these methods of action. If a susceptible animal is inoculated with the bacilli of anthrax it dies in twentyfour to forty-eight hours, and the minute blood-vessels are found to be absolutely filled with the large bacilli, often to such an extent that many of the capillaries are ruptured. The very number of the bacilli present are sufficient to mechanically interfere with the circulation, and produce a dearth of oxygen on account of the strong affinity of the bacilli for oxygen. On the other hand if an animal is inoculated with tetanus it dies just as soon, but no bacilli are found except at the seat of the inoculation. In the one instance the bacilli have caused death by mechanical interference with the oxygenation of the blood, in the other by the formation of a virulent poison. In man the anthrax bacilli do not always multiply with the rapidity that they do in more susceptible animals, and as the process is a slower one we often have symptoms of a general septic disease dependent upon the ptomaines produced by the bacilli. Reasoning by analogy from the facts as established in other infectious diseases, we have good reason to suppose that the general symptoms of influenza, so varied in character, are all dependent upon some as yet unknown poison produced by the growth of microorganisms. sert practically a translation of the notes published by (1) In the purulent bronchial secretion of all cases of influenza a definite bacillus was found. In uncomplicated cases these rods are the only bacteria present and are found in enormous numbers; often found in the protoplasm of pus cells, and may extend into the peribronchial tissue; in two cases found in the purulent secretion of the pleura. (2) These bacilli are found only in influenza, as shown by numerous analyses in cases of bronchitis, pneumonia and phthisis. (3) They disappear as the influenza passes off. (4) Pfeiffer saw the same bacilli in the epidemic of 1889-90, in the sputum in large masses. (5) They are very fine rods, similar to the bacilli of mouse septicemia, but not as long; often arranged in threads. They are difficult to stain; they may be stained by a hot Ziehl solution or a hot Loeffler solution; they are more stained at the ends thau in the central portion, so Pfeiffer thinks they have been seen by other observers who have taken them for cocci. [This describes an organism often called a “Belted organism."] As influenza presented many symptoms suggestive (6) They grow in one and one-half per cent. sugar of an infectious disease on the first wide-spread appear-agar as very fine colonies; they cannot be carried on ance in 1889-90, numerous and careful bacteriological beyond the second generation. examinations were made to isolate if possible some specific germ. Many germs were isolated, but no one germ was found in a sufficient number of cases to warrant the conclusion that it might be considered as the cause of the disease. Such confusion existed that Koch expressed the opinion at the Tenth International Congress, that we must probably look for the etiological factor of the disease among the protozoa rather than among bacteria. In the light of the subsequent studies of Pfeiffer (January, 1892), it is probable that several observers found the germ which is now sug. gested as the possible etiological factor in the causation of influenza. Babes of Bucharest made the most careful experiments which are published at length in the Centralblatt für Bacteriologie for 1890, Vol. 7; he isolated seventeen germs, several of which in their morphological and biological characteristics resemble very closely the germ recently described. As a result of their investigations Weichsellaum, Prior, Strümpell, Prudden and others, all expressed the opinion that acute intercurrent diseases in influenza were to be considered as complications, and not as direct manifestations of influenza per se. Subsequent investigation has only strengthened this opinion. Ribbert alone (Deutsche Medical Wochenschrift, 1890, No. 15) expressed the opinion that the streptococcus pyogenes probably stood in an important etiological relation to influenza; his only reason offered in substantiation was that the streptococcus pyogenes was almost always found in cases of influenza. I should say that this reasoning was about as fallacious as that of the author who observed that cats were invariably found in families where cases of scarlet fever appeared. (7) Positive results on monkeys and rabbits. (What the results are remains a blank.) (8) "From these results I consider myself justified as looking upon these bacilli as the cause of the influenza." (9) Infection in influenza is probably through the medium of the sputum. Kitisato. (Same journal as above.) The colonies are so small and transparent that they may have been overlooked by previous observers. He says he has obtained pure culture of the organism directly from the sputum by a method employed to cultivate the