be obtained
with the carbonate.

After a series of experiments with the various alkalies, it was found
that potassium carbonate was the one best suited to furnish the alka-
linity. As the reducing power of glucose decreases with increase in
the volume of the solution, it is necessary to have the volume of the
solutions containing the copper and alkali which are added to the

♦Reprinted from tbe Journal of the American Chemical Society, Vol.
XXXIV, No. 3, March, 1912.

'J. Biol. Chem., 3, 101 (1907) ; 5, 485 (1908).

288

DETERMINATION OF REDUCING SUGARS 289

sugar solution as small as possible. Potassium carbonate is better than
sodium carbonate, being much more soluble and having a slight ad-
vantage in giving more copper reduced for the same weight of glucose.
Some experiments showing the relation between these two carbonates
are as follows :

50 mg. of glucose gave with

5 g. sodium carbonate, 129.8 mg. copper.
10 g. sodium carbonate, 133.3 mg. copper.

15 g. sodium carbonate, 133.3 mg. copper.

All conditions being the same with

12 g. potassium carbonate, 140.4 mg. copper.
14 g. potassium carbonate, 142.8 mg. copper.

16 g. potassium carbonate, 140.4 mg. copper.

Having found that potassium carbonate was best suited to furnish
the alkalinity to the copper solution, it still remained to determine
whether a better medium than Rochelle salts could be found to hold
the copper in solution.

Some results according to Munson and Walker's method showed
that unless the spontaneous reducing power of the alkaline tartrate
solution is determined and allowed for, the results obtained will be
considerably too high. Some results we obtained, using the method of
Munson and Walker, but not allowing for the reducing power of the
tartrate solution, are :

Sugar equivalent

Sugar taken Copper found given in table

60 126.5 62.4

60 124.6 61.4

100 203.0 102.5

100 202.7 102.3

In their original article2 Munson and Walker give a series of figures
showing the reducing power of their alkaline tartrate solution from
day to day during the course of the investigation. These results
varied from 0 to 2.0 mg. of cuprous oxide. Apparently the reducing
power of the alkaline tartrate solution varies with different samples
of Rochelle salts and it is imperative to make some correction for all
samples which we have examined.

The amount of copper reduced by the alkaline tartrate seems to be

'This Journal, 28, 663 ; 29, 541.

290 ST. LUKE'S HOSPITAL REPORTS

much greater when the reduction takes place in a bath of boiling water
than it does when the solution is heated for a short time over the flame
as in Munson and Walker's method. By heating for 20 minutes in a
bath of boiling water 50 c.c. of the mixed Defren solution in a total
volume of 150 c.c. may reduce as much as 7 mg. of copper. Provided
the reduction was caused by an impurity in the tartrate it would be
possible to free the solutions from such impurities by treating the al-
kaline tartrate with a copper solution, reduce by heating in a bath of
boiling water, filter, and use the resulting solution which would have
no reducing power of its own. This was tried and it was then found
that when such a solution was heated again in the boiling water a
second reduction, as large as the first, took place. If the cuprous
oxide was then filtered off and the solution again heated, a third re-
duction took place. Since this showed that the reduction is due to the
tartrate itself, and that a previous reduction is not capable of removing
the source of error, it seemed imperative to find some medium other
than Rochelle salts for keeping the copper in solution.

Many compounds have been proposed for this purpose, among
which may be mentioned the bicarbonate solution of Soldaini8 and the
citrate solution proposed by Benedict.4 In Benedict's volumetric
method for the determination of sugar the disappearance of the blue
color is taken as the end point of the titration and this method allows
of an accurate determination of the sugar. Experiments were there-
fore made to see if Benedict's citrate solution could be adapted to a
gravimetric method. It was then found that marked changes in the
reducing powers of the sugars followed changes in concentration of
the sodium carbonate and citrate.

Thus, using 50 mg. of glucose and 2 g. of copper sulfate in a vol-
ume of 150 c.c, the following weights of copper, expressed in milli-
grams, were obtained under the conditions as given below, when heated
for 20 minutes in a bath of boiling water :

Sodium carbonate Sodium carbonate Sodium carbonate

Sodium citrate

5 grams

10 grams

15 grams

Grams

Mg.

116.5

134.1

144.2

100.0

117.3

127.1

89.3

107.9

122.0

65.3

101.8

117.8

"Gaz. chim. Ital., 6, 322.

4 J. Biol. Ctaem., 5, 485 (1908).

DETERMINATION OF REDUCING SUGARS 291

The change in the reducing power of sugar is explained only in
part by assuming that the citrate solution dissolved the reduced cu-
prous oxide. This was shown by placing 150 mg. of Kahlbaum's cu-
prous oxide in each of four flasks and heating it under identical con-
ditions of volume, time, and concentration of solution as in the above
experiments. Oxidation of the cuprous oxide during the heating was
prevented by displacing the air in the flask with illuminating gas and
closing the flask with a two-hole stopper.

Determination of the copper content of 150 mg. of the cuprous
oxide used showed on duplicate determination 125.6 and 126.1 mg.
of copper, average 125.9 mg. All conditions being the same as above,
the following weights of cuprous oxide were recovered after heating
for 20 minutes:

Sodium carbonate Sodium carbonate

Sodium citrate 5 grams 15 grams

Grams Mg. Mg.

5 125.2

10 123.3 122.4

15 120.2 122.4

20 118.3 122.1

As 20 g. of sodium citrate in the presence of 5 g. of sodium car-
bonate could dissolve but 7.6 mg. of cuprous oxide the low results
obtained with the sugar must be due to a depression of the reducing
power of the sugar by the citrate. The results of other experiments
in which the weights of sugar varied showed that a citrate solution
does not furnish a satisfactory solution in a gravimetric method.

As the spontaneous reduction of Rochelle salts and the depression
and variations caused in the reducing power of sugar by sodium
citrate are serious objections to these two salts, further work was
done to find some other agent for holding the copper in solution.

Theoretically, any organic compound having a carboxyl and alcohol
group is capable of holding the copper in solution in an alkaline mix-
ture. Glycerol and mannite have also been suggested as possible
agents, but they do not furnish a convenient solution with which to
work. Lactic acid will hold the copper in solution, but the reducing
power of sugar is but slight in such a solution.

Among a number of organic compounds which were tried, salicylic
acid was found to be one which will furnish a medium for the re-
duction of sugar, but which has no reducing power of its own, and
will not dissolve the cuprous oxide.

292 ST. LUKE'S HOSPITAL REPORTS

An alkaline salicylate solution replacing the alkaline tartrate
showed no reduction of copper when heated in a bath of boiling
water for 7 hours, and the following results show that there is no ap-
preciable change in reducing power with small changes in concen-
tration of the salicylic acid.

50 mg. glucose. 5 grams sodium carbonate in 150 c.c. volume.

3 grams salicylic acid, 125.7 mg. copper.

4 grams salicylic acid, 126.0 mg. copper.

5 grams salicylic acid, 125.7 mg. copper.

6 grams salicylic acid, 124.8 mg. copper.

Further experiments showed that with the other reducing sugars,
maltose, lactose, and invert sugar, the alkaline salicylate solution fur-
nishes a satisfactory medium for the reduction of the copper.

It now remained to determine what weights of copper, potassium
carbonate and salicylic acid give the optimum conditions for the re-
duction of the copper.

In Munson and Walker's conditions, 1.858 grams of copper sulfate
(crystalline) are used per determination, the largest weight of copper
reduced being 435.3 mg. While larger amounts of copper give greater
reducing powers to the sugars, it was decided to use two grams of
copper sulfate (crystalline) per determination and limit the reduction
to 450 mg. of copper.

The weights of potassium carbonate and salicylic acid which give
the optimum conditions for maltose were determined and these weights
were used for the determination of the reducing power of the other
sugars.

The effect of varying amounts of potassium carbonate and salicylic
acid is shown in the following table. The volume was 140 c.c. and
2 g. of copper sulfate were present:

Sugar Salicylic Potassium carbonate

maltose

acid

Mg.

Grams

12 g.

14 g.

15 g.

100

151.7

153.8

154.9

100

151.0

157.1

155.0

100

149.1

154.6

154.8

100

135.7

150.4

154.9

These and other determinations showed that 15 grams of potassium
carbonate, 5 grams of salicylic acid, and 2 grams of copper sulfate in
a total volume of 140 c.c. give satisfactory conditions for the deter-

DETERMINATION OF REDUCING SUGARS 293

urination of maltose. The least volume of water which will conve-
niently dissolve the copper sulfate is 15 c.c. and the least volume for
the 15 grams of potassium carbonate is 25 c.c. While it would be
possible to make one solution of the three compounds, it was found
that both copper and potassium salicylate are so slightly soluble that
the volume of such a solution would be too great to give satisfactory
results. The potassium carbonate and copper sulfate are therefore
dissolved in water and added separately to the sugar solution while
the salicylic acid is added in the dry condition.

In regard to the method of heating, the following experiments were
carried out to determine whether or not any cuprous oxide was lost
during the heating by surface oxidation:

150 mg. of Kahlbaum's cuprous oxide were placed in each of four
flasks, 15 grams of potassium carbonate, 2 grams of copper sulfate and
5 grams of salicylic acid were added in a volume of 140 c.c.

The weight of copper in 150 mg. of the cuprous oxide used was
found to be 125.9 mg. The weights of copper recovered from the
four flasks after the treatment indicated below were as follows:

1. Solution boiled over free flame under conditions of Munson and
Walker, 124.5 mg. copper recovered.

2. Solution heated 20 minutes in bath of boiling water, 126.3 mg.
copper recovered.

3. Solution heated 20 minutes in bath of boiling water with surface
covered with toluene, 125.7 mg. copper recovered.

4. Solution heated 20 minutes in bath of boiling water, air above
solution being displaced with illuminating gas, 126.3 mg. copper re-
covered.

These results showed that there is no appreciable loss of cuprous
oxide due to surface oxidation when the heating is continued for 20
minutes in the boiling water.

The two methods of heating which have been used for the reduction
of copper with sugar are by heating over a free flame or in a bath of
boiling water. In choosing between these two methods, ease of oper-
ation, time required, and accuracy of the results obtained were the
factors considered.

The following results bear on this point:

The conditions of the solutions in each of the following sets were
those found to be the optimum conditions for determining the re-
ducing power of sugars. Volume 140 c.c, potassium carbonate 15
grams, salicylic acid 5 grams, copper sulfate 2 grams.

294

ST. LUKE'S HOSPITAL REPORTS

HEATING IN BATH OF BOILING WATER

Glucose,

Invert sugar,

Lactose,

Maltose,

Time,

50 mg.

100 mg.

min.

Mg. Cu.

Mg. Cu

Mg. Cu.

132.7

142.4

123.6

124.8

145.1

152.5

144.5

144.8

149.8

154.7

154.4

153.1

150.1

157.4

161.1

158.5

155.0

162.9

165.4

163.3

157.1

164.9

171.6

167.9

159.9

166.3

176.2

172.2

HEATING OVEB FLAMI

Total time Time of

Glucose,

Lactose,

of heating, boiling,

50 mg.

100 mg.

min.

Mg. Cu.

112.2

103.0

134.1

132.8

137.1

139.0

143.8

154.1

143.0

161.1

148.3

163.6

150.4

167.3

153.4

169.4

The figures in the first line of the last table above give the weights
of copper reduced under the conditions of Munson and Walker. It
is apparent that the reduction under these conditions is far from
complete and that the speed of reaction at this point is too great to
allow of an accurate determination of reducing power. The reason
for the incomplete reduction after two minutes ' boiling is undoubtedly
due to the slower reaction of the carbonate-salicylate solution than
of the hydroxide-tartrate solution.

When the determinations of reducing power are done in sets of
four or more time is saved per determination by making the time of
heating as short as possible. However, it is evident that at least
12 minutes of boiling over a flame are required. When the time of
heating is limited to 12 minutes it is impossible to filter one set while
the following set is being heated, but if the time of heating be ex-
tended it is possible to give one's entire attention to filtering the re-
duced copper and hence there is no actual loss of time per determi-
nation.

To boil a solution over a flame for 12 to 16 minutes requires more

DETERMINATION OF REDUCING SUGARS 295

or less attention to maintain uniform conditions, but it is an easy
matter to duplicate conditions of heating in a bath of boiling water
and no attention is required during the heating. Furthermore, it
was found that the results obtained by heating in boiling water are
more accurate than those obtained by boiling the solution. After
20 minutes' heating in boiling water the reaction is nearly complete
for glucose and invert sugar and there is only a slow rate of reduction
for lactose and maltose. As heating beyond 20 minutes would mean
a needless expenditure of time, it was decided to limit the reduction
for all of the sugars to that obtained during 20 minutes' heating in
boiling water.

Although the salicylic acid is employed in the alkaline solution and
must, therefore, exist as potassium salicylate, it was found impossible
to replace the acid with sodium salicylate and obtain the same re-
ducing power for maltose.

The following results show the difference between the free acid and
the sodium salt:

Grams

Sodium salicylate

Salicylic acid

117.4

141.3

126.0

143.1

131.9

148.4

136.2

148.7

The volume was 125 c.c, 2 g. copper sulfate, 11.5 g. potassium car-
bonate, and 100 mg. of maltose being present. The figures are milli-
grams of copper reduced.

When the salicylic acid and sodium salicylate were kept constant
and the potassium carbonate varied, the following results were ob-
tained :

Potassium Sodium salicylate Salicylic acid

carbonate

3 grams

Grams

Mg. Cu.

123.1

145.6

125.7

146.8

130.4

148.1

135.8

151.9

The volume was 125 c.c, 2 g. of copper sulfate and 100 mg. maltose
were used.

Another series where more salicylic acid and sodium salicylate
were used gave the following results :

296

ST. LUKE'S HOSPITAL REPORTS

Potassium
carbonate

Sodium salicylate

Grams

Copper

138.3

142.1

144.3

147.8

Potassium
carbonate

Salicylic acid

Grams

Copper

148.1

152.6

157.0

158.3

Although it would seem to make no difference when the sugar was
added to the solution of potassium-copper salicylate, experiment
showed that it is necessary to add the copper to the solution and not
vice versa. A series where 15 g. of potassium carbonate and 5 g. of
salicylic acid were used, and 100 mg. of maltose were added to this
solution gave 152.6, 146.2, 149.1, and 156.2 mg. of copper reduced.
Under identical conditions, but where the copper solution was added
to the sugar, the following weights of copper were obtained: 154.9,
155.0, 154.8, 154.9.

The effect of mixing the sugar and alkaline copper solutions and
allowing to stand in the cold is shown by the following results: To
four flasks, each containing 100 c.c. of water, 100 mg. of lactose and
25 c.c. of copper sulfate (2 grams) were added. At intervals of 5
minutes, 12 grams of potassium carbonate and 3 grams of salicylic
acid were added to the 4 flasks in succession. The flask to which the
potassium carbonate and salicylic acid was first added would have
stood 15 minutes before the mixture had been added to the fourth
flask. As soon as the fourth flask was ready they were all placed in
the boiling water, and allowed to remain 20 minutes; the following
weights of copper were obtained :

Solution stood in the cold 15 min., 149.8

Solution stood in the cold 10 min., 147.4

Solution stood in the cold 5 min., 146.3

Solution stood in the cold 0 min., 146.5

These results show that the sugar can stand in the alkaline copper
solution for 5-6 minutes in the cold without any appreciable change,
but that a slight reduction will occur if they are allowed to stand

DETERMINATION OF REDUCING SUGARS 297

10-15 minutes. In practice 2-3 minutes is all that is needed to dis-
solve the salicylic acid and prepare the solutions for the boiling water.
The temperature at which the solutions are added to the boiling
water is without appreciable influence between 18° and 50°. Four
solutions, each containing 12 g. potassium carbonate, 3 g. salicylic
acid, 2 g. copper sulfate, and 100 mg. lactose, when placed in the boil-
ing water at the indicated temperature gave the following weights of
copper reduced :

18°, 150.4 mg. copper; 30°, 150.7 mg. copper; 40°, 150.7 mg. copper; 50°,
151.5 mg. copper.

