Part 1

THE HOSPITAL BULLETIN

Published Monthly in the Interest of the Medical Department of the University of Maryland

PRICE $1.00 PER YEAR

Contributions invited from the Alumni of the University. Business Address, Baltimore, Md.

Entered at the Baltimore Post office as Second Class Matter.

VOL. V BALTIMORE, MD., MAY 15, 1909 NO. 3

THREE ESOPHAGEAL CASES.

BY RICHARD H. JOHNSTON. M. D.,

_Lecturer on Laryngology in the University of Maryland, Surgeon to the Presbyterian Hospital, Baltimore._

The esophagoscope has passed the experimental stage in the diagnosis and treatment of esophageal lesions. Its usefulness has been demonstrated so often that it would seem superfluous to dilate upon its value. Its use, however, is not as general as it should be. There are still those who consider esophagoscopy unnecessary or impracticable. At the Presbyterian Hospital we have had numerous instances of its practicability, and with us it has become the routine practice to examine all patients complaining of obscure esophageal symptoms. Dr. Chevalier Jackson records the case of a patient whose only symptom was a lump on swallowing. She appeared to be a neurasthenic, and his advice to have the esophagus examined was ignored by the family physician. Two months later, with the patient etherized for a radical antrum operation, he passed the esophagoscope and found a malignant growth.

Three interesting cases have recently come under my observation, and they illustrate so well the value of the esophagoscope I shall report them somewhat in detail. The first patient was seen with Dr. E. B. Freeman; she was 67 years old. The morning before she came to the hospital, while eating ham, she swallowed a large piece that had not been sufficiently masticated. It lodged in the introitus esophagi and remained there. When she came to the hospital she had swallowed neither solid nor liquid food for nearly thirty-six hours. A half hour before examining the esophagus she was given a hypodermic of morphia and atropia. With the patient in the sitting position the throat and upper end of the esophagus were anesthetized with 10 per cent solution of cocaine. Jackson's laryngeal speculum was introduced and the larynx pulled forward. A large mass resembling somewhat an ulcerative epithelioma was seen, and proved to be the piece of ham. Dr. Freeman and I removed it piecemeal with Pfau's foreign body forceps. It required about forty-five minutes to remove it entirely. The patient stood the ordeal well, and was able to go home the same afternoon. For about a week she had temperature, cough and expectoration, but ultimately made a good recovery. In this case the esophagoscope probably saved the patient an esophagotomy. The second patient was a female, thirty-three years old, referred to me by Dr. J. F. Chisolm, of Savannah. While at an oyster supper she attempted to swallow a large oyster, with the result that she choked for a few seconds and then had a sense of fulness in the region of the larynx. The next day she had some difficulty in swallowing, so that she took only liquids. The second day afterward swallowing was decidedly painful; she grew rapidly worse, until the fourth day her condition was serious. She reached this city the morning of the fifth day, with a temperature of 100 degrees and extreme prostration. The examination of the esophagus was made under ether with the head in the extended position. No foreign body was found, but the upper end of the esophagus was red, swollen and edematous, and seemed to be closed. The patient was given cold milk and ice bags to the throat. For two days she suffered excruciating pain on swallowing, and it looked as if we would have to resort to rectal feeding. The next day there was slight amelioration of the pain, which gradually disappeared. In this case the esophagoscope enabled us to see at once that a foreign body was not present, and that the symptoms were due to a severe, acute inflammation, probably caused by a piece of shell attached to the oyster.

I was asked by Dr. A. M. Shipley to examine a patient who had been referred to him for probable cancer of the stomach. The man was sixty years old and had had some trouble in swallowing for about two months. Attempts to pass the stomach tube were unsuccessful. The patient was examined in the sitting position after cocaine anesthetization. No difficulty was experienced in passing the esophagoscope. About three inches below the cricoid cartilage the progress of the instrument was arrested by a tumor partially closing the esophageal lumen. The esophagoscope showed that the tumor was too low for removal. In this case the patient can be dilated through the esophagoscope and made more comfortable for the short time he has to live.

919 North Charles street.

SYPHILITIC OSTEO-PERIOSTITIS.

BY C. G. MOORE, '09.

_Senior Medical Student._

The bony manifestations of syphilis occur as secondary and tertiary lesions, and as Keyes, of New York, has pointed out, these so-called “nodes” are simply local periosteal congestions, accompanied by serious effusions without cell hyperplesia. Any bone in the body may be affected by syphilis, but certain of them suffer by preference, such as the thin bones of the nose and pharynx—that is, those exposed to climatic changes and injuries, such as the bones of the skull, ulna, tibia, etc.