bacilli of tuberculosis from sputum. In the Deutsche Med. Wochenschrift, 1892, No. 2, Pfeiffer published a preliminary report on "The Bacillus of Influenza," based upon work done at the Berlin Institute for Infectious Diseases. He published only his results, and reserves for a subsequent date the publication of the details of his work. I here in The colonies show no tendency to run together, but remain separate, offering a strong point in differential diagnosis. Kitisato has never seen this organism in other cases, though his experience has been large in analyzing the sputum in many cases of bronchitis, tuberculosis and pneumonia. Canon. (Same journal as above.) Canon has found the bacillus in the blood, and, in No. 3 of the Deutsche Med. Wochenschrift, reports that he has cultivated the bacillus from the blood. He employs a special stain: Conc. aqueous meth. blue. 40 20 · 40 The specimens remain in this solution three to six hours at 36° Cent., and are then washed in water. Canon reports that the bacillus may be carried on for several generations if the cultures are renewed every seven days. Babes (Deutsche Med. Wochenschrift, Feb. 11, 1892) draws attention to the fact that in the epidemic of 1889-90 he found in several cases of uncomplicated influenza very fine rods in large numbers: their growth on glycerine agar was poor. Babes considers that these organisms are the same as the organisms described by Pfeiffer. Also, Klein (British Medical Journal of January 23, 1892) reports that in 1889-90 he found in the blood of influenza cases fine bacilli, morphologically and biologically identical with the organisms described by Pfeiffer. We have the following facts which strongly suggest that influenza is an infectious disease: (1) Its appearance in epidemics; the manner in which it spreads from individual to individual. (2) The symptoms suggestive of some toxic influ ence. (3) Reduction of the general system and thereby induced susceptibility to disease. (4) A germ has been discovered which may be the cause of the disease. With all due respect to the exhaustive and exhausting investigations of the scientific observers, I cannot but close my paper with a quotation from Mrs. Thrale's Journal. In allusion to the rage for scientific experimentation in 1811, she writes: "Never was Nature so put to the rack, and never, of course, was she made to tell so many lies." May not this be as true now as it was eighty years ago? over the point of a sound, introduced through the perineal wound. Through this opening above, the stone could readily be reached. It was found to be about the size of an English walnut, and to be contained in a pocket, the neck of which was not larger than a small pencil, and attached to this was a little, roughened bit of bone, projecting into the bladder cavity. The neck of the sac was gradually enlarged so as to admit a pair of forceps, and after many attempts to withdraw the stone, it was finally broken by the forceps and removed piecemeal. It was difficult to remove the last fragments, but with a scoop and irrigation this was apparently accomplished. The bladder cavity now seemed to be free. He had a slight chill the following day, with a temperature up to 102°. From this time on he did pretty well until the 6th of April; but at that time the urine still contained an abundance of pus, and it being necessary to readjust the tubes, an examination was made under ether, and the bladder was searched without anything being found. The opening into the sac had, at this time, contracted so that it could with difficulty be found. The temperature again rose to 102° after this operation, but two days later came back to the normal point. The urine, which had hitherto been abundant, began soon after this to diminish in quantity. A CASE OF SACCULATED BLADDER, WITH It contained a little albumen, but no more than the AUTOPSY. BY A. T. CABOT, A.M., M.D. THE following case of sacculated bladder presented certain points of practical interest. I will first report the clinical part of the case, and then will describe the pathological condition. William H., consulted me first in November, 1889. He was then fifty-seven years of age, and had suffered with symptoms of stone for three or four years. As far as could be determined, this stone originated in the bladder, as he had never suffered from renal colic. In the middle of November I removed, by litholapaxy, a stone weighing 116 grains, and composed of uric acid. and urates. He made a good recovery from this operation. The bladder was washed out with a lithola paxy pump on two subsequent occasions, the first time a small quantity of sand and gravel coming away, and the last time the washing being perfectly clear. He was not seen again until March, 1891. At that time he again applied to me, and reported that, though very much more comfortable after the last operation, he was not entirely relieved of his symptoms, some frequency of passing