It is essential to have the boiling water heated with a flame large
enough to cause the water to begin boiling within 1.5-2 minutes after
the addition of the flasks containing the sugar-copper solutions.

Two flasks, containing 12 g. of potassium carbonate, 3 g. of sali-
cylic acid, 2 g. of copper sulfate, and 120 mg. of lactose in 125 c.c,
were placed in the boiling water with a flame under the bath, which
caused the water to boil within 1.5-2 minutes after the flasks were
placed in the bath. The copper reduced at the end of 20 minutes was
175.5 and 176.3 mg. Two other flasks containing identical solutions
were placed in the boiling water with a flame under the bath which
caused the water to boil in 5-6 minutes after the addition of the flasks.
After 20 minutes from the time the flasks were placed in the water
the copper reduced was 167.9 and 171.8 mg., showing lower and ir-
regular results.

In order to show the variations caused by slight differences in the
weights of potassium carbonate and salicylic acid added, the following
series of determinations were made under identical conditions of time
and volume. The volume was 140 c.c. and time 20 minutes :

Potassium Salicylic Invert

irbonate

acid

Glucose

sugar

Lactose

Maltose

Grams

50 mg.

100 mg.

148.9

155.2

160.0

154.9

149.2

155.7

157.2

155.0

156.7

154.9

150.0

158.0

151.4

154.9

151.4

152.9

153.0

151.4

158.3

154.5

154.6

149.4

155.7

157.2

155.0

149.4

156.1

156.9

156.3

147.3

155.5

160.1

158.4

298 ST. LUKE'S HOSPITAL REPORTS

These results show that glucose, maltose, aud invert sugar vary but
slightly for differences in amounts of potassium carbonate and sali-
cylic acid present and that lactose is more sensitive in this respect.

In practical determinations of sugar, the variations in the weights
of potassium carbonate and salicylic acid can be controlled within
± 0.2 g. without taking any special precautions, and it is apparent that
such a variation causes no appreciable change in the reducing power
of any of the sugars.

DETERMINATION OP THE COPPER REDUCED.

The writer recently described a method for the determination of
copper by means of the iodide method. The method described was
devised primarily for the determination of copper obtained by the
reduction with sugar. It differs from the original iodide method in
that the solutions are prepared for titration in the cold, thus over-
coming the delay caused by boiling the solution or evaporating to
dryness.

During the course of this investigation several hundred determina-
tions of copper have been made by this modification of the iodide
method, and these results show that, if the conditions prescribed are
followed, the determination of copper can be made by this method
with great accuracy. Irrespective of the way the reduced copper is
determined it has to be removed from its filter, and the most conve-
nient way to do this is to dissolve it in nitric acid. The iodide method
allows of the accurate determination of the copper thus dissolved,
hence doing away with drying and weighing, which is time-consuming
and laborious.

The cuprous oxide reduced by the sugar is filtered on a glass fun-
nel such as is usually employed to hold a Gooch crucible. The filter
is made by placing a perforated porcelain disk in the bottom of the
funnel and making an asbestos felt 6 to 8 mm. in thickness. A porce-
lain disk should be used to hold the asbestos, as glass wool retains
traces of alkaline copper solution. After the solution has been filtered
with suction and washed with hot water, the funnel and rubber stop-
per are removed from the suction flask, washed free from any copper
solution which may adhere to the outside, and placed on a 350 c.c.
suction flask. If the stopper does not fit, the top of the flask is ground
smooth on a carborundum hone so that when suction is applied it will
hold the stopper down tightly over the mouth. Before the suction is
applied to the flask the cuprous oxide is dissolved in not less than 10

DETERMINATION OF REDUCING SUGARS 299

c.c. of hot nitric acid (1 part of acid to 3 of water). It is imperative
to have the nitric acid hot and it should be contained in a wash bottle
which delivers a small stream. The flask in which the reduction takes
place and the sides of the funnel are washed with the hot acid and
then the asbestos is stirred up by the jet from the wash bottle. It is
best not to have a porcelain disk on the surface of the asbestos. The
hot nitric acid will dissolve only a trace of nitrous oxide, but if cold
nitric acid is used large amounts of nitrous acid will be dissolved,
which will prevent the accurate determination of the copper. When
all of the cuprous oxide has been dissolved the suction is applied and
the funnel is washed with several additions of small amounts of water
— not more than 10-12 c.c. at a time. The wash water is sucked
through each time before more is added. All of the copper, when
washed in this way, can be removed with 40-50 c.c. of wash water.
The copper in solution may now be determined as described in the
method.5

PREPARATION AND ANALYSIS OP THE SUGARS USED.

The four sugars used to determine the relation between sugar and
copper given in the table below were prepared and analyzed as fol-
lows:

The glucose of highest purity, furnished by Merck & Co., when
analyzed for moisture and rotating power, showed 0.16 per cent of
moisture and a specific rotating power of 52.68°. As the specific ro-
tating power was in accordance with that given by Tollens for pure
glucose no further purification was considered necessary.

The sucrose was prepared from Kahlbaum's C. P. saccharose by
the method outlined by the International Commission for the Unifi-
cation of Sugar Analysis. The sample thus prepared contained 0.13
per cent of moisture and showed a specific rotating power of 66.5 Y

The lactose was prepared from Kahlbaum's crystallized lactose by
dissolving in boiling water, filtering, and allowing the lactose to crys-
tallize for 7 days from this solution. These crystals were dried in a
vacuum over sulfuric acid for three days, ground into a powder, and
again dried in vacuum over sulfuric acid. The determination of

BThis Journal, 33, 1947.

6The sucrose was inverted essentially by the method used by Munson and
Walker, by heating for 30 minutes in boiling water with n/10 HC1, using 20 c.c.
for every 100 c.c. final volume. The solution was barely neutralized with
N/10 sodium hydroxide, cooled, and filled at 20° to the mark of graduation.

300 ST. LUKE'S HOSPITAL REPORTS

moisture showed 5.62 per cent of water. One molecule of water, cor-
responding to the formula C^H^OnH-jO, requires 5.0 per cent of
water, therefore the sample thus prepared contained 0.62 per cent ex-
cess water calculated as lactose hydrate. Its specific rotating power
calculated as C12H„20]1H20 was 52.51°.

The maltose was prepared by letting barley diastase act on soluble
starch as described by Baker and Day7 and Baker.8 The maltose thus
prepared was dried in an electric oven at 70-80° for 15-18 hours, and
was then ground and passed through a 60-mesh sieve. The moisture
determination showed 5.33 per cent of water. As maltose hydrate,
C^H^On-HaO, requires 5 per cent of water there was present 0.33
per cent excess water. The specific rotating power was 137.3°.

The rotating power of all preparations was determined with so-
dium light, using a 4 decimeter tube in a Schmidt and Haensch polari-
scope at 20°. The solutions were 10 per cent of sugar, except for
maltose, which was 5 per cent. The solutions, except for sucrose,
were allowed to stand 24 hours at room temperature to destroy the
multirotation.

The water content of all preparations were determined as follows :
Two grams of the sample in a small weighing bottle was placed in the
bottom of a 4-inch desiccator which had a suction outlet in the lid.
Around the weighing bottle was placed a wire gauze collar about 1.75
inches in diameter. This wire gauze supported a Petri dish of 3
inches diameter which contained phosphorus pentoxide. A second
Petri dish of almost the same diameter as the desiccator was supported
above the first Petri dish by three wire supports at a distance of 0.5
inch above the lower Petri dish. This top Petri dish acted as a cover
and prevented the phosphorus pentoxide from dusting when the
suction was released. After placing the cover on the desiccator it
was placed inside an electric oven and connected with stout suction
hose to a Gaede pump. The temperature of the oven was kept for
lactose at 130°, maltose 110°, sucrose and glucose 100°, for 4-5 hours.
The suction was maintained during the entire time of heating. At
intervals of one hour the weighing bottle was taken out of the desic-
cator and weighed. When heating for one hour produced a change
of less than 0.5 mg. the heating was discontinued. Duplicate deter-
minations were made in all cases.

7Analyst, 33, 393 (1908).
*J. Chem. Soc, 1902, 1177.

DETERMINATION OF REDUCING SUGARS 301

DETERMINATION OF RELATION BETWEEN SUGAR AND COPPER.

For maltose and lactose the sugar was weighed out in such quan-
tities as to make 5 mg. per e.c. of solution, allowance being made for
the presence of the water; the weights of sugar were calculated as
maltose and lactose hydrate, C12H22011.H20.

For invert sugar and glucose, solutions were made which contained
2.5 mg. of sugar calculated as C6H1206.

The temperature of graduation of both flasks and burets was 20°.

THE REDUCING POWER OF THE SUGARS.

The reducing power of the sugars was determined as follows : The
varying weights of sugar as indicated below were measured into 200
c.c. Erlenmeyer flasks and the volume in each case made up to 100 c.c.
with distilled water. Five grams of salicylic acid were now added
to each of 4 flasks containing the sugar to be determined. Fifteen
c.c.9 of copper sulfate solution and then 25 c.c. potassium carbonate10
solution were added to each of the flasks without any agitation of
the solution. It was found necessary to observe this order for the
addition of the reagents. The flasks were then shaken with a rotary
motion. The precipitate of copper carbonate dissolved, forming a
dark green solution. As soon as the salicylic acid dissolved the four
flasks were put in a holder and placed in a bath of boiling water.11

The copper sulfate solution is prepared by dissolving 133.33 grams of
CuS04.5H20 per liter of water ; 15 c.c. of such a solution contains 2 grams of
copper sulfate.

10The potassium carbonate solution contains 600 g. of anhydrous potassium
carbonate per liter; 25 c.c. of this solution contains 15 g. of potassium car-
bonate. As potassium carbonate is hygroscopic, it is necessary to drive off all
water before making up the solution. This is done by heating the carbonate
for 3 to 4 hours at a temperature from 190° to 200°. A sample of the salt thus
treated, when heated in a small test tube, should not give any evidence of
liberation of water. The carbonate solution should be made up in a liter or
other size graduated flask, and should be diluted almost to the proper volume,
well mixed, and then adjusted to the mark of graduation.

"The water bath used during this investigation was one 10 inches in diame-
ter and &/o inches deep. It contained 4 liters of water. The level of the water
could be maintained constant by using the ordinary constant water-level bath,
or by means of a syphon acting between the water bath and a reservoir of
water of constant level. The syphon, for constant use, must have a T or Y
tube inserted at its highest point. A 20 c.c. pipet closed at one end with
rubber hose and pinchcock is connected with the T tube. To start the syphon,

302 ST. LUKE'S HOSPITAL REPORTS

The flame under the bath must be of such size that boiling begins
within 1.5 to 2 minutes after addition of the flasks. At the end of 20
minutes from the time the flasks were placed in the bath the solutions
were filtered and the copper determined as described above.

both ends are placed under water and (the pinchcock being open) the air is
withdrawn from the pipet. When the pipet is full of water the pinchcock
is closed. Any bubbles of air liberated from the water in the tube of the
syphon will rise to the highest point of the tube, and will there be caught in
the pipet, displacing the water. Should the pipet become filled with air,
the syphon may be re-established by again withdrawing the air through the
rubber tube and pinchcock. The end of the syphon which is in the water bath
must have a small opening (about Ys inch). If a large opening is used, the
the water, when boiling, may syphon out of the bath. The diameter of the
rest of the syphon may be of any sized tubing.

The flame under the water bath was supplied by one large-sized Fletcher
and two Bunsen burners. The water should be boiling vigorously when the
flasks are placed in the water, and all of the flames should be burning. As
soon as the water has begun to boil, after the addition of the flasks (which
should be in less than two minutes), the two Bunsen burners are turned out,
as the Fletcher burner is sufficient to maintain the boiling.

In the practical application of this method for the determination of the
reducing sugars, it is most convenient to make a set of 4 determinations at
once. A rack is made to hold the 4 flasks, as follows : a brass rod ^ inch in
diameter and 14 inches long, is erected at the center point, and perpendicular
to a brass disk 8 inches in diameter and 3/32 inch thick. This disk forms the
bottom upon which the flasks are placed. Another disk of the same size as
the bottom one, but with a hole s/w inch in diameter, slides up and down the
rod. Four holes 1% inches in diameter are drilled through this second disk,
the centers of the holes being arranged symmetrically 2*4 inches from the
center of the disk. This top disk being lifted up, the four flasks are placed
on the bottom of the holder. When the top disk is lowered the flasks will
pass through the four holes, and, as the opening is only sufficiently large to
allow the neck of the flask to pass through, the flasks are held secure. A hook
at the end of the rod is used to hang the entire holder from a support above
the bath, at such a height that the rack sinks in the water up to the level of
the top disk. In the bottom disk a number of %-inch holes are drilled, so that
the rack may be placed in and removed from the water with ease. When
the flasks are removed from the rack the solutions are filtered immediately
on four suction flasks.

DETERMINATION OF REDUCING SUGARS

303

Weight of
sugar

Glucose

TABLE I.

Weight of
Invert sugar sugar

Lactose

Maltose

mg.
10

1— ■■ '

30.4

30.2

30.9

30.7

31.9

32.1

31.0

30.3

60.9

61.8

63.2

62.4

64.0

62.5

61.0

61.3

90.2

90.6

94.4

94.7

95.5

95.2

93.4

92.3

120.0

120.1

126.5

126.8

124.5

125.0

123.6

148.1

149.9

157.5

156.7

100

157.7

154.6

176.8

179.2

188.2

186.4

120

287.4

286.3

187.9

187.2

206.1

207.4

5 217.5
I 217.5

219.7 |
215.6 j

140

218.5

217.0

219.2

218.5

233.8

5 245.3
{ 245.6

245.3 |
*248.0 j

160

246.3

246.7

250.6

250.4

261.3

263.3

276.1

180

279.0

278.4

278.6

280.1

100

288.0

289.2

302.6

200

306.8

305.9

j 309.6

I 310.9

342.2

*313.6
*312.4

110

316.2

314.7

330.8

330.7

220

338.7

337.1

342.2

120

343.1

341.5

359.4

358.6

240

5 364.6|

1 364.9 S

397.3

*363.4

373.3

372.9

130

367.7

385.5

386.4

260

397.1

403.2

401.6

140

391.2

393.0

410.9

280

424.9

427.0

431.4 j.

431.4
*429.4

150

418.5

438.1

300

455.6

454.3

\ 459.4
\ *456.2

458.1
*454.3

160

443.3

442.1

462.1

460.9

TABLE

Glucose

Invert sugar

Lactose

Maltose

. A

Calcu-
F'nd lated Error
Mg. Mg. Mg.

30.3 30.6

61.4 60.9
90.4 90.8

120.1 120.3
149.0 149.4
178.0 178.1

206.8 206.4

233.8 234.3

262.3 261.7

288.6 288.8

315.5 315.5

342.3 341.7

367.7
392.1
418.5
442.7

367.6
393.0
418.1
442.7

0.3
—0.5

0.4

0.2

0.4

0.1
—0.4

0.5
—0.6

0.2

0
—0.6
—0.1

0.9
—0.4

Calcu-
lated
Mg.
31.43
63.55
95.24

F'nd

Mg.

30.8

62.8

94.6
126.7
157.1 157.15
187.3 187.37

Error F'nd

Mg. Mg.

0.63 32.0

0.75 63.3

0.64 95.4

126.44 —0.26 124.8

0.05 157.7

0.07 186.9

217.7 217.10 —0.60 217.8

245.5 246.33 0.83 246.5

276.1 275.07
302.6 303.33
330.8 331.09

-1.03 278.7
0.73 306.4
0.29 337.9

359.0 358.35 —0.65 364.8

386.0 385.14 —0.86 397.2
410.9 411.43 0.53 426.0

438.1 437.23 —0.87 455.0
461.5 462.55 1.05

Calcu-
lated
Mg.
32.07
63.38
94.52
125.48
156.28
186.90
217.34
247.60
277.70
307.63
337.38
366.95
396.35
425.58
454.64

Error
Mg.