We must call special attention to injury as a powerful pre-disposing cause of bone syphilis, for, when we consider that bone lesions may be the only manifestations of existing syphilis, with the presence of a bone lesion before us, with an antecedent history of an injury, we must not forget that we may overlook the true nature of the disease, and hence must be constantly on the alert for the syphilitic taint.

Lancereaux classified the bone lesions under three heads, viz.:

(a) Inflammatory osteo-periostitis.

(b) Gummy tumor of bone.

(c) Dry caries, atrophic form.

(1) Inflammatory osteo-periostitis is the most frequent form, and is characterized by inflammatory phenomena, vascularization and exudation of a serio-glutinous material. It may be either diffuse or circumscribed, and located, as its name implies, in the area of contact with the osseous and periosteal surfaces. The pain is aching, acute, throbbing or boring in character, while tenderness upon pressure and percussion is most exquisitely excruciating. The diagnosis of inflammatory osteo-periostitis is comparatively easy, if we remember the characteristics, viz., an oval, painful, boggy or even hard bony lesion, accompanied by nocturnal exacerbations of pain, with a concomitant or antecedent history of syphilis. Ostitis with parenchymatous thickening is somewhat less positive in its character, but with nocturnal pains which are usually constant.

(2) Gummy tumor of bone develops either under the periostum, in the substance of bone, or in the medullary canal. It is simply an intensification of the process found in the inflammatory form just described, the difference being that the cell hyperplasia is more abundant. Much of the new material collects in a circumscribed space, and being more rapidly formed and less capable of organization, it entails more profound lesions by its retrograde metamorphosis. Generally tumor of the bone is, therefore, a much more serious form of disease than osteo-periostitis.

In the long bones the medullary canal is the usual seat of deposit. The bone becomes hypertrophied in a porous manner, the Haversian canals and canaliculi become enlarged and filled with a gummy material which resembles a solution of gum arabic. In the flat bones, especially the cranial bones, the cancellar tissue is attacked, and may cause a separation of the two tables, and often necrosis of one or the other plates results. If it happens to be the inner one which undergoes carious degeneration, brain symptoms will develop.

(3) Dry Caries.—According to Virchow, dry caries is always due to syphilis. This affection is a miniature gummy ostitis. Around one of the vascular canals the gummy material is deposited, this gummy material being later absorbed, leaving a stellate induration. This goes on leaving a funnel-shaped depression, its point leading into the diploe, which may be plainly appreciated by palpation. The essential features of this caries is the fact that no sequestra are formed, no pus extruded, nor is the skin but rarely involved.

The following is a case of syphilis in which osteo-periostitis developed:

On January 22nd, 1909, R. B., age 35, white, a housewife, applied to the Medical Department of the University Hospital Dispensary for treatment, complaining of rheumatism in her back and a sore shin. The patient has been married 14 years and has had four children; the two eldest are the only ones now living. Three years ago she gave birth to a full-term child which only lived a few minutes after expulsion.

One year later she gave birth to another child, which was not at full term, but about six months advanced. She says two days previous to this birth she fell down stairs and struck on her abdomen. When the child was born its thigh was fractured, and the physician who attended her said the fracture was caused by the fall.

Her father died nine years ago, at the age of 68 years, of apoplexy; her mother was killed a few years ago in an accident. She has two brothers and three sisters, all living and in good health, as far as she knows. She is at present living with her husband, and says he is apparently well and sound, but drinks heavily, and when under the influence of liquor abuses her a great deal. Patient denies ever having had tuberculosis, syphilis, diphtheria, typhoid, scarlet fever, malaria, grippe, gonorrhoea, or any of the nervous or malignant diseases. She sometimes has a sore throat when she takes cold, but it only lasts a few days. She has complained of rheumatism in her back and limbs for the past three or four years, and thinks it is worse at night.

Patient never complained of any trouble other than those mentioned until three years ago, when her third child was born. She says that at that time her hair fell out, and an eruption, which itched slightly, broke out all over her body, including her face, but only extended down her arms as far as her wrists. This lasted a few weeks, then seemed to subside, but never entirely disappeared, and when she gave birth to the still-born child, one year later, it broke out again worse than before. She went to Dr. McElfresh, who treated her for about three weeks, giving her some medicine to take internally, also some sulphur ointment. She for a time got some better, but owing to her circumstances was unable to continue treatment with Dr. McElfresh, and has done nothing for her condition until the present time. For the past four months she has been suffering with a pain in her right shin; this has been gradually getting worse, and one week ago began to swell and cause her considerable pain, being worse at night, and sometimes hurting her so much that she is unable to sleep, hence her reason for coming to the dispensary.

Upon questioning her in regard to her general health, she says she feels as well as she ever did, with the exception of the previously mentioned pain.

Her appetite and digestion are good, and her bowels are regular