water and slight pain, referred to the penis, continuing. He had used a catheter during this time every night, drawing each time from two to three ounces of residual urine. had occasionally passed a little gravel. I sounded him without detecting a stone, and advised an ether examination. He This was made on the 18th of March, 1891. The bladder felt roughened to the sound, but no stone could be touched. For further exploration, I made a perineal incision, and the finger, introduced into the bladder, touched a little rough surface of stone rather high up on the posterior wall, where it could be barely reached with the aid of the hand above the pubes, pressing the bladder downward. It was made out that this bit of stone was a projecting portion of a calculus which was enclosed in a pocket, and it being impossible to dislodge it from this pocket by any manipulation of the finger, a suprapubic incision was made This represents the bladder laid open by a cut through its anterior wall and through the roof of the prostatic urethra. The ureters are then laid open by cuts at right angles to the first cut. On each side a diverticulum was cut through by the incision that opened the ureter. a, a represent the two halves of the large diverticulum on the two halves of the other pocket, with a stone still in it. The little left side, from which the stone had been removed; and s, s show the openings into other diverticula may be seen on the posterior bladder wall. The whole specimen is much shrunken by alcohol. The granular, ulcerated condition of the right ureter is indicated. The left ureter is smooth, but also somewhat dilated. At c is seen the pros tatic urethra. From this time on, in spite of all efforts to assist and supplement the action of the kidneys, he gradually failed, with a progressively diminishing amount of urine; and about six weeks after the last examination he died. At the autopsy nothing of especial importance was found, except in the urinary organs. The bladder was much thickened and inflamed, the mucous membrane being highly congested and eroded in places. The wall of the bladder was not much trabeculated. The ureters on both sides were somewhat dilated, and were slit up with the scissors directly through to the bladder. These incisions passed directly through two pockets arranged symmetrically, one associated with each ureter, lying a little above and outside of it. One of these pockets was the one from which the stone had been previously removed. It still contained a little fragment of stone. On the other side the pocket was very much more narrow, opening into the bladder by a very small opening, and this contained in the upper part a little calculus about the size of a kidney bean. This smaller pocket lay rather closer to the ureter with which it was associated, than did the pocket on the other side. A careful search of the posterior walls of the bladder revealed the existence of a number more pockets similar to the last one found, that is, having very small communications with the bladder. A careful search among these failed to show any other containing a stone. The right ureter, which was that one associated with the smaller pocket, which lay closer to it than was the case on the other side, was considerably distended with thick, purulent material, and the pelvis of the kidney on that side was slightly dilated and filled with the same sort of grumous material. This right kidney was somewhat shrunken, in a state of interstitial nephritis, with which was associated a pyelo-nephritis. On the other side the ureter was more nearly normal, though somewhat dilated. That kidney, the left, was in a state of moderate pyelo-nephritis. The condition, then, which led to the fatal result was an interstitial nephritis, with a pyelo-nephritis superadded to it. The pyelitis was no doubt secondary, and was unquestionably aggravated by the obstruction to the ureters due to the pressure upon them of the sacculated stones. The symmetrical disposition of the sacculi, and the thickness of their walls led me to think that there might be some congenital cause for them. I therefore had the walls of these pockets carefully examined under the microscope, and found that the muscular coat of the bladder ran a considerable way up on the pockets and ceased towards the apex, the outermost part of the pockets being simply composed of the mucous membrane surrounded by fibrous tissue. In regard to vesical diverticula, Orth says they are situated preferably on the sides and base of the bladder, and also on the posterior wall. They are either congenital or acquired: In the congenital cases, also in the acquired cases which are brought about by the pressure of stones, we find all the coats of the bladder in their walls, even the muscular layer. On the contrary, in the greater number of the acquired diverticula, the condition is a hernia of the mucous membrane between enlarged bands of muscular