0.07

0.08
—0.88

0.68
—1.42

0
—0.46

1.10
—1.00

1.23
—0.52

2.15
—0.85
—0.42
—0.36

F'nd

Mg.

30.6

61.2

92.9

123.6

154.6

187.6

218.9

250.5

279.4

310.3

342.2

373.1

402.4

431.4

458.7

Calcu-
lated
Mg.
30.2
61.96
93.57
125.02
156.32
187.47
218.47
249.32
280.04
310.59
341.00
371.25
401.35
431.31
461.12

Error

Mg.

—0.40

0.76

0.67

1.42

1.72

—0.13

—0.43

—1.18

0.64

0.29

—1.20

—1.85

—1.05

—0.09

2.42

304 ST. LUKE'S HOSPITAL REPORTS

TABLE m.

Dextrose Invert sugar Lactose Maltose

50 100 50 100 100 200 100 200

Method mg. mg. mg. mg. mg. mg. mg. mg.

Defren 89.8 178.1 125.7 248.4 109.5 216.5

Munson and Walker... 102.2 198.4 98.5 192.3 132.7 261.6 108.7 215.4

Allihn 98.2 195.0

Lehmann 101.4 190.0

Meissl 96.0 189.2

Soxhlet 138.3 269.6

Wein H5.1 226.8

Ost 165.6 294.3 170.0 298.0 167.5 331.8

Kjeldahl 107.2 197.7 101.7 190.2

Brown, Morris & Millar 103.0 202.7 97.5 194.1

This method 149.3 288.7 157.0 303.3 156.3 307.6 156.3 310.6

Using this method of procedure, the results in Table I were obtained
for the indicated weights of sugar. All of the results which were
obtained are given, but the ones which were not used in the calculation
of the curve are starred:

From these results the following equations showing the relation
between sugar and copper were deduced by means of the method of
least squares.12

In the equations X refers to weights of copper reduced, Y to
weights of sugar reacting:

Glucose X = — 0.17 + 3.0923 Y — 0.002026 Y»

Invert sugar X = — 1.30 + 3.2918 Y — 0.002455 Y»

Lactose X= 0.59 + 1.5786 Y — 0.000217 Y1

Maltose X = — 1.69 + 1.5988 Y — 0.000187 Y1

The weights of sugar given in Table I were substituted in the
proper equation and the corresponding values of X were found. The
differences between the values thus calculated and actually found is
given in Table II.

By means of the equation the copper equivalent to weights of mal-
tose and lactose from 20 to 300 mg. were calculated for every 4 mg. of
sugar. With glucose and invert sugar the copper equivalent for every
2 mg. of sugar from 10 to 160 was found. This gave a series of points
which differed by about 6 mg. of copper. These figures were changed

UA good example of the use of this method is given in Allihn's original
article, J. prakt. Chem., 22, 46 (1880).

DETERMINATION OF REDUCING SUGARS

305

to integral weights of copper and hence decimal weights of sugar.
The figures lying between each 6 mg. of copper were interpolated, the
interpolations being carried to the second decimal place. The com-
plete table giving the relation between the 4 reducing sugars and
copper for every mg. of copper from 30 to 450 mg. is given in
Table IV.

A comparison of the reducing power of the sugars obtained by
this method with that obtained with other methods in use is given in
Table III.

I wish to express my appreciation to Mr. A. W. Thomas for assist-
ance during the course of this investigation.

TABLE IV

Cuprous

Cupric

Glucose

sugar

Lactose

Maltose

Copper

oxide

Mg.

CgH^Og

CeH^Oa

Ci2H22On. H20

C^A^O

33.8

37.6

9.8

9.6

19.3

19.9

34.9

38.8

10.2

9.9

20.0

20.5

36.0

40.1

10.5

10.2

20.6

21.1

37.2

41.3

10.8

10.5

21.2

21.7

38.3

42.6

11.1

10.8

21.8

22.4

39.4

43.8

11.5

11.1

22.5

23.0

40.5

« 45.1

11.8

11.4

23.1

23.6

41.7

46.3

12.1

11.8

23.7

24.3

42.8

47.6

12.4

12.1

24.4

24.9

43.9

48.8

12.8

12.4

25.0

25.5

45.0

50.1

13.1

12.7

25.6

26.1

46.2

51.3

13.4

13.0

26.3

26.8

47.3

52.6

13.8

13.3

26.9

27.4

48.4

53.8

14.1

13.6

27.5

28.0

49.5

55.1

14.4

13.9

28.1

28.7

50.7

56.3

14.8

14.2

28.8

29.3

51.8

' 57.6

15.1

14.5

29.4

29.9

52.9

58.8

15.4

14.8

30.0

30.6

54.0

60.1

15.7

15.2

30.6

31.2

55.2

61.3

16.1

15.5

31.3

31.8

56.3

62.6

16.4

15.8

31.9

32.4

57.4

63.8

16.7

16.1

32.5

33.1

58.5

65.1

17.1

16.4

33.2

33.7

59.7

66.3

17.4

16.7

33.8

34.3

60.8

67.6

17.7

17.0

34.4

35.0

61.9

68.8

18.1

17.3

35.0

35.6

63.0

70.1

18.4

17.6

35.7

36.2

64.2

71.3

18.7

17.9

36.3

36.9

306

ST. LUKE'S HOSPITAL REPORTS

table iv (continued)

Cuprous

Cuprie

Glucose

sugar

Lactose

Maltose

Copper

oxide

Mg.

CeHj^O,,

CoH^Os

CjjE^Oh.HsO

C^Hj^Oh.HjO

65.3

72.6

19.1

18.3

36.9

37.5

66.4

73.9

19.4

18.6

37.6

38.1

67.6

75.1

19.7

18.9

38.2

38.8

68.7

76.4

20.0

19.2

38.8

39.4

69.8

77.6

20.4

19.5

39.4

40.0

70.9

78.9

20.7

19.8

40.1

40.7

72.1

80.1

21.0

20.1

40.7

41.3

73.2

81.4

21.4

20.5

41.3

41.9

74.3

82.6

21.7

20.8

41.9

42.5

75.4

83.9

22.0

21.1

42.6

43.2

76.6

85.1

22.4

21.4

43.2

43.8

77.7

86.4

22.7

21.7

43.8

44.4

78.8

87.6

23.0

22.0

44.4

45.1

79.9

88.9

23.4

22.3

45.1

45.7

81.1

90.1

23.7

22.7

45.7

46.3

82.2

91.4

24.0

23.0

46.3

47.0

83.3

92.6

24.4

23.3

46.9

47.6

84.4

93.9

24.7

23.6

47.5

48.2

85.6

95.1

25.0

23.9

48.1

48.9

86.7

96.4

25.4

24.2

48.8

49.5

87.8

97.6

25.7

24.5

49.4

50.1

88.9

98.9

26.0

24.9

50.0

50.8

90.1

100.1

26.4

25.2

50.7

51.4

91.2

101.4

26.7

25.5

51.3

52.0

92.3

102.6

27.1

25.8

51.9

52.7

93.4

103.9

27.4

26.1

52.6

53.3

94.6

105.1

27.7

26.4

53.2

53.9

95.7

106.4

28.1

26.8

53.9

54.6

96.8

107.6

28.4

27.1

54.5

55.2

97.9

108.9

28.7

27.4

55.1

55.8

99.1

110.1

29.1

27.7

55.8

56.5

100.2

111.4

29.4

28.0

56.4

57.1

101.3

112.7

29.7

28.3

57.1

57.7

102.4

113.9

30.1

28.7

57.7

58.3

103.6

115.2

30.4

29.0

58.4

58.9

104.7

116.4

30.8

29.3

59.0

59.6

105.8

117.7

31.1

29.6

59.7

60.2

106.9

118.9

31.4

29.9

60.3

60.9

108.1

120.2

31.8

30.2

60.9

61.5

109.2

121.4

32.1

30.6

61.6

62.2

110.3

122.7

32.4

30.9

62.2

62.8

111.5

123.9

32.8

31.2

62.8

63.4

DETERMINATION OF REDUCING SUGARS

307

table iv (continued)

Invert

Cuprous

Cupric

Glucose

sugar

Lactose

Maltose

Copper

oxide

Mg.

C6H120«

C6H1206

Ci:H22Ou. H20

C12H22Ou.H20

100

112.6

125.2

33.1

31.5

63.5

64.1

101

113.7

126.4

33.5

31.8

64.2

64.7

102

114.8

127.7

33.8

32.2

64.8

65.3

103

116.0

128.9

34.1

32.5

65.4

66.0

104

117.1

130.2

34.5

32.8

66.1

66.6

105

118.2

131.5

34.8

33.1

66.8

67.2

106

119.3

132.7

35.2

33.4

67.4

67.8

107

120.5

134.0

35.5

33.8

68.0

68.5

108

121.6

135.2

35.9

34.1

68.7

69.1

109

122.7

136.5

36.2

34.4

69.3

69.8

110

123.8

137.7

36.6

34.7

70.0

70.4

111

125.0

139.0

36.9

35.0

70.6

71.1

112

126.1

140.2

37.2

35.4

71.3

71.7

113

127.2

141.5

37.5

35.7

71.9

72.3

114

128.3

142.7

37.9

36.0

72.6

73.0

115

129.4

144.0

38.2

36.3

73.2

73.6

116

130.6

145.2

38.5

36.7

73.8

74.2

117

131.7

146.5

38.9

37.0

74.5

74.9

118

132.8

147.7

39.2

37.3

75.1

75.5

119

134.0

149.0

39.6

37.6

75.8

76.2

120

135.1

150.2

39.9

37.9

76.4

76.8

121

136.2

151.5

40.3

38.3

77.1

77.4

122

137.4

152.7

40.6

38.6

77.7

78.1

123

138.5

154.0

40.9

38.9

78.4

78.7

124

139.6

155.2

41.3

39.2

79.0

79.4

125

140.7

156.5

41.6

39.5

79.7

80.0

126

141.9

157.7

42.0

39.9

80.3

80.6

127

143.0

159.0

42.3

40.2

81.0

81.3

128

144.1

160.2

42.6

40.5

81.6

81.9

129

145.2

161.5

43.0

40.8

82.3

82.5

130

146.4

162.7

43.3

41.2

82.9

83.2

131

147.5

164.0

43.7

41.5

83.6

83.8

132

148.6

165.2

44.0

41.8

84.2

84.5

133

149.7

166.5

44.4

42.1

84.9

85.2

134

150.9

167.7

44.7

42.5

85.5

85.8

135

152.0

169.0

45.1

42.8

86.2

86.5

136

153.1

170.2

45.4

43.1

86.8

87.1

137

154.2

171.5

45.7

43.4

87.4

87.7

138

155.4

172.7

46.1

43.8

88.1

88.3

139

156.5

174.0

46.4

44.1

88.7

88.9

140

157.6

175.2

46.8

44.4

89.4

89.6

141

158.7

176.5

47.1

44.7

90.0

90.2

308 ST. LUKE'S HOSPITAL REPORTS

table iv (continued)

Invert

Cuprous

Cupric

Glucose

sugar

Lactose

Maltose

Copper

oxide

Mg.

C6H12O0

C„H1206

C^H^On.HoO

C12H,2On.H2<

142

159.9

177.7

47.5

45.1

90.7

90.8

143

161.0

179.0

47.8

45.4

91.3

91.5

144

162.1

180.2

48.1

45.7

92.0

92.1

145

163.2

181.5

48.5

46.0

92.6

92.8

146

164.4

182.7

48.8

46.4

93.3

93.4

147

165.5

184.0

49.2

46.7

93.9

94.0

148

166.6

185.2

49.5

47.0

94.6

94.7

149

167.7

186.5

49.9

47.4

95.3

150

168.9

187.8

50.2

47.7

95.9

96.0

151

170.0

189.0

50.6

48.0

96.6

152

171.1

190.3

50.9

48.3

97.2

153

172.3

191.5

51.3

48.7

97.9

154

173.4

192.8

51.6

49.0

98.5

155

174.5

194.0

52.0

49.3

99.2

156

175.6

195.3

52.3

49.6

99.8

157

176.8

196.5

52.7

50.0

100.5

100.4

158

177.9

197.8

53.0

50.3

101.1

159

179.0

199.0

53.4

50.6

101.8

101.7

160

180.1

200.3

53.7

50.9

102.4

161

181.3

201.5

54.0

51.3

103.1

103.0

162

182.4

202.8

54.4

51.6

103.7

103.6

163

183.5

204.0

54.7

51.9

104.4

104.3

164

184.6

205.3

55.1

52.3

105.0

104.9

165

185.8

206.5

55.4

52.6

105.7

105.6

166

186.9

207.8

55.8

52.9

106.3

106.2

167

188.0

209.0

56.1

53.3

107.0

106.8

168

189.1

210.3

56.5

53.6

107.6

107.5

169

190.3

211.5

56.8

53.9

108.3

108.1

170

191.4

212.8

57.2

54.2

108.9

108.8

171

192.5

214.0

57.5

54.6

109.6

109.4

172

193.6

215.3

57.9

54.9

110.2

110.1

173

194.8

216.5

58.2

55.2

110.9

110.7

174

195.9

217.8

58.6

55.6

111.6

111.3

175

197.0

219.0

58.9

55.9

112.2

112.0

176

198.1

220.3

59.3

56.2

112.9

112.6

177

199.3

221.5

59.6

56.6

113.5

113.3

178

200.4

222.8

60.0

56.9

114.2

113.9

179

201.5

224.0

60.3

57.2

114.9

114.5

180

202.6

225.3

60.7

57.6

115.5

115.2

181

203.8

226.5

61.0

57.9

116.1

115.8

182

204.9

227.8

61.4

58.2

116.8

116.5

183

206.0

229.0

61.7

58.6

117.4

117.1

DETERMINATION OF REDUCING SUGARS

309

table iv (continued)

Invert

Cuprous

Cupric

Glucose

sugar

Lactose

Maltose

Copper

oxide

Mg.

C8H1206

C8H1203

Ci^E^On-I^O

C12H22Ou. H20

184

207.1

230.3

62.1

58.9

118.1

117.8

185

208.3

231.5

62.4

59.2

118.8

118.4

186

209.4

232.7

62.8

59.6

119.4

119.0

187

210.5

234.0

63.1

59.9

120.1

119.7

188

211.7

235.3

63.5

60.2

120.7

120.3

189

212.8

236.5

63.9

60.6

121.4

121.0

190

213.9

237.8

64.2

60.9

122.0

121.6

191

215.0

239.0

64.6

61.2

122.7

122.3

192

216.2

240.3

64.9

61.6

123.3

122.9

193

217.3

241.5

65.3

61.9

124.0

123.6

194

218.4

242.8

65.6

62.2

124.7

124.2

195

219.5

244.0

66.0

62.6

125.3

124.8

196

220.7

245.3

66.3

62.9

126.0

125.5

197

221.8

246.5

66.7

63.2

126.6

126.1

198

222.9

247.8

67.0

63.6

127.3

126.8

199

224.0

249.0

67.4

63.9

127.9

127.4

200

225.2

250.3

67.8

64.2

128.6

128.1

201

226.3

251.5

68.1

64.6

129.2

128.7

202

227.4

252.8

68.5

64.9

129.9

129.4

203

228.5

254.0

68.8

65.2

130.6

130.0

204

229.7

255.3

69.2

65.6

131.2

130.6

205

230.8

256.5

69.5

65.9

131.9

131.3

206

231.9

257.8

69.9

66.2

132.5

131.9

207

233.0

259.0

70.2

66.6

133.2

132.6

208

234.2

260.3

70.6

66.9

133.8

133.2

209

235.3

261.5

71.0

67.3

134.5

133.9

210

236.4

262.8

71.3

67.6

135.2

134.5

211

237.6

264.0

71.7

67.9

135.8

135.2

212

238.7

265.3

72.0

68.3

136.5

135.8

213

239.8

266.5

72.4

68.6

137.1

136.5

214

240.9

267.8

72.7

69.0

137.8

137.1

215

242.1

269.0

73.1

69.3

138.5

137.8

216

243.2

270.3

73.4

69.6

139.1

138.4

217

244.3

271.5

73.8

70.0

139.8

139.1

218

245.4

272.8

74.2

70.3

140.4

139.7

219

246.6

274.1

74.5

70.7

141.1

140.3

220

247.7

275.4

74.9

71.0

141.8

141.0

221

248.7

276.6

75.2

71.4

142.4

141.6

222

249.9

277.9

75.6

71.7

143.1

142.3

223

251.0

279.1

76.0

72.0

143.7

142.9

224

252.1

280.4

76.3

72.4

144.4

143.6

225

253.3

281.6

76.7

72.7

145.1

144.2

310

ST. LUKE'S HOSPITAL REPORTS

table iv (contmued)

Invert

Cuprous

Cupric

Glucose

sugar

Lactose

Maltose

Copper

oxide

Mg.

C6H1206

C0H12O6

CuHjjOu.HjO

C^H^Ou.HgO

226

254.4

282.9

77.0

73.1

145.7

144.9

227

255.6

284.1

77.4

73.4

146.4

145.5

228

256.7

285.4

77.8

73.7

147.0

146.2

229

257.8

286.6

78.1

74.1

147.7

146.8

230

258.9

287.9

78.5

74.4

148.4

147.5

231

260.1

289.1

78.8

74.8

149.0

148.1

232

261.2

290.4

79.2

75.1

149.7

148.8

233

262.3

291.6

79.6

75.4

150.3

149.4

234

263.4

292.9

79.9

75.8

151.0

150.1

235

264.6

294.1

80.3

76.1

151.7

150.7

236

265.7

295.4

80.6

76.5

152.3

151.4

237

266.8

296.6

81.0

76.8

153.0

152.0

238

268.0

297.9

81.4

77.2

153.6

152.6

239

269.1

299.1

81.7

77.5

154.3

153.3

240

270.2

300.4

82.1

77.8

155.0

153.9

241

271.3

301.6

82.5

78.2

155.6

154.6

242

272.5

302.9

82.8

78.5

156.3

155.2

243

273.6

304.1

83.2

78.9

157.0

155.9

244

274.7

305.4

83.5

79.2

157.6

156.5

245

275.8

306.6

83.9

79.6

158.3

157.2

246

277.0

307.9

84.3

79.9

159.0

157.8

247

278.1

309.1

84.6

80.2

159.6

158.5

248

279.2

310.4

85.0

80.6

160.3

159.1

249

280.3

311.6

85.4

80.9

160.9

159.8

250

281.5

312.9

85.7

81.3

161.6

160.4

251

282.6

314.1

86.1

81.6

162.2

161.1

252

283.7

315.4

86.5

82.0

162.9

161.7

253

284.8

316.6

86.8

82.3

163.6

162.4

254

286.0

317.9

87.2

82.7

164.2

163.0

255

287.1

319.1

87.6

83.0

164.9

163.7

256

288.2

320.4

87.9

83.4

165.6

164.3

257

289.3

321.6

88.3

83.7

166.2

165.0

258

290.5

322.9

88.7

84.1

166.9

165.6

259

291.6

324.1

89.0

84.4

167.6

166.3

260

292.7

325.4

89.4

84.8

168.2

166.9

261

293.8

326.6

89.8

85.1

168.9

167.6

262

295.0

327.9

90.1

85.5

169.5

168.3

263

296.1

329.1

90.5

85.8

170.2

168.9

264

297.2

330.4

90.8

86.1

170.9

169.6

265

298.3

331.6

91.2

86.5

171.6

170.2

266

299.5

332.9

91.6

86.8

172.2

170.9

267

300.6

334.1

91.9

87.2

172.9

171.5

DETERMINATION OF REDUCING SUGARS

311

table iv (continued)

Cuprous

Cupric

Glucose

sugar

Lactose

Maltose

Copper

oxide

Mg.

C6H12Ob

CaHjjOg

C12H22OU.H2O

Ci2H22Ou.H20

268

301.7

335.4

92.3

87.5

173.5

172.2

269

302.8

336.7

92.7

87.9

174.2

172.8

270

304.0

338.0

93.1

88.2

174.9

173.5

271

305.1

339.2

93.4

88.6

175.5

174.1

272

306.2

340.5

93.8

88.9

176.2

174.8

273

307.3

341.7

94.2

89.3

176.9

175.4

274

308.5

343.0

94.5

89.6

177.5

176.1

275

309.6

344.2

94.9

90.0

178.2

176.7

276

310.7

345.5

95.3

90.3

178.9

177.4

277

311.9

346.7

95.6

90.7

179.5

178.0

278

313.0

348.0

96.0

91.1

180.2

178.7

279

314.1

349.2

96.4

91.4

180.9

179.3

280

315.2

350.5

96.7

91.8

181.5

180.0

281

316.4

351.7

97.1

92.1

182.2

180.6

282

317.5

353.0

97.5

92.5

182.9

181.3

283

318.6

354.2

97.9

92.8

183.5

181.9

284

319.7

355.5

98.2

93.1

184.2

182.6

285

320.9

356.7

98.6

93.5

184.9

183.2

286

322.0

358.0

99.0

93.9

185.5

183.9

287

323.1

359.2

99.4

94.2

186.2

184.6

288

324.2

360.5

99.7

94.6

186.9

185.2

289

325.3

361.7

100.1

94.9

187.6

185.9

290

326.4

363.0

100.5

95.3

188.2

186.5

291

327.5

364.2

100.8

95.6

188.8

187.2

292

328.7

365.5

101.2

96.0

189.5

187.8

293

329.9

366.7

101.6

96.3

190.1

188.5

294

331.0

368.0

101.9

96.7

190.8

189.1

295

332.1

369.2

102.3

97.1

191.4

189.8

296

333.3

370.5

102.7

97.4

192.1

190.4

297

334.4

371.7

103.1

97.8

192.8

191.1

298

335.5

373.0

103.4

98.1

193.5

191.8

299

336.6

374.2

103.8

98.5

194.2

192.4

300

337.8

375.5

104.2

98.9

194.9

193.1

301

338.9

376.7

104.6

99.2

195.6

193.7

302

340.0

378.0

105.0

99.6

196.2

194.4

303

341.1

379.2

105.3

99.9

196.9

195.0

304

342.3

380.5

105.7

100.3

197.6

195.7

305

343.4

381.7

106.1

100.6

198.3

196.3

306

344.5

383.0

106.4

101.0

198.9

197.0

307

345.6

384.2

106.8

101.3

199.6

197.6

308

346.8

385.5

107.2

101.7

200.3

198.3

309

347.9

386.7

107.6

102.1

200.9

199.0

312

ST. LUKE'S HOSPITAL REPORTS

table rv (continued)

Invert

Cuprous

Cupric

Glucose

sugar

Lactose

Maltose

Copper

oxide

Mg.

CeH^Oe

C6Hi;Oe

GuHjjjOh.HjO

C12H,2011.Hi!<

310

349.0

388.0

107.9

102.4

201.6

199.6

311

350.1

389.2

108.3

102.8

202.3

200.3

312

351.3

390.5

108.7

103.1

202.9

200.9

313

352.4

391.7

109.1

103.5

203.6

201.6

314

353.5

393.0

109.5

103.8

204.3

202.2

315

354.6

394.2

109.8

104.2

204.9

202.9

316

355.8

395.5

110.2

104.6

205.5

203.6

317

356.9

396.7

110.6

104.9

206.2

204.2

318

358.0

398.0

111.0

105.3

206.8

204.9

319

359.1

399.2

111.4

105.6

207.5

205.5

320

360.3

400.5

111.7

106.0

208.2

206.2

321

361.4

401.7

112.1

106.4

208.9

206.8

322

362.5

403.0

112.5

106.7

209.6

207.5

323

363.7

404.2

112.9

107.1

210.3

208.2

324

364.8

405.5

113.2

107.5

211.0

208.8

325

365.9

406.7

113.6

107.8

211.7

209.5

326

367.0

408.0

114.0

108.2

212.3

210.1

327

368.2

409.2

114.4

108.5

213.0

210.8

328

369.3

410.5

114.8

108.9

213.6

211.5

329

370.4

411.8

115.1

109.3

214.3

212.1

330

371.5

413.1

115.5

109.6

214.9

212.8

331

372.7

414.3

115.9

110.0

215.6

213.4

332

373.8

415.6

116.3

110.3

216.3

214.1

333

374.9

416.8

116.7

110.7

217.0

214.7

334

376.0

418.1

117.0

111.1

217.7

215.4

335

377.2

419.3

117.4

111.5

218.4

216.1

336

378.3

420.6

117.8

111.8

219.1

216.7

337

379.4

421.9

118.2

112.2

219.8

217.4

338

380.5

423.1

118.6

112.5

220.4

218.0

339

381.7

424.4

119.0

112.9

221.1

218.7

340

382.8

425.6

119.4

113.3

221.7

219.3

341

383.9

426.9

119.8

113.6

222.4

220.0

342

385.0

428.1

120.1

114.0

223.0

220.7

343

386.2

429.4

120.5

114.4

223.7

221.3

344

387.3

430.6

120.9

114.7

224.4

222.0

345

388.4

431.9

121.3

115.1

225.1

222.6

346

389.6

433.1

121.7

115.5

225.8

223.3

347

390.7

434.4

122.1

115.8

226.5

224.0

348

391.8

435.6

122.4

116.2

227.2

224.6

349

392.9

436.9

122.8

116.6

227.9

225.3

350

394.0

438.1

123.2

117.0

228.5

225.9

351

395.2

439.4

123.6

117.3

229.2

226.6

DETERMINATION OF REDUCING SUGARS

313

table iv (continued)

Cuprous

Cupric

Glucose

sugar

Lactos

Copper

oxide

Mg.

CeHuOg

c^o.

CuHjjOu.I

352

396.3

440.6

124.0

117.7

229.9

353

397.4

441.9

124.3

118.1

230.6

354

398.6

443.1

124.7

118.4

231.2

355

399.7

444.4

125.1

118.8

231.9

356

400.8

445.7

125.5

119.2

232.6

357

401.9

446.9

125.9

119.5

233.2

358

403.1

448.1

126.3

119.9

233.9

359

404.2

449.4

126.7

120.3

234.6

360

405.3

450.6

127.1

120.7

235.3

361

406.4

451.9

127.5

121.0

236.0

362

407.6

453.1

127.9

121.4

236.6

363

408.7

454.4

128.2

121.8

237.3

364

409.8

455.6

128.6

122.1

238.0

365

410.9

456.9

129.0

122.5

238.7

366

412.1

458.1

129.4

122.9

239.4

367

413.2

459.4

129.8

123.2

240.1

368

414.3

460.6

130.2

123.6

240.7

369

415.4

461.9

130.6

124.0

241.4

370

416.6

463.1

131.0

124.3

242.1

371

417.7

464.4

131.4

124.7

242.8

372

418.8

465.6

131.8

125.1

243.5

373

420.0

466.9

132.1

125.5

244.1

374

421.1

468.1

132.5

125.8

244.8

375

422.2

469.4

132.9

126.2

245.5

376

423.3

470.6

133.3

126.6

246.2

377

424.5

471.9

133.7

127.0

246.8

378

425.6

473.0

134.1

127.4

247.5

379

426.7

474.3

134.5

127.7

248.2

380

427.8

475.6

134.9

128.1

248.9

381

429.0

476.8

135.3

128.5

249.6

382

430.1

478.1

135.7

128.8

250.2

383

431.2

479.3

136.1

129.2

250.9

384

432.3

480.6

136.5

129.6

251.6

385

433.5

481.8

136.9

130.0

252.3

386

434.6

483.1

137.3

130.3

253.0

387

435.7

484.3

137.7

130.7

253.6

388

436.8

485.6

138.0

131.1

254.3

389

438.0

486.9

138.4

131.5

255.0

390

439.1

488.2

138.8

131.9

255.7

391

440.2

489.4

139.2

132.2

256.4

392

441.3

490.7

139.6

132.6

257.0

393

442.4

491.9

140.0

133.0

257.7

Invert

Maltose
Mg.

227.3
227.9
228.6
229.2
229.9
230.6
231.2
231.9
232.6
233.2
233.9
234.5
235.2
235.9
236.5
237.2
237.8
238.5
239.2
239.8
240.5
241.2
241.8
242.5
243.1
243.8
244.5
245.1
245.8
246.5
247.1
247.8
248.5
249.1
249.8
250.4
251.1
251.8
252.4
253.1
253.8
254.4

314

ST. LUKE'S HOSPITAL REPORTS

table rv (continued)

Invert

Cuprous

Cupric

Glucose

sugar

Lactose

Maltose

Copper

oxide

Mg.

C6H1208

CoH^Og

CjsH^Ou. H20

C^HjjOu.HjO

394

443.6

493.2

140.4

133.4

258.4

255.1

395

444.7

494.4

140.8

133.8

259.1

255.8

396

445.9

495.7

141.2

134.2

259.8

256.4

397

447.0

496.9

141.6

134.5

260.5

257.1

398

448.1

498.2

142.0

134.9

261.1

257.8

399

449.2

499.5

142.4

135.3

261.8

258.4

400

450.3

500.7

142.8

135.7

262.5

259.1

401

451.5

502.0

143.2

136.1

263.2

259.8

402

452.6

503.2

143.6

136.4

263.9

260.4

403

453.7

504.5

144.0

136.8

264.5

261.1

404

454.8

505.7

144.4

137.2

265.2

261.8

405

456.0

507.0

144.8

137.6

265.9

262.4

406

457.1

508.2

145.2

137.9

266.6

263.1

407

458.2

509.5

145.6

138.3

267.3

263.8

408

459.4

510.7

146.0

138.7

267.9

264.4

409

460.5

512.0

146.4

139.1

268.6

265.1

410

461.6

513.2

146.8

139.5

269.3

265.8

411

462.7

514.5

147.2

139.9

270.0

266.4

412

463.8

515.7

147.6

140.2

270.7

267.1

413

465.0

517.0

148.0

140.6

271.4

267.8

414

466.1

518.2

148.4

141.0

272.1

268.4

415

467.2

519.5

148.8

141.4

272.8

269.1

416

468.4

520.7

149.2

141.8

273.5

269.7

417

469.5

522.0

149.6

142.2

274.1

270.4

418

470.6

523.2

150.0

142.6

274.8

271.1

419

471.8

524.5

150.4

143.0

275.5

271.8

420

472.9

525.7

150.8

143.3

276.2

272.4

421

474.0

527.0

151.2

143.7

276.9

273.1

422

475.1

528.2

151.6

144.1

277.6

273.8

423

476.2

529.5

152.0

144.5

278.3

274.4

424

477.4

530.7

152.4

144.9

278.9

275.1

425

478.5

532.0

152.8

145.3

279.6

275.8

426

479.6

533.2

153.2

145.7

280.3

276.5

427

480.7

534.5

153.6

146.1

280.9

277.1

428

481.9

535.7

154.0

146.4

281.6

277.8

429

483.0

537.0

154.4

146.8

282.3

278.5

430

484.1

538.2

154.8

147.2

282.9

279.1

431

485.3

539.5

155.3

147.6

283.6

279.8

432

486.4

540.7

155.7

148.0

284.3

280.5

433

487.5

542.0

156.1

148.4

285.0

281.1

434

488.6

543.2

156.5

148.8

285.7

281.8

435

489.7

544.5

156.9

149.1

286.4

282.5

DETERMINATION OF REDUCING SUGARS

315

table rv (contmued)

Invert

Cuprous

Cupric

Glucose

sugar

Lactose

Maltose

Copper

oxide

Mg.