tissue. Only when they are small can a part of the muscular coat still be shown in their wall. These hernia of the mucosa are often very numerous in hypertrophied bladders, and may be symmetrically arranged in accordance with the arrangement of the muscular bundles. They are at first quite small and flat, but become more rounded and larger, until they reach the size of a walnut, an egg, or a child's head. The opening between the muscular fibres, at first angular, becomes more rounded with the increase of size, but may be very small, even when the diverticulum is large. In my case the way in which the muscular coat ran part of the way up on the walls of the diverticula, seemed to show that in part, at least, they depended upon a congenital condition for their production. The openings in all of them were round and very small, instead of irregular, as you would expect if the mucous membrane had simply pushed out between the muscular bundles. The muscular tissue surrounding their necks was more abundant and ran much further up on their walls, than would be the case if it simply repres ented the muscular bundles which had been pushed aside as the mucous membrane forced out between them. So that I am inclined to regard this as a case of congenitally diverticulated bladder, in which perhaps the mechanical effects of the pressure of urine had some influence in enlarging the pouches. The fact that there were stones in but two of them, and that in one case the stone was very small, shows that they were not pockets formed by the pressure of stones. This case illustrated very well the importance of making a digital exploration of the bladder in cases of uncertain diagnosis, where persistent symptoms continue, and also showed how much more easily such conditions can be reached and treated by supra-pubic incision than through the perineum. I think there can be but little doubt that it is better practice to crush a stone in situ, when it is so thoroughly encapsulated as in this case, rather than to try to free it by incision. For a considerable incision in the neck of the sac would have exposed the patient to the danger of urine infiltration and perivesical abscess. Finally, the possibility of the symmetrical arrangement of pockets should be borne in mind when operating on these cases, and a knowledge of this point may lead to the discovery of pouches that would otherwise be overlooked. Clinical Department. ACONITE POISONING. BY SAMUEL Q. ROBINSON, Assistant Surgeon, U. S. A., Fort du Chesne, Utah. J. A., private, Company D, Twenty-first Infantry, a prisoner in the post guard-house, recovering from a debauch, at about 4 P. M. on July 3d, took, as nearly as can be ascertained, two drachms of tincture of aconite. I was summoned as soon as the fact was known, and reached him perhaps an hour after the ingestion of the poison, the nature of which was at once determined by the tingling of the tongue produced by a remaining drop. He was recumbent, tossing his limbs about, excited, complaining of numbness and cramps in the arms and hands, but making no mention of any odd sensations about the lips or tongue until after recovery; with radial pulse imperceptible, carotid 119, respirations 19 (normal in character at first, but afterwards becoming shallow), pupils slightly dilated but responsive to light, nose pinched, extremities cold, face bedewed with cold sweat, at times lapsing into unconsciousness. It required but little effort to hold him when I passed the stomach-tube, but the muscles of the jaw seemed to be endowed with unusual power, since the gag could not be rotated wher the teeth were set. The symptom-complex typified approaching dis solution. Between a tenth and a fifth of a grain of apomorphia, hypodermatically, produced vomiting; but, as he could not be made to swallow water enough to ensure the removal of the poison, the stomach was thoroughly washed out with the pump and stiff tube. Before he was thought out of danger, at 8 P. M., there were given, at irregular intervals, as demanded by his varying condition, hypodermatic injections, amounting to, in all, twenty-five minims of tincture of digitalis, forty-five minims of aromatic spirits of ammonia, and two drachms of brandy. Hot-water bottles to the feet, and mustard plasters to the precordia, were also used. Urine was passed in small amount at 10 P. M. on the following day, at which time the patient had completely recovered as far as the aconite was concerned. The case was so urgent that I used the aromatic spirits of ammonia which had been brought by mistake, and did not sufficiently dilute it for subcutaneous use. Some induration, too, followed the injections of brandy which were all made deep in muscular tissue. Medical Progress. RECENT PROGRESS IN THORACIC DISEASE. THE INFLUENCE OF THE DOCTRINE OF CONTAGION THE CITY OF PHILADELPHIA.11 FLICK gives a table of the general mortality and the mortality from consumption for the years 1861-91, inclusive, together with the estimated population of Philadelphia for each year, and says that if we study the mortality-rates from pulmonary tuberculosis, side by side with the number of deaths from the disease and the population for the thirty years as a whole, we shall see that during the entire period there has been no material decrease in the death-rate from this cause until the last few years (that is, since the doctrine of contagion has been more generally accepted) and that the decrease becomes more rapid as we approach the present year, the actual decrease Recently, I was called to a case of impending heart- from 1881 to 1891 amounting to a saving of 784 failure in an alcoholic subject who had suffered from lives a year, reckoning from the present population. influenza in the winter and more recently from He considers this most fortunate reduction can only pneumonia. He had just arrived at the post, 5,000 be explained on the theory of the contagiousness of feet elevation, after a two days' stage-ride, during which time he had scarcely eaten anything. For the relief of some pulmonary symptoms, he had taken in the preceding twenty-four hours six doses of a mixture containing four minims of tincture of aconite root to the dose, and as he had considered that "a small mouthful" was equivalent to the teaspoonful ordered, the amount taken was considerable. The symptoms came on three hours after the ingestion of the last dose. There was numbness of the limbs but no tingling of the tongue or lips. How much the symptoms were due to the aconite and how much to other existing causes of cardiac weakness is conjectural. Atropia first, and when that proved useless, strychnia, both hypodermatically, as nothing could be retained on the stomach, produced in turn slight but characteristic symptoms in ten to fifteen minutes, but only an evanescent improvement. The effects of digitalis, which was next given, were not markedly shown for perhaps thirty minutes, but, when they did appear, resulted in permanent benefit, and a second injection of ten minims again was all that was needed. Twenty hours intervened between the acts of micturition. So far as these two cases warrant the deduction, digitalis is superior to atropia or strychnia as a physiological antidote for aconite, but stimulation with alcohol or ammonia will usually be required to tide over the interval before digitalis acts. I may be permitted to remark that the aconite in both cases was obtained elsewhere than at post. In consequence of the preparations for combating a possible outbreak of cholera in Germany, the prices of disinfecting substances have risen quite materially. Crude carbolic acid has risen 50 per cent., chloride of lime 10 per cent., perchloride of mercury, 50 per cent., and permanganate of potassium about 10 per cent. phthisis. Since this question has been agitated in the Α STUDY OF THE PROCESSES WHICH RESULT IN (1) Out of 763 persons dying of a non-tubercular disease 71, or over 9 per cent., at some time in their life had phthisis, from which they had recovered. (2) The new fibrous tissue by which the advance of the disease was apparently checked, and the cure effected, developed principally by round-cell infiltration of the interlobular connective-tissue, which in some instances had increased to an enormous extent. Some of the new fibrous tissue was formed later by round-cell infiltration in the alveolar walls and around the blood-vessels and bronchi. Pleuritic fibrosis appears to be secondary to tubercular processes in the lung-substance. The interlobular connective-tissue is the primary and principal source of the fibrosis. (3) Tubercle bacilli were present in the healed areas in three out of twelve of the lungs examined. These healed areas did not differ in their gross or microscopical appearances from those in which they were not found. (4) Thirty-six per cent. of all cases where the lungs were free from disease, showed localized or general adhesions of the two surfaces of the pleura. 11 Medical News, May 14, 1892. 12 New York Medical Record, January 9, 1892. THE CONDITIONS OF CURE IN CONSUMPTION.18 new by dry cups can be of very little value. Alcoholic Burney Yeo says that it is generally admitted that pulmonary tuberculosis in certain forms and under certain conditions is commonly and spontaneously cured, and, secondly, that phthisis is rarely cured, meaning by phthisis pulmonary tuberculosis which has reached such a degree of development as to seriously affect the general health and to give rise to easily recognized physical signs. Yet whenever a remedy is announced it is seriously tested in many cases in which cure is inconceivable, and these hopeless cases are brought into the statistics to discredit the remedy. One of the chief conditions for cure is, of course, its early recognition, and for that reason he is disposed to consider the early occurrence of hæmoptysis as favorable, in that it calls