C.H^O,

C6H1208

OuHgjOu-HjO

C12H22Ou.H20

436

490.9

545.7

157.3

149.5

287.1

283.1

437

492.0

547.0

157.7

149.9

287.8

283.S

438

493.1

548.2

158.1

150.3

288.5

284.5

439

494.3

549.5

158.5

150.7

289.2

285.2

440

495.4

550.7

158.9

151.1

289.9

285.8

441

496.5

552.0

159.3

151.5

290.6

286.5

442

497.6

553.2

159.8

151.9

291.3

287.2

443

498.8

554.5

160.2

152.3

292.0

287.8

444

499.9

555.7

160.6

152.7

292.7

288.5

445

501.0

557.0

161.0

153.1

293.4

289.2

446

502.1

558.2

161.4

153.5

294.1

289.8

447

503.2

559.5

161.8

153.9

294.8

290.5

448

504.4

560.7

162.2

154.3

295.5

291.2

449

505.5

562.0

162.6

154.7

296.2

291.9

450

506.6

563.3

163.0

155.1

296.9

292.5

ATROPIN THERAPY IN DIABETES MELLITUS.*t
Herman 0. Mosenthal, M.D.

The atropin therapy of diabetes mellitus has recently been ad-
vocated by Rudisch1 and by Forchheimer.2 Carbohydrate tolerance
is, according to Rudisch, greater with atropin than without. The
more striking results were obtained with atropin sulphate, though in
some instances atropin methyl bromid was substituted.

The following two cases of diabetes mellitus were tested out with
atropin sulphate. A constant weighed diet, as detailed in the pro-
tocols, was given. When the daily variations in the amount of glu-
cose excreted had been reduced to a minimum, atropin sulphate was
administered in increasing doses for a sufficiently long period of time
to give the drug a chance to exert any action of which it was capable.
With both subjects the experiments were continued until toxic effects
were observed. Under these conditions the glycosuria should be di-
minished if atropin sulphate is capable of increasing the carbohydrate
tolerance.

Any drug which modifies the carbohydrate metabolism may in-
fluence the formation of the so-called acid bodies, acetone, diacetic
acid and beta-oxybutyric acid. If atropin diminished the utilization
of glucose within the organism, the acid bodies would increase in the
urine. Therefore there is some interest attached to the determination
of these substances in a study of this kind. In one of the cases ob-
served, small but persistent amounts of acetone and diacetic acid
were present in the urine, as shown by previous qualitative tests.
Any possible increase in these substances was measured by the am-
monia output and its relation to the total nitrogen of the urine.
Normally the amount of ammonia nitrogen excreted is about 5 per

♦From the service of Dr. F. C. Wood, St Luke's Hospital, New York.
tReprinted from the Journal of the American Medical Association, March
16, 1912.

'Rudisch, J. : The Journal A. M. A, Oct. 23, 1909, p. 1366.
'Forchheimer, F. : Am. Jour. Med. Sc, 1911, cxli, 157.

316

ATROPIN THERAPY IN DIABETES

317

cent of the total nitrogen. A rise in this percentage indicates an in-
crease in the excretion of acid substances.

In these analyses the glucose was determined by Benedict's meth-
od,3 the ammonia according to Folin, and the nitrogen by the Kjel-
dahl process. The presence or absence of acetone was established
by the Legal reaction, that of diacetic acid by the ferric chlorid test.

TABLE 1— URINE ANALYSES AND MEDICATION IN A CASE OF DIABETES

MELLITUS (CASE 1).

Urine in Twenty-four Hours.

OS
rH

oT •

o o

— a

d
o

■4-» .

a * o

3 a

a a

V v

ol a>

a hvi

®rh

a-°

Symptoms.

3/18

1,460

2.2

23.4

9.1

.34

3.1*

3/19

1,290

2.4

30.3

9.6

.45

3.9*

3/20

1,720

2.8

47.5

8.9

.55

5.1

3/21

1,680

1.9

31.1

9.9

.58

4.9

3/22

1,080

2.1

22.9

7.7

.48

5.1

3/23

1,200

2.0

23.5

9.7

.58

4.9

1/100

3/24

1,320

2.0

26.7

9.8

.55

4.6

1/100

Mouth slightly dry-

3/25

1,800

1.5

26.7

9.9

.63

5.2

1/100

Cheeks flushed.

3/26

1,910

1.5

29.0

12.2

.79

5.4

1/100

3/27

1,560

1.2

18.4

9.7

.57

4.9

1/50

3/28

1,300

1.6

20.2

9.2

.65

5.8

1/50

3/29

1,480

0.6

8.7

5.5

.43

6.5

1/50

3/30

1,300

0.8

13.4

7.0

.54

6.3

1/25

Vertigo ; very dim vision.

3/31

1,940

1.6

30.3

10.1

.81

6.6

1/25

4/1

1,560

1.3

19.5

10.1

.66

5.4

1/25

Head "feels full."

4/2

1,730

1.9

32.0

10.1

.75

6.1

4/3

1,200

2.9

35.4

8.7

.59

5.6

4/4

930

1.8

17.1

7.8

.59

6.2

4/5

1,175

2.1

24.9

12.6

.76

5.0

•The initial low figures for ammonia may be regarded as the after-effects of bicar-
bonate of soda taken before admission to the hospital.

'Benedict, S. R. : The Journal A. M. A, Oct. 7, 1911, p. 1193.

318

ST. LUKE'S HOSPITAL REPORTS

TABLE 2. RECORD OP URINE ANALYSES AND MEDICATION IN A CASE OP

DIABETES MELLITUS (CASE 2).

Urine in Twenty-four Hours.

1-1

V
+->
OS

3
©
>

u
m

o &
3 <o

arJ

■
o

CSO
08 ft

Q
u
<o

ce
s>

o
Q

8/9

1,000

1.0

9.6

Symptoms.

8/10

740

1.1

7.8

8/11

1,150

1.1

12.2

8/12

860

1.0

8.6

8/13

810

1.1

8.8

8/14

1/100

8/15

980

0.6

6.2

1/100

Mouth slightly dry.

8/16

1/100

8/17

1,085

0.7

7.2

1/100

8/18

1,145

0.7

8.1

1/100

Vision dim temporar

8/19

1,095

0.8

9.1

2/100

8/20

1,550

0.5

8.2

2/100

8/21

1,485

0.3

4.6

2/100

Mouth very dry.

8/22

1,340

0.3

4.0

3/100

8/23

1,150

0.4

4.1

3/100

8/24

1,690

1.0

16.6

3/100

8/25

1,155

1.0

11.6

4/100

8/26

1,800

1.7

29.9

4/100

8/27

1,030

1.3

12.9

5/100

Face flushed.

8/28

2,360

0.4

9.9

5/100

8/29

1,920

0.7

13.6

6/100

8/30

1,720

0.4

7.1

6/100

8/31

1,600

0.5

7.2

7/100

Mouth Intensely dry

9/1

865

1.0

8.3

7/100

Pupils dilated.

9/2

1,430

0.4

6.0

7/100

9/3

1,300

0.5

5.9

9/4

1,400

2.3

31.8

9/5

1,045

1.1

11.1

9/6

1,400

1.8

25.2

Case 1. — Patient, a tailor, of Russian birth, aged 38, about two years ago
began to suffer with polyuria, thirst, increased appetite and loss of weight.
Glucose was discovered in the urine, but dietary restrictions were never ob-
served for very long periods of time. After being treated for one month at
the Vanderbilt Clinic as an out-patient, he was sent to Dr. Wood's service at
St. Luke's Hospital. The patient's urine gave constant positive reactions of
moderate intensity for acetone and diacetic acid. He was placed on the
following diet:

Breakfast. — Coffee or tea, with V/2 ounces of cream ; two eggs, cooked with
y2 ounce butter; 3 ounces ham; one slice bread, weight exactly 1 ounce, with
14 ounce butter.

Lunch. — Bouillon, with one raw egg; 3 ounces any lean meat, 1 ounce

ATROPIN THERAPY IN DIABETES 319

bacon ; vegetables from list,* 3 ounces, with % ounce butter or oil ; 1 ounce
whisky or brandy ; one slice bread, weight exactly 1 ounce, with *4 ounce butter.

Afternoon tea, with % ounce cream.

Dinner. — Any clear soup ; 4 ounces any lean meat ; vegetables from list,* 3
ounces, with y2 ounce butter or oil ; 1 ounce cheese, English, pineapple, Swiss,
or full-cream cheese; one slice white bread, weight exactly 1 ounce, with %
ounce butter ; 1 ounce whiskey or brandy ; demitasse coffee.

Case 2. — Patient, a native of France, aged 59, foreman in a factory, was
found to have sugar in his urine about four years ago. Only during the last
year before examination had he been complaining of diabetic symptoms : occa-
sional increased appetite and thirst. There had been some stiffness, pain and
weakness in the legs. The neurologic department of the Vanderbilt Clinic
diagnosed the case as one of multiple neuritis of diabetic origin. The urine
occasionally showed a trace of acetone, but no diacetic acid. After being ob-
served for one month at the Vanderbilt Clinic, he was sent to St. Luke's Hos-
pital. He was given the same diet as the patient in Case 1, except that 2
ounces of bread were ordered with each meal instead of 1.

The above reports give no indication that atropin sulphate effects
any change in the carbohydrate tolerance of sufficient importance to
make the drug of clinical value in the treatment of diabetes mellitus.

Vegetables allowed were: Asparagus, beet greens, Brussels sprouts, cab-
bage, cauliflower, celery, chicory, cresses, cucumbers, egg plant, endive, lettuce,
mushrooms, radishes, rhubarb, salsify, spinach, string beans, tomatoes, vege-
table marrow.

ANATOMICAL STUDY OF A THORACOPAGUS.
J. R. Pawling, M.D.
From the Pathological Department.
F. C. Wood, M.D., Director.

This specimen was sent to the laboratory from the service of Dr.
C. L. Gibson, in February, 1911. Some one had named the twins
"John and Mary," evidently forgetting his embryology, for they are,
of course, identical or homologous twins; i.e., have developed in the
same amniotic sac and have resulted probably from the division of a
single ovum. In such cases, there may be produced two separate in-
dividuals, i.e., normal twins of like sex; or, on the other hand, there
may be formed, in some way, a double monster.

We may classify double monsters in two main classes: first, those
showing decidedly unequal development; for example, the case of a
more or less completely developed autosite having an aeardiac para-
site springing from its thorax ; and, second, those showing practically
equal development. This second class may still further be divided
(according to Adami) into two classes: first, those that have resulted
from cleavage in the very early embryo — at the superior pole, at the
inferior pole, at both, or between these poles ; i.e., if cells of the head
center become split, those cells developing from them at each side
would form duplicate sets of tissue, a double head, for instance;
whereas the cells of the rump center developing in the normal way
would produce a single body. (Examples of superior duplication
would thus include all varieties, from a monster having two heads,
four arms, a double trunk, and two legs, down to a case simply of
bifurcation of the hypophysis of the brain.) His second class in-
cludes those that he believes have resulted from fusion of what would
otherwise have become identical twins; and these may be subdivided
according to the location and extent of this fusion.

The specimen we have to consider belongs to this latter class, and
it may be termed an equal monosymmetrical thoracopagus. The term
equal is used because the twins show practically the same measure-

320

Fig- 1- — The specimen before dissection, showing the double thumb.

ANATOMICAL STUDY OF A THORACOPAGUS 321

ments. They are monosymmetrical because, as is more often the case,
the union is not exactly face to face ; i.e., the arms, for example, are
somewhat farther apart on one side than on the other because the
antero-posterior planes of the fetuses do not exactly coincide. The
term thoracopagus is really not exact because the union includes not
only the thorax but the upper part of the abdomen as well, for it will
be noticed in the photograph taken before dissection that the cord
springs from the under surface of the bond of union. (The same
picture shows also the double thumb in one fetus which Nature added
as a finishing touch to an already interesting specimen.)

The age of the twins may be estimated at about four months, to
judge from their development; the mother's last menstruation oc-
curred October 14, 1910, and she aborted February 2, 1911.

In order to show the relations of the viscera, one side of the speci-
men (which, for convenience, we may speak of as the "front") was
removed completely. In dissecting up the skin, the recti muscles
were exposed and found to extend from the lower ribs downward
and outward to each pubis. By making translucent the portion of
chest-wall removed, we found that instead of the sternum of each
side coming in contact face to face (as, at first glance, we might ex-
pect), each sternum had split, the corresponding parts on each side,
i.e., the front and back of the specimen, forming a separate sternum.

The thorax, therefore, is common ; it contains a single pericardium
inclosing one heart having five chambers. The apex of the heart, as
we look at the specimen, points directly forward. The auricles lie
at about the same level, so that the long axis of the heart is in a hori-
zontal plane. Two aortae leave the two left ventricles, the arch in
each fetus taking the normal direction. Two inferior venas cava? pierce
the diaphragm and enter a common right auricle. This is continuous
with a common left auricle. Into this common chamber enters also a
pulmonary vein from the right fetus. (The other pulmonary veins
have not been followed.) The course taken by the blood seems to
have been as follows: entering the common right auricle by the in-
ferior and superior venae cava?, it reached the common left auricle,
and thence to the two left ventricles and the two aortae to the arterial
system, but also partly back to the lungs through the ductus arterio-
sus of each fetus. Some left the common right auricle to enter the
single right ventricle, then through the pulmonary artery of the right
fetus to the lungs on that side. The pulmonary artery of the left
fetus appears to be represented only by a fibrous cord which extends

322 ST. LUKE'S HOSPITAL REPORTS

to the root of the aorta (there being no right ventricle for that fetus),
so that its lungs received blood only from its aorta by way of the
ductus arteriosus.

The lungs show the usual divisions into lobes. The left lung of
the right fetus presents a cardiac incisure which receives the apex
of the heart. The left lung of the left fetus is abnormal in that a
lobe hooks over the aorta, and there is, in addition, a groove accom-
modating the left superior vena cava, which runs down between the
outer surface of the left lung and the chest wall.

We come next to the diaphragm, which is single and arches over
a single large liver. The upper part of the liver has in the median
line a shallow groove, from which a thin fibrous partition extended
to the abdominal wall. The umbilical vein is single and enters the
liver through a deep notch situated at about the center of this "front"
surface. Above and below this the liver is continuous across. At
each side of this opening there is a deep horizontal cut, as if to rep-
resent what would have been an umbilical fissure in each liver. The
umbilical vein, followed into the substance of the liver, divides into
two branches: that at the left becomes lost by smaller subdivisions,
but the right branch also connects by a distinct branch with the right
inferior vena cava, this connection being a ductus venosus.

The intestinal tract is very interesting. As the abdominal wall was
opened, a small, pointed pouch, about half a centimeter long, was
seen adherent to the inner surface of the cord. It is the remnant of
the vitelline duet, or a Meckel's diverticulum. This opens into a
horizontal loop of gut and is located at a Y-shaped junction formed
by what we may call a common jejunum meeting the two ilea. That
is to say, below this point each fetus has its own intestinal tract.
The cecum and appendix are located at the left side in the right
fetus and slightly to the right of the median line in the left fetus.
Following upward this common jejunum, we find that it continues
single almost up to the stomachs, where it joins a horizontal loop
made up of the two short duodena. This is shown in the diagram of
the intestinal tract.

We see, then, that in regard to the two important systems, viz.,
the circulatory and the alimentary, the twins are very closely con-
nected. The viability of such a monster, even if it could have been
delivered at term, seems very unlikely. We have spoken of the speci-
men as the "Siamese twins," but the two cases are really not very
similar, since the Siamese twins were joined only by a band which

Fig. 2. — The dissection of thorax and abdomen.

A ?,

j 5 i

- u •+-

_ '-C c

~ £ S

01 —

J 3

ANATOMICAL STUDY OF A THORACOPAGUS 323

measured a few inches in diameter when they had reached adult life.
It contained, however, a narrow band of liver. They lived to be
sixty-three years old.

The underlying causes of the production of such monsters are, of
course, far from settled. Experimental teratology surely is an in-
teresting study, but so far it has been confined chiefly to lower animals,
e.g., the production of double tadpoles by tying a fine thread about
the egg, or of spina bifida and cyclopia by subjecting normal fish-eggs
to the action of sodium salts. These and similar experiments tend to
show that the production of monsters is the result of external caus-
ation. It is believed that the same holds good for human pathological
embryos and monsters.

F. P. Mall calls attention to the fact that whereas only 0.7 per cent
of all pregnancies end in the production of pathological ova, in tubal
pregnancies 96 per cent become pathological or produce monsters;
and the data of von Winkel of 87 live fetuses removed from ruptured
tubal pregnancies show that only 8 were really normal.

Professor Mall concludes from this and from experimental tera-
tology that the cause of the production of monsters is not germinal,
i.e., inherent in the ovum or sperm, but is the result of external in-
fluences. His 33 cases of pathological human ova, he finds, can be
classified in three groups: in the first group of 11 cases, a severe
hemorrhage for several days preceded the abortion ; the second group
of 12 specimens were abortions from newly married women or rela-
tively sterile women who had been married for some time; and the
third group of 10 specimens were from women who had given birth
to a number of healthy children and then began to abort, often two
or three times. This last group showed that the cause could not have
been germinal, because these women had previously borne normal
children. The explanation is rather that the uterus was at first
normal, but later became pathological, so that the fertilized ovum
could not implant itself properly, but was aborted.

In this connection it is interesting to note that the case we have
been considering was that of a woman, aged 33, married 7 years, who
had had two children, followed by three abortions, the last of which
was preceded by a metrorrhagia lasting three months. And it may
be added that this patient returned to the hospital in January, 1912,
about a year after her last abortion, presenting again the symptoms
of threatened abortion, but left after a week, the pregnancy not hav-
ing been interrupted.

REPORT OF THE PATHOLOGICAL DEPARTMENT OF ST.
LUKE'S HOSPITAL FOR THE YEAR 1911.

F. C. Wood, M.D., Director.

The following abbreviated report gives the statistical results of the

work done in the various laboratories of the department during the
year.

DIVISION OF SURGICAL PATHOLOGY.

In the course of the year 762 specimens of tissue were examined
histologically. The diagnoses were as follows :

TUMORS.

Adenocarcinoma of abdomen 1

Adenocarcinoma of breast 1

Adenocarcinoma of colon 3

Adenocarcinoma of ovary 1

Adenocarcinoma of rectum 6

Adenocarcinoma of stomach 1

Adenocarcinoma of uterus 5

Adenomyoma of uterus 1

Carcinoma of antrum 1

Carcinoma of abdominal wall 1

Carcinoma of breast 34

Carcinoma of cervix uteri 2

Carcinoma of jaw 1

Carcinoma of lymph nodes 2

Carcinoma of neck 1

Carcinoma of omentum 2

Carcinoma of ovary 5

Carcinoma of peritoneum 1

Carcinoma of prostate 1

Carcinoma of rectum 2

Carcinoma of sternum 1

Carcinoma of stomach 1

Carcinoma of tonsil 1

324

REPORT OF PATHOLOGICAL DEPARTMENT 325

TTJMOBS — Cont.

Carcinoma, gelatinous, of caput coli 1

Carcinoma, gelatinous, of omentum 1

Carcinoma, gelatinous, of ovary 1

Carcinoma, gelatinous, of rectum 3

Carcinoma, squamous cell, of urinary bladder 1

Cystadenoma of breast 6

Cystadenoma of ovary 3

Cystoma of ovary 1

Cystoma of peritoneum 1

Cystoma, multilocular mucinous, of ovary 1

Ep
Ep
Ep

Ep
Ep
Ep
Ep
Ep
Ep
Ep
Ep

thelioma of ala nasi 1

thelioma of cervix uteri 7

thelioma of cheek and face 6

thelioma of conjunctiva 1

thelioma of esophagus 1

thelioma of eyelid 2

thelioma of groin 1

thelioma of hand 2

thelioma of jaw 2

thelioma of larynx 1

thelioma of lip &

Epithelioma of lymph nodes 5

Epithelioma of mouth 1

Epithelioma of neck 2

Epithelioma of pharynx 1

Epithelioma of scalp I

Epithelioma of tongue 4

Epithelioma of vulva 1

Epithelioma, basal cell, of face 4

Epithelioma, basal cell, of eyelid 2

Fibroadenoma of breast 7

Fibroadenoma of prostate 1

Fibroadenoma, intracanalicular, of breast 2

Fibroma of thigh 1

Fibroma, soft, of hand 1

Fibromyoma of uterus 75

Fibrosarcoma of femur 1

Fibrosarcoma of small intestine 1

Hemangioma of face 1

Lipoma of arm 1

Lipoma of back 1

Lipoma of chest 1

Lipoma of neck 1

Lipoma of knee 1

Lipoma of thigh 1

Myxo-fibroma of ulnar nerve 1

326 ST. LUKE'S HOSPITAL REPORTS

tumors — Cont

Neuro-fibro-liporna 1

Osteoma of palate 1

Papilloma of bladder 1

Papilloma of face 1

Polyp of cervix uteri 3

Polyp of endometrium 1

Sarcoma of abdomen 1

Sarcoma of orbit 1

Sarcoma of pelvis 1

Sarcoma of spinal cord and vertebrae 1

Sarcoma, giant cell, of jaw 1

Sarcoma, lympbo-, of cervical nodes 1

Sarcoma, lympbo-, of neck 1

Sarcoma, lympbo-, of tonsil 1

Sarcoma, lympbo-, of thorax 1

Sarcoma, melano-, of ovary, breast and peritoneum 1

Sarcoma, myxo-, of foot 1

Sarcoma, osteo-, of tibia 1

CYSTS.

Dermoid cyst of ovary 7

Epidermoid cyst of neck 1

Follicular cyst of ovary 2

Parovarian cyst 4

Perinephritic cyst 1

Sebaceous cyst of scalp 1

Strangulated ovarian cyst 1

MISCELLANEOUS TISSUES.

BEPBODUCTIVE SYSTEM — FEMALE.

Corpus luteum 1

Decidua and Chorionic Villi 18

Ectopic gestation 10

Endocervicitis, glandular 7

Endometrium, normal 9

Endometrium, atrophy of 3

Endometrium, hyperplasia of 21

Endometrium, edema of 6

Endometrium, menstrual 4

Endometrium, premenstrual 2

Endometritis, chronic 4

Endometritis, interstitial 6

Fallopian tubes, normal 11

REPORT OF PATHOLOGICAL DEPARTMENT 327

REPRODUCTIVE SYSTEM — FEMALE — Cont.

Fallopian tubes, atrophy of 2

Hematosalpinx 1

Galactocele 1

Hydrosalpinx 2

Mastitis, acute 1

Mastitis, chronic 3

Mastitis, tuberculous 1

Oophoritis, subacute 1

Oophoritis, chronic 42

Ovary, normal 2

Pyosalpinx 13

Salpingitis, acute 7

Salpingitis, chronic 20

Salpingitis, subacute 10

Salpingitis, tuberculous 2

Salpingo-oophoritis, acute 6

Salpingo-oophoritis, chronic 26

Salpingo-oophoritis, subacute 7

Sinus of breast 1

Tubo-ovarian abscess 5

Uterus, tubes and ovaries, tuberculosis of 1

REPRODUCTIVE SYSTEM — MALE.

Epididymis, tuberculosis of 2

Prostate, adenomatous hyperplasia of 1

Prostate, hypertrophy of 2

Prostatitis, subdurative 1

Testicle, tuberculosis of 2

GASTROINTESTINAL SYSTEM.

Appendicitis, acute 15

Appendicitis, catarrhal 4

Appendicitis, chronic 26

Appendicitis, subacute 6

Appendicitis, peri- 1

Appendicitis, tuberculous 1

Appendix, normal 3

Cholecystitis, acute 2

Cholecystitis, chronic 6

Cholecystitis, subacute 2

Colitis, acute 1

Peritonitis, acute 4

Peritonitis, subacute 1

Peritonitis, tuberculous 2

328 ST. LUKE'S HOSPITAL REPORTS

GASTBOINTE8TINAL SYSTEM — Cont

Thrombosed vein of intestine 1

Tonsil, chronic inflammation of 3"

Tonsil, normal 1

Tonsil, tuberculosis of 1

TTRINABY SYSTEM.

Kidney, multiple abscesses of 1

Kidney, tuberculosis of 3

Hemorrhage into kidney, site not discovered 1

Hydronephrosis 2

Pyonephrosis 1

Nephritis, suppurative 3

BONES AND JOINTS.

Osteitis 1

Osteitis, productive 1

Osteitis, rarefying and productive 1

Osteomyelitis, chronic 4

Osteomyelitis, tuberculous 3

Synovitis, chronic 1

Tuberculosis of carpal bones 1

Tuberculosis of chest wall 1

Tuberculosis of femur 1

Tuberculosis of knee 1

LYMPH NODES

Adenitis, simple 4

Adenitis, tuberculous 29

Nodes, chronic hyperplasia of 3

Nodes, normal 1

MISCELLANEOUS.

Abscesses of liver, miliary 1

Actinomycosis of abdomen 1

Blood clot 6

Cartilage 1

Connective tissue 8

Connective tissue, inflamed 11

Corneal ulcer 1

Endarteritis, with gangrene of foot 1

Fibrin 3

Furuncle 1

REPORT OF PATHOLOGICAL DEPARTMENT 329

MISCELLANEOUS — Cont.

Gangrene of thumb, diabetic 1

Goitre, colloid 8

Goitre, exophthalmic 1

Granulation tissue, simple 11

Granulation tissue, tuberculous 4

Hemorrhoids, inflamed granulation tissue 1

Iridocyclitis 1

Mucous membrane, normal 1

Myositis 3

Nasal polyp 2

Panophthalmitis, chronic 1

Pigmented mole of abdomen 1

Salivary glands, normal 1

Sebaceous cyst, chronic inflammation of 1

Tuberculosis of intercostal tissue 1

Ulcer of leg 1

POST-MORTEM EXAMINATIONS.

During the past year fifty-three autopsies have been performed.
Several of the more interesting cases are reported at length elsewhere.

840. Anatomical Diagnosis: Acute aortitis. Chronic fibrous myocarditis,
with cardiac hypertrophy and dilatation, and relative mitral and tricuspid
insufficiency. Healed tuberculosis of lungs, with passive congestion. Chronic
diffuse nephritis. Chronic passive congestion of liver and spleen.

841. Case of sudden death, a child, twelve years of age, in the hospital
for tuberculosis of spine, hip and both knees. Besides the above tuberculous
conditions, the autopsy showed a very large thymus extending from the thyroid
gland to within one inch of lower border of heart. The left lateral lobe passed
down over the left side of heart in a thin, flat layer. The mesenteric and
transverse mesocolic nodes were enlarged, and there was hyperplasia of the
lymphoid nodules throughout the intestine.

842. Anatomical Diagnosis : Subdural hemorrhage. Multiple cerebral and
cerebellar hemorrhages. General arteriosclerosis. Coronary sclerosis. Cardiac
hypertrophy. Healed tuberculosis of lungs. Chronic adhesive pleurisy. Chronic
diffuse nephritis.

843. Anatomical Diagnosis: Epithelioma of cervix, with extension to
pelvic and inguinal lymph nodes and left iliac vein. Metastases to spleen and
lung. Thrombosis of cerebral veins and softening of right hemisphere. Double
hydrothorax. Anemia of viscera.

844. Anatomical Diagnosis : Acute fibrino-purulent pericarditis and empy-
ema. Acute bronchopneumonia. General lymphatic hyperplasia. Cloudy swell-
ing of liver and kidneys, with congestion. Acute splenic tumor. Culture
from pericardial exudate showed pneumococcus.

330 ST. LUKE'S HOSPITAL REPORTS

845. Case of corrosive sublimate poisoning. Partial autopsy. Anatomical
diagnosis : Acute parenchymatous nephritis.

846. Anatomical Diagnosis : Chronic mitral endocarditis, with acute
exacerbation. Auricular thrombosis. Hypertrophy of heart, dilatation of
auricles. Infarction of lung. Hydrothorax. Atelectasis of lung. Healed
tuberculosis of lungs. Acute ulcerative aortitis. Chronic diffuse nephritis
(chiefly parenchymatous). Chronic passive congestion of liver, spleen and
intestine. Chronic gastritis. Chronic interstitial pancreatitis. Edema of
cerebral pia mater. Cystic degeneration of left lenticular nucleus (old soft-
ening).

847. Anatomical Diagnosis : Chronic diffuse nephritis. Cardiac hyper-
trophy. Edema of lungs. Ulcerative laryngitis and pharyngitis. Acute splenic
tumor. Fatty degeneration of liver. Chronic cystitis.

848. Anatomical Diagnosis : Chronic interstitial nephritis of severe grade.
Practically no other changes. Moderate hypertrophy of left ventricle.

849. Anatomical Diagnosis : Tuberculous meningitis. General miliary tu-
berculosis. Perforating appendicitis. General purulent peritonitis.

850. Anatomical Diagnosis : Lobar pneumonia of right upper, middle, and
part of lower lobe. Congestion and chronic tuberculosis of both lungs. Chronic
adhesive pleuritis and pericarditis. Cloudy swelling of liver and kidneys.
Edema of pia.

851. Anatomical Diagnosis : Arteriosclerosis. Cylindrical aneurism of
aorta. Chronic myocarditis. Double hydrothorax. Congestion, edema, and
healed tuberculosis of lungs. Passive congestion of liver, spleen and intestine.
Slight chronic diffuse nephritis. Meckel's diverticulum.

852. Anatomical Diagnosis : False aneurism of aorta, with rupture into
left pfeura. Fusiform and dissecting aneurisms of aorta. Extreme aortitis.
Edema and congestion of lungs. Subacute serofibrinous pleurisy. Aortic
insufficiency and cardiac hypertrophy. Passive congestion of liver, spleen
and kidneys.

853. Anatomical Diagnosis : Acute vegetative endocarditis, involving mi-
tral, aortic and tricuspid valves. Free thrombus in right auricle. Acute
serofibrinous pericarditis and pleurisy. Mitral insufficiency and dilatation of
right auricle. Edema of lungs. Passive congestion of heart, liver, spleen
and kidney.

Bacterial Diagnosis: Smears from mitral valve and from pericardium
show Gram-positive diplococci resembling pneumococci. Cultures show similar
organisms in mixed culture.

854. Partial Autopsy. Anatomical Diagnosis : Acute ulcerative colitis.
Etiology not determined.

855. Anatomical Diagnosis: Chronic pulmonary tuberculosis. Cavity in
right lower lobe. Acute mitral endocarditis. Acute splenic tumor. Chronic
hyperplasia of lymph nodes. (Death occurred after diabetic coma.)

850. Anatomical Diagnosis : Chronic endocarditis, with ball thrombus in
right auricle. Thrombosis of right vertebral artery, with softening in medulla.
Infarct of spleen. Chronic passive congestion of lungs and liver.

857. Anatomical Diagnosis : Microgyria, with secondary external and
internal hydrocephalus ex vacuo. Bronchopneumonia.

REPORT OF PATHOLOGICAL DEPARTMENT 331

858. Partial Autopsy. Anatomical Diagnosis: Cholelithiasis of common
duct. Bacillus aerogenes capsulatus infection of sinus and liver, and septi-
cemia following cholecystectomy.

859. Anatomical Diagnosis: Bronchopneumonia. Fibrinopurulent pleu-
ritis.

860. Anatomical Diagnosis : Chronic mitral endocarditis. Fatty degenera-
tion of heart. Tuberculosis of bronchial nodes. Fatty degeneration of liver.
Hydrosalpinx. Cystic ovaries. Fibromyoma of uterus.

861. Anatomical Diagnosis: Chronic fibrous pleuritis. Tuberculosis of
the lungs. Tuberculosis of bronchial lymph nodes. Bronchopneumonia. En-
docarditis, acute mitral. Chronic diffuse nephritis. Ulceration (typhoid) of
ileum, cecum and colon. Hyperplasia of lymph nodules and Peyer's patches
of ileum. Hyperplasia of mesenteric nodes. Congestion and hyperplasia of
spleen.