attention in an impressive manner to the disease in a stage where it might otherwise be overlooked. At the same time he warns against considering those cases phthisis in which marked physical signs are found at the apex, due to a When cyanosis with pulmonary edema is very dry pleurisy of rheumatic origin. Other conditions marked, oxygen has seemed to give relief to the dyswhich favor cure in the more advanced stage, are the pnoea if cautiously administered. The most satisfacnatural tendency in the evolution of tubercle to fibrous tory results have been obtained by mixing it with change, the absence of tissue irritability - the absence atmospheric air by holding the tube perhaps two inches of that tendency to acute inflammatory reaction to the from the patient's mouth. Quickly acting cathartics bacillary infection, or of marked hereditary predisposi- will aid in giving relief. In the acute general pulmoand the possession of a sound, vigorous constitu-nary edema occurring in connection with pneumonia, tion. Another possible condition is a mitigated viru- the strychnine, atropine and nitro-glycerine have often lence of the bacillary infecting agent and the small been of service. number that originally gain access to the lungs. The channel by which the bacilli reach the lungs has also a modifying influence, the conditions being much more unfavorable when they enter by the blood-vessels or lymphatics than with the inspired air, owing to the lawyer's clerk, twenty years of age. While sitting wide diffusion of the infecting agent. Another condi- quietly at home after dinner the patient felt a sudden tion is the selection of a proper climate; but the most severe pain in the region of the left shoulder-blade, essential of all is the ability to digest and assimilate which rapidly spread downward to the axillary region nourishment, for the therapeutic measure in which the and was followed by so much breathlessness and dismost faith must be placed is hyperalimentation. Intress on the slightest exertion that he was forced to lie treatment by drugs, repeated and continuous counter-in bed, but while there was very comfortable. On that irritation is almost universally esteemed as curative, and in his experience the diligent use of antiseptic in halations has almost invariably been followed by considerable, and in some cases by lasting, benefit. Of antiseptics given internally, none have seemed so uniformly beneficial as creasote or guiacol. He has seen some good results from tuberculin and thinks it will survive in a modified form the temporary opposition tion to it. ACUTE PULMONARY EDEMA.14 a A CASE OF SPONTANEOUS PNEUMO-THORAX AND PNEUMO-PERICARDIUM.15 Lundie records an interesting case which occurred in day he had had to carry a number of heavy books at the office, and had also been swinging by his hands from a door, but had felt no discomfort at the time. Signs of pneumo-thorax were found on examination, the chief peculiarity being a displacement of the heart backwards instead of to the right. In ten days he returned to work, no unequivocal signs of disease being found in the chest after recovery. About two months later, while walking quietly home from his office, he again felt pain in his left side, but the onset was more gradual than on the previous occasion. A tympanitic A. A. Smith says that hydræmia, changes in the area was found which occupied the position of a slightly walls of the blood-vessels, an enfeebled heart and an enlarged pericardium, the heart falling to the most obstruction to the blood flow from any cause are well dependent portion of it in each position of the patient. recognized causes for the occurrence of oedema in any The heart sounds were obscured by irregular tumultupart, but he is convinced that interference with the ous tinkling accompaniments with intense metallic functional activity of the nerve supply to the blood-resonance. Recovery gradually took place and when vessel wall plays an important part in the production seen a year later he was leading an active life, doing of oedema, and is the only satisfactory explanation of his office work regularly and playing cricket each its cause in many cases. Especially is this true of evening. Lundie thus summarizes the most remarkapulmonary edema. In the sudden attacks of this ble points in the history of this case. sort which come on suddenly in the various forms of Bright's disease its occurrence must be attributed to the influence of the uneliminated poisons in the nervous system and especially the ganglionic system. As regards measures of relief the orthodox treatment 13 British Medical Journal, January 16, 1892. (1) The presence of a chronic morbid process in the chest sufficient to lead ultimately to rupture of the pleura and pericardium with an almost entire absence of symptoms. (2) The occurrence of pneumo-thorax in conditions of apparent health. 15 Edinburgh Medical Journal, 1891, vol. xxxvii, p. 220. |