862. Anatomical Diagnosis : Chronic fibrous pleurisy. Healed tuberculosis
of lungs. Carcinoma of lesser curvature of stomach, with perforation. Metas-
tases in liver, pancreas, mesenteric lymph nodes and sigmoid, involving blad-
der wall. Acute peritonitis. Chronic diffuse nephritis.

863. Anatomical Diagnosis : Acute colitis. ■ '•

864. Anatomical Diagnosis: Bronchopneumonia. Acute enteritis.

865. Partial Autopsy : Glioma, with softening, of floor of fourth ventricle.

866. Anatomical Diagnosis : Acute vegetative endocarditis. Bronchopneu-
monia of left upper lobe. Cyst of brain partially replacing lenticular nucleus
and anterior limb of internal capsule on right side. Cloudy swelling of
kidneys.

867. Anatomical Diagnosis : Acute hemorrhagic pancreatitis. Acute chole-
dochitis. Multiple areas of old necrosis in and about the pancreas. Fatty
degeneration of the liver. Tuberculosis of the liver.

868. Anatomical Diagnosis : Sarcoma of retroperitoneal region, with me-
tastases in kidneys, lymph nodes, and subcutaneous tissue. Left pyonephrosis.
Atrophy and dilatation of heart. Passive congestion of spleen and liver..
Edema of lungs. Anasarca of legs and hips, due to blocking of inferior vena
cava and left common iliac veins. Chronic cystitis. Compensatory hyperplasia
of bone marrow.

869. Anatomical Diagnosis : Chronic fibrous pleurisy. Lobar pneumonia.
Healed pulmonary tuberculosis. Chronic diffuse nephritis.

870. Anatomical Diagnosis : Umbilical hernia. Umbilical fistula. Ascites.
Acute peritonitis. Cirrhosis of liver. Chronic passive congestion of spleen.
Chronic diffuse nephritis. Chronic endocarditis. Aortic stenosis.

871. Anatomical Diagnosis : Acute ulcerative endocarditis of the aortic
and mitral valves. Cardiac hypertrophy and dilatation. Hydropericardium.
Double hydrothorax and ascites. Edema and chronic tuberculosis of lungs.
Infarct of spleen. Parenchymatous degeneration of left kidney. Chronic pas-
sive congestion and hemangioma of liver. Chronic seminovesiculitis.

872. Partial Autopsy. Anatomical Diagnosis : Hyperplasia and ulceration
of Peyer's patches and lymph follicles of ileum, cecum and colon (typhoid).
Perforation of ileum. Hyperplasia of mesenteric nodes. General peritonitis.

873. Case of man 45 years of age, who had been troubled for nine months

332 ST. LUKE'S HOSPITAL REPORTS

previous to entering hospital with difficulty in swallowing, and pain in chest,
of indefinite localization. He had lost nine pounds in two months. Three weeks
after entrance, the patient vomited three ounces of blood, grew gradually
weaker, and died in five hours. At autopsy, a tumor was found projecting
into the esophagus from its anterior wall, about 1 cm. above the level of the
bifurcation of the trachea, the lumen thus being narrowed so as just to admit
the passage of the index finger. From this point to about 1 cm. above the
cardiac orifice of the stomach, the entire mucosa and a considerable portion
of the walls of the esophagus were destroyed, a large cavity being formed in
the posterior mediastinum, bounded by soft necrotic tissue. At the level of
the fourth intercostal artery the wall of the aorta, over an area about 2 cm.
in diameter, was destroyed nearly to the intima. The fourth right intercostal
artery was torn from the aorta, and its point of exit marked by a small
perforation about 2 mm. in diameter, leading directly into the esophagus. The
stomach contained one liter of clotted blood. There were metastases in the
pancreas and liver. Microscopical examination showed the tumor to be an
epithelioma.

874. Anatomical Diagnosis: Double hydrothorax. Pericarditis. Cardiac
hypertrophy. Chronic endocarditis. Mural thrombus in right auricle. Rup-
ture of chordae of anterior cusp of mitral valve. Infarction of both lungs.
Chronic adhesive peritonitis. Chronic passive congestion of liver and spleen.

875. Anatomical Diagnosis : Double hydrothorax. Acute and chronic en-
docarditis. Aortic stenosis and insufficiency. Cardiac hypertrophy. Chronic
diffuse nephritis. Sclerosis of coronaries and aorta.

876. Anatomical Diagnosis : Chronic ulcerative colitis. Chronic parenchy-
matous nephritis. Left bronchopneumonia. Miliary abscesses of both lungs.
Subacute cholecystitis. Multiple ulcers of skin.

877. Partial Autopsy. Anatomical Diagnosis: Operative skull defect.
Local meningitis. New growth of cerebellum and cyst communicating with
aqueduct of Sylvius. Compression of fourth ventricle. Internal hydro-
cephalus.

878. Anatomical Diagnosis: Tuberculosis of lungs. Chronic adhesive
pleurisy. Miliary tuberculosis of liver and spleen. Chronic diffuse nephritis.
Thrombosis of right femoral vein. Arteriosclerosis.

879. Case of a woman 23 years of age, entering hospital in moribund
condition. No history was obtained, except that she had had a headache and
backache for eight days, with temperature varying from 101° to 103°. She is
said to have coughed considerably for some time, the expectoration being at
times bloody, but never to have had heart trouble until three weeks before,
when she began to complain of shortness of breath. The autopsy findings
were interesting on account of the extreme grade of congenital pulmonary
stenosis, the orifice, 2.7 cm. in circumference, barely admitting the tip of the
little finger. The right auricle and ventricle were greatly hypertrophied, the
right ventricular wall measuring 2.3 cm. in thickness. The left auricle and
ventricle were both small. The left ventricular wall measured 1.5 cm. Neither
the foramen ovale nor the ductus arteriosus were patent. There were three
small, apparently recent, vegetations on one cusp of the pulmonary valve.
The lungs showed healed tuberculous lesions and two areas of infarction in

REPORT OF PATHOLOGICAL DEPARTMENT 333

the right lower lobe and one in the left. The liver and spleen showed the
effects of chronic passive congestion.

880. Anatomical Diagnosis : Chronic endocarditis. Mitral stenosis. Car-
diac hypertrophy and dilatation. Edema, ascites and double hydrothorax.
Chronic passive congestion of liver, spleen and kidneys.

881. Partial Autopsy. Anatomical Diagnosis: Tuberculous enteritis and
localized peritonitis. Amyloid degeneration of spleen. Chronic parenchyma-
tous degeneration of spleen. Passive congestion of liver.

882. Anatomical Diagnosis : Carcinoma of stomach. Metastases in liver,
spleen, retroperitoneal and posterior mediastinal lymph nodes. Mural throm-
bus of left ventricle. Septic thrombus of right pulmonary artery, with septic
infarct of lung and acute fibrinopurulent pleurisy. Left hydrothorax. Edema
of lungs. Chronic diffuse nephritis.

883. Anatomical Diagnosis : Edema of legs. Right hydrothorax. Chronic
adhesive pleurisy. Chronic adhesive pericarditis. Gumma of heart wall. Car-
diac hypertrophy. Aneurism of aorta, ascending and transverse portion. Arte-
riosclerosis. Edema of lungs. Gummata of liver. Atrophy of left lobe of
liver. Gall stones. Chronic passive congestion of liver, spleen and kidneys.

884. Partial Autopsy. Anatomical Diagnosis : Carcinoma of the bronchi,
with metastases in pleura, liver, kidney and peritoneum.

885. Anatomical Diagnosis : Double hydrothorax. Acute pericarditis. Car-
diac hypertrophy. Edema of lungs. Chronic passive congestion of liver and
spleen. Chronic interstitial nephritis. Colitis.

886. Anatomical Diagnosis: Chronic diffuse nephritis. Hypertrophy of
the heart. Arteriosclerosis. Right bronchopneumonia. Petechial hemorrhages
in intestines.

887. Anatomical Diagnosis: Chronic adhesive pleurisy. Edema of lungs.
Ulcerative colitis. Ethmoiditis.

888. Anatomical Diagnosis. Lobar pneumonia of right lower and middle
lobes and left lower lobe. Double fibrinopurulent pleurisy. Cloudy swelling
of kidneys.

889. Anatomical Diagnosis : Infected wound of wrist. Acute axillary
adenitis. Bronchopneumonia. Infarction of spleen. General lymphatic hyper-
plasia. Cloudy swelling of kidneys. Smears from axillary nodes show Gram-
positive cocci in chains. Similar organism in lung.

890. Anatomical Diagnosis : Chronic adhesive pleurisy. Peritonitis. Fatty
degeneration of liver. Acute hemorrhagic pancreatitis.

891. Partial Autopsy. Anatomical Diagnosis : Carcinoma of breast. Me-
tastatic carcinoma of ribs, left femur (with fracture of femur), and spleen.

892. Anatomical Diagnosis : Lobar pneumonia of right upper lobe. Acute
fibrinous pleurisy. Healed pulmonary tuberculosis.

DIVISION OF BACTERIOLOGY.

The routine bacteriological examinations made during the year may
be classified as follows:

334 ST. LUKE'S HOSPITAL REPORTS

Blood Cultures:

Typhoid bacillus 28

Streptococcus 11

Staphylococcus 4

Pneumococcus 4

Negative 129

Total 176

Urine Cultures :

Colon bacillus 27

Typhoid bacillus 2

Staphylococcus 3

Streptococcus 2

Mixed cultures 8

Negative 38

Total 80

Throat Cultures for diphtheria bacillus :

Positive 104

Negative 233

Total 337

Miscellaneous Cultures 189

Smears examined for tubercle bacillus:

Sputum Positive 158

Negative 479

637

Urine Positive 2

Negative 40

Chest and abdominal fluids. .Positive 1

Negative 5

Spinal fluid Positive 10

Negative 24

Stools Positive 2

Negative 2

723

Guinea-pigs inoculated for tubercle bacillus. .Positive 9

Negative 45

REPORT OF PATHOLOGICAL DEPARTMENT 335

Guinea-pigs inoculated for diphtheria bacillus 23

Mice inoculated 28

Vaginal smears examined for gonococeus 481

Urethral smears examined for gonococeus 60

Miscellaneous smears examined 197

The only serological examinations which have been made in any
number are the Wassermann and Widal reactions :

Wassermann reaction 597

Widal reaction 312

DIVISION OF CLINICAL PATHOLOGY.

The following routine specimens were examined during the year :

Abdominal fluids 26

Blood : Estimation of coagulation time IS

" " hemoglobin 898

" " red cells 582

" " white cells 3,780

Examination for malarial parasites 77

" filaria 5

" " trichinellae 2

Chest fluids 94

Duodenal contents 4

Gastric contents 254

Glyco-tryptophan tests 4

Spinal fluids : Total and differential counts 31

Butyric acid tests 6

Stools 381

Urines 23,780.

Roentgen Ray Laboratory

DER

dby
dark
aent,
died,
the

PLANS OF THE ROENTGEN RAY LABORATORY, UNDER

CONSTRUCTION ON THE THIRD FLOOR OF THE

TRAVERS PAVILION, ST. LUKE'S HOSPITAL.

Leon Theodobe Le Wald, M.D.

Protection for the patients and the operators has been secured by
the use of X-Ray-proof partitions and steel doors. Access to the dark
room will be through a labyrinth, and a method of tank-development,
which will accommodate the largest sized plates, will be installed.
Room for expansion of the laboratory has been reserved on the
same floor.

The plans appear on the two succeeding pages of this report.

339

REPORT OF A CASE OF DILATATION OF THE STOMACH.

MEDICAL TREATMENT. RECOVERY RECORDED

BY MEANS OF THE X-RAY.

Leon Theodore LeWald, M.D.

The following ease appears to be worth reporting on account of the
striking result of treatment, and the graphic record of this result as
shown by the X-Ray examination.

Miss A. 0., aged 21, a telephone operator by occupation, was
admitted to the service of Dr. Austin W. Hollis on February 24, 1912,
suffering from "chronic stomach trouble." Her family history was
negative. She had had the usual diseases of childhood, and at the
age of seven she first showed symptoms relevant to her trouble on
admission. At that time she had been seized, while playing, with an
attack of vomiting. There was no nausea, either before or after the
attack, and the patient went on playing entirely undisturbed. For
three months thereafter, each meal was followed immediately by an
attack of vomiting, which was sometimes projectile in character, some-
times not. Occasionally the patient was nauseated. The stomach was
not emptied at once, but the vomiting would continue at intervals for
as much as five hours after each meal, being increased by any exertion
and allayed by keeping quiet. A cramplike pain in the epigastrium
with soreness and tenderness in this region accompanied the vomiting.

At first these attacks had occurred at intervals of four or five
months, and lasted from two to three months, the patient's skin being
dry and yellow and her bowels constipated throughout the period of
disturbance. Recently the attacks had been more frequent, occurring
every two or three months, with especial severity in spring and fall.

The attack which occasioned the patient's entrance to St. Luke's
began two weeks previous to admission with severe and unremitting
headache in the right occipital region. A week before admission
vomiting recommenced, accompanied by nausea. Six months previous
to this admission the patient had been operated on at St. Luke's for
appendicitis. The physical examination made on her present entrance
was negative, except for a slight general tenderness of the abdomen
on deep pressure.

The X-Ray examination made on March 4, 1912, showed the stomach
dilated and the greater curvature 4% inches below the umbilicus. The
stomach was not empty in 6 hours. The colon was sluggish.

The course of treatment consisted mainly of rest in bed, with daily
lavage and a restricted diet, chiefly protein. On March 27th, one

340

X-RAY OF DILATED STOMACH 341

month after admission, the patient had apparently regained her health,
and could now eat without nausea or discomfort. The second X-Ray
examination, made for the purpose of determining the condition of the
stomach after treatment, shows in a very striking manner that the
stomach has regained its tone. The dilatation has disappeared; the
greater curvature has retracted so that it is only one inch below the
umbilicus in contrast to the four and a half inches shown before treat-
ment. The size and position are within normal limits, so that a very
good prognosis can be offered as to continued good health if ordinary
care is exercised. A further examination shows that the stomach
empties itself in normal time. The tone of the colon has also improved,
so that the tendency to constipation has been relieved.

Out- Patient Department

PRACTICAL NOTES FROM THE SURGICAL DIVISION OP
THE OUT-PATIENT DEPARTMENT.

William S. Thomas, M.D.

The intention of this paper is to present a number of procedures
in frequent use in the Surgical Division of the 0. P. D., with com-
ments upon the result of experience with them.

The subjects considered will be as follows :

1. Nitrous oxide anesthesia.

2. Use of picric acid in burns.

3. Removal of foreign bodies from the tissues.

4. Use of scarlet red on ulcers.

5. Open treatment of fractures.

6. Mode of demonstrating lesion of anal region.

7. Rigid supporters for varicosities.

8. Enucleation of tonsils.

9. Spring retractors.

1. Nitrous Oxide Anesthesia. — Nitrous oxide gas, with oyxgen,
in the past 3 years has been coming into very frequent use in our
minor surgical work. It has so far supplanted ether and chloroform
that, without statistics before me, I feel safe in saying that where
one of the latter was administered 10 times 3 or 4 years ago, it
is not used more than once now. Nitrous oxide gas has proved es-
pecially useful in the diagnosis of treatment of b6ne fractures and its
use permits careful and painless manual examination in almost every
case. It seems as though patients were entitled to its benefit. It is
contraindicated or ineffectual in the cases of very young patients, pa-
tients with severe organic cardio-vascular diseases, and alcoholics.

In the case of alcoholism, rather than struggle to anestheticize a
patient with gas or ether alone, it is frequently found quite feasible
to attain relaxation and insensibility if the gas is preceded by a hypo-
dermic of morphine. The particular advantage of this short an-
esthesia and rapid awakening without nausea or sickness in the case
of ambulatory patients is obvious.

345

346 ST. LUKE'S HOSPITAL REPORTS

2. Use op Picric Acid in Burns. — The use of this acid in super-
ficial burns was begun in the surgical clinic in 1907, and has proven
to be a distinct advance over old procedures. At first, used as an
ointment, later in hypersaturated solutions, it was found to have a
poisonous effect if used on large surfaces. Its best manner of use
seems to be as a wet dressing in watery solutions of one-half of 1
per cent. In burns of the first and second degree, pain is relieved,
the serous effusion ceases and the growth of epithelium is enhanced.
The principal disadvantage of the remedy is its ability to stain every-
thing yellow with which it comes in contact.

3. Foreign Bodies. — Bits of steel, fragments of glass, wooden
splinters, but especially fragments of sewing-needles, lost under the
skin, are very common in any minor surgical clinic, and frequently
prove to be difficult of removal. After free incision, and guided by a
skiagram made immediately before, there is no doubt that the most
important aid in discovering these lost fragments is the sense of
touch. In the case of metallic foreign bodies material assistance has
been afforded in our clinic by the telephonic searcher described in
the bulletin of last year, which is in steady use, and is made by
Wappler. When a metallic foreign body is located in a finger or toe
or in the webs between them, its shadow may often be seen in the
dark room by transillumination with a small electric light shielded
on all sides but one, as is used for the illumination of the accessory
sinuses of the nose. Elsewhere, these lights are of no use. When
used to demonstrate a foreign body in a finger or toe the light must
be applied to that side farthermost from the foreign body. In other
words, the foreign body must lie nearest to the skin next the observer's
eye or it cannot be seen.

4. Scarlet Red. — The extended use of this dye as a dressing for
granulating surfaces has demonstrated that it has a field of usefulness.
In our experience, corroborated by control experiments, it has been
shown to hasten the growth of epithelium upon healthy surfaces. In
the case of varicose, or infected ulcers, where there is no previous
tendency to heal, scarlet red alone is worse than useless. It seems
to have no antiseptic power.

5. Open Treatment of Fracture. — Continued use of the metallic
plate in selected cases of fracture confirms the good opinion of this
surgical procedure. It is seldom necessary, however, and the indi-
cations for the method seem to be clearly the following : Impossibility
of fairly good reduction of deformity, rotation deformity of radius,

SURGICAL NOTES FROM THE O. P. D. 347

mal-union and persistent non-union. Careful asepsis and avoidance
of traumatism, when operating, are necessary. Lane's steel plates
require a considerable outlay for a full set and cannot always be ob-
tained. Sheet aluminium is cheap, and may be easily obtained at
wholesale hardware stores and fashioned into the proper form for
internal splints in a few minutes, to suit the exigencies of each case.
The writer described the use of such plates in the Bulletin of 2 years
ago. In an experience of 3 years with the use of aluminium plates,
no serious cases of infection have been encountered. In 2 patients
there was enough infection to make it necessary to remove the plates
in order to cure a sinus, but in both of these cases the ultimate result
of the operation was perfectly good.

6. Mode of Demonstrating Lesion of Anal Region. — Ever since
suction cups have been used as recommended by Bier in his hyper-
emia treatment, we have turned this method of producing a partial
vacuum to use in certain rectal conditions. With the patient in a
lithotomy position, a suction cup of a diameter of 1% to 2y2 inches,
and properly curved, is applied over the anus and the air exhausted.
Any external hemorrhoidal conditions will be exaggerated and plainly
visible where they might otherwise be obscured by horizontal posture
of the patient. In the case of internal hemorrhoid or a fissure or of
a lesion within the first inch of the rectum, suction with a cup will
evert the rectal mucous membrane in such a manner that hemor-
rhoids will stand out more distinctly and the mucous membrane of
the whole circumference of the bowel will be brought into view.

7. Rigid Supporters for Varicosities. — The day of the elastic sup-
porter for slack abdominal walls and misplaced viscera is past, or
ought to be. In like manner the elastic stocking for the support of
the leg has at last found a rival in rigid appliances. A writer in the
New York State Medical Journal has recommended the use of adhesive
strapping of the whole leg in cases of varicose ulcer; and Dr. John
B. Murphy, of Chicago, in the Journal of the American Medical As-
sociation of March 27, 1909, recommended the use of inelastic leggings
in varicose ulcers. A mode of procedure in use in the Medical Di-
vision of the 0. P. D. was to treat varicose leg ulcers by adhesive
strapping from the toes to the knee, omitting the sole, and after the
ulcer is cured to have made a muslin corset for the leg to prevent re-
currence. The strapping is of strips about one-half inch wide, ap-
plied obliquely in two directions and crossing each other so as to
leave openings of regular intervals, like a checker-board. This strap-

348 ST. LUKE'S HOSPITAL REPORTS

ping is left on about a week, with a pad of gauze over the ulcer and
the usual bandage over the whole, changed as frequently as neces-
sary. The method is not applied when there is a phlebitis, or where
the skin is much macerated or eczematous, or where the ulcer is be-
hind or below the ankle. The method seems to have given most en-
couraging results in these cases, which have long been considered the
bane of every minor surgical clinic.

8. Enucleation of Tonsils. — For the past 4 years it has been
our practice to enucleate the tonsils in practically every case oper-
ated upon. Only in cases where the tonsil projects far into the
pharynx and is not covered by the interior pillar of the fauces has the
guillotine been used without a preliminary dissection of the tonsil
from its bed. The procedure ordinarily employed requires complete
anesthesia, but is very simple. In children, where the tonsil has not
been the seat of a fibroid degeneration, to make it abnormally ad-
herent to its surroundings, a short incision is made along the most
prominent portion of the edge of the interior pillar. The finger is
worked into this incision with its palmar surface toward the tonsil,
and the latter is shelled out of its bed by blunt dissection from all
its attachments except along its posterior aspect. At this point the
tonsil is grasped with the sponge forceps or other convenient instru-
ment, and the pedicle is snipped with a pair of curved scissors or
possibly with a tonsillotime. This method is chosen rather than sharp
dissection on account of the fact that less hemorrhage follows and be-
cause there is less danger of cutting what is not desired to be cut.
Routine questioning of patients in respect to possible hemophilia is
insisted upon. In the case of weak, anaemic children, calcium salts are
administered some days prior to the operation, in the hope of lessening
hemorrhage.

9. Spring Retractors. — The German silver wire self-holding re-
tractors described in the Journal of the American Medical Association,
in April, 1903, have been found to be of use in our operating room,
where the desired number of assistants are not always available.

POSSIBLE CAUSES OF FAILURE FOLLOWING THE USE OF
BACTERIAL VACCINES AND ANTISERA.*

H. E. Plummer, M.D.

"The most mischievous ignorance is that of the critic." So many
unjust criticisms are heard relative to the value of bacterial vaccines
and antiserum in the treatment of infections, that the above quotation
of Voltaire seems scarcely out of place. Some reports indicate such
successful results and others such absolute failures in similar cases
that they stimulate us to inquire into the reasons for such diversity
of conclusions. May not these failures be in part due to faulty dosage,
to incorrect intervals elapsing between the doses, to a wrong apprecia-
tion of the benefits to be expected from the use of a bacterial vaccine or
antiserum, and to a faulty selection of the remedy to be used? Let
us first study briefly the qualities of a bacterial vaccine and of an
antiserum and the theories upon which their use is based.

Antisera are obtained from some bacteria that do not produce ex-
tracellular toxins in sufficient quantities : as, for example, the strepto-
coccus and the gonococcus. The germs themselves are injected into
the animal, first in minute doses of greatly attenuated cultures, then
in gradually increasing doses until such a resistance exists in the ani-
mal that large amounts are tolerated. These antisera may be said to
possess antibacterial power. The fact that antisera are elaborated in
the horse distinguishes them from bacterial vaccines which are simply
suspensions of killed bacteria in physiological salt solution. From
this it may be seen that when antisera are used the patient is inocu-
lated with the protective substances produced by an animal, whereas
when bacterial vaccines are injected the patient must produce his own
protective bodies.

Wright and others have demonstrated the fact that there are sub-

*Read before the West Side Clinical Society.

Note. — The vaccines used in the preparation of this article were kindly
furnished by the Department of Experimental Medicine of Parke, Davis
& Co.

349

350 ST. LUKE'S HOSPITAL REPORTS

stances in the blood stream that assist, or are necessary to aid the
phagocytes in their successful warfare against invading bacteria. If,
however, Nature's laboratory is unable to completely overwhelm them
at once, the destruction of a portion of the invading host will produce
a strengthening of the defending force. This is known as autoin-
oculation and is best illustrated in the pneumonic crisis. In some in-
fections the protection afforded is lasting, as in smallpox and in yellow
fever, while in others, as in tuberculosis, the protection is transient.
When Nature is able to cope with the infecting bacteria, self-immun-
ization is likely to take place. This is due to the death of a certain
number of the organisms and their immediate effects as immunizing
agents. The artificial introduction of a suitable number of dead
microorganisms, i.e., the injection of a bacterial vaccine, may turn the
scale and produce the reinforcement necessary to Nature, which at the
moment is so urgent. As a result of the injection of these bacterial
products such indefinite substances as bacteriolysins, precipitins, ag-
glutinins, and opsonins are produced. The latter, which are measur-
able, act on the bacteria in such a way as to make them more vulner-
able to the attacks of the phagocytes. The phenomena accompanying
spontaneous recovery from an infectious disease, and which for a time
at least prevents a new attack, we term natural acquired active im-
munity. That produced by the injection into the tissues of small
quantities of living or killed microorganisms or of toxins produced
by these organisms we call acquired active immunity. "In passive
acquired immunity, on the other hand, the patient does little or noth-
ing toward obtaining this immunity. The toxins, which characterize
the disease, are simply neutralized or rendered inert by the injection
into the individual of protective substances, which have developed in
the serum of another animal, as the result of active immunization.
This form of immunity is a temporary expedient, which simply serves
to hold the disease processes in check sufficiently long to permit Na-
ture to manufacture and bring into play such protective and bac-
tericidal substances as will rid the individual of the offending bacteria
and their toxins."

The opsonic index is the comparative phagocytosis of the patient's
serum to a normal pool serum. The technique is complicated and the
slightest inaccuracy produces decidedly varied results. The index
has proven of great value in indicating the proper dosage, frequency
of injection, and results obtained. It has been found that the care-
ful observation of the clinical symptoms acts as a sufficient guide to

FAILURES FOLLOWING USE OF VACCINES 351

the treatment by bacterial vaccines in the more common infections.
By determination of the opsonic index, "Wright has demonstrated that
following the injection of vaccines, there is first a drop in the opsonic
index and later a rise. This drop he calls the negative phase and the
rise the positive phase. The use of bacterial vaccines in infections is
clearly defined. It is useless to suppose that every case of infection
is a suitable one for this treatment. The question is of necessity
whether the patient is capable of producing antibodies to the in-
fecting agent or whether they should be introduced from without, i.e.,
from an animal already immunized to the infecting agent.

A case occurs to me of a patient infected by an attenuated strain
of streptococcus which ran a chronic course. A culture was obtained
and an autogenous vaccine prepared and administered at intervals.
The patient continued to grow worse and ultimately died. This pa-
tient was already so surfeited with streptococci that the introduction
of a few million more dead germs seemed scarcely the rational treat-
ment for such a condition. Had such a patient the power to produce
his own antibodies, it would appear rational that he would have pro-
duced them with the many streptococci swarming in his system, with-
out the introduction of more. Thus antistreptococcic serum should
have been first used to modify the infection. Therefore, in general
septicemias the serums are indicated; whereas in localized or semi-
localized conditions the bacterial vaccines are to be preferred.

In reviewing the important subject of dosage we find a great va-
riety of opinions. There are, on the one hand, the advocates of small
doses and, on the other, those of large doses, but no set rule can be
laid down for the administration of bacterial vaccines. The guiding
factor in these cases must be more or less the resistance of the in-
dividual to the infecting organism and therefore the ability of the
tissues of the patient to produce antibodies. Overdosage has been a
not infrequent cause of absolute failure. It has often been noted
that the administration of 400,000,000 staphylococci in cases of furun-
culosis has produced an increased number of pustules or furuncles in-
stead of benefiting the condition. In other words, there has been a
production of a prolonged or more severe so-called negative phase,
thereby allowing the invading bacteria to obtain the mastery over
the protecting forces of the blood stream. During the aggravated or
very violent stage of the infection one should not administer a vac-
cine, as the activity of the infecting agent itself may be producing a
negative phase.

352 ST. LUKE'S HOSPITAL REPORTS

No definite time can be positively made as to the proper interval
for reinoculation, but in every case sufficient time should elapse be-
tween injections to allow the formation of the high wave of the positive
phase. In scarcely any instance should the interval between the ad-
ministrations be less than 3 days or in very rare instances more than
7 days, the average time being about 4 to 5 days. An instance has
occurred to me in which bacterial vaccines were administered in maxi-
mum doses daily and it was noted that the patient was gradually
becoming worse. The treatment was therefore discontinued, and at
the end of the second day most marked improvement was observed
in the condition of the infection. The lack of improvement was un-
doubtedly due to the fact that the patient was kept in a constant
state of negative phase.

Freeman, working in Wright's laboratory, noted the occurrence
of autoinoculation following the manipulation and massage of af-
fected joints in gonorrheal arthritis. Therefore, in the handling of
localized infections one must always bear this fact in mind; that
following any form of treatment, be it massage, X-ray, electric, radiant
heat application or Bier's hyperemia, observations have shown the
regular sequence of positive and negative phase and phase of in-
creased resistance, identical with that produced by an ordinary vac-
cine prepared from the invading organism. Therefore, when treating
a patient with bacterial vaccines care must be taken to avoid over-
manipulation of the infected area, as this may result in self -inoculation
which would be equivalent to an overdose of bacterial vaccine.

On the other hand, knowing as we do that the opsonins render the
bacteria vulnerable to the phagocytes, it is very important to the
success of the treatment that the lymph be made to flow through the
infected tissues. In cases of infection, English authorities advise the
use of a wet dressing compound of 4 per cent sodium chloride and .5
per cent sodium citrate. This solution is an ideal lymphagogue, and
prevents, by inhibiting coagulation, the formation of a scab. Let us
remember also that leucocytes are essential to the success of vaccine
therapy and that the best results may be expected when large num-
bers of healthy leucocytes are present. MacWatter claims that the
leucocytes may be increased in number 6 or 7 fold by the adminis-
tration of yeast. This method is rather crude, as no definite amount
of nucleinic acid is administered. As the success following the use of
yeast in these cases is undoubtedly due to the nucleinic acid which it

FAILURES FOLLOWING USE OF VACCINES 353

contains, it would seem more scientific to use nucleinic acid which,
under the name of nuclein solution, is readily obtainable.

Some failures are due to the selection of unsuitable vaccines, as
the following case will show: A young man suffering from chronic
prostatitis came under my personal observation. Improvement was
obtained by the use of gonococcus vaccine, but it seemed impossible
by this means to effect a cure. At this stage, I resorted to the use
of a combined vaccine made from a mixture of common pyogenic or-
ganisms. The results of these injections were very gratifying. In
this case, though the infection was primarily due to the gonococcus
it is evident that other organisms replaced, at least in part, the one
named. It should be borne in mind that though a specific organism
may be the original cause of the trouble, the advent of other germs
producing a mixed infection may delay a cure and, in the absence of
indications to the contrary, it may be well in such cases to employ
such a mixture of vaccines.

CONCLUSIONS.

1. There should be a proper determination of whether an antiserum
or a bacterial vaccine is indicated. 2. Care should be exercised in de-
ciding on the proper dosage for each individual infection. 3. The ad-
ministration of vaccines during the aggravated stage of infection may
produce harmful effects. 4. A proper interval should elapse before
repeating the injections. 5. Too much local treatment of the infection
may produce harmful results. 6. Such aids as tend toward the in-
crease of leueocytosis or the freer movements of lymph should be
given to assist the effects of the bacterial vaccine. 7. Any possible
change in the character of the infection should be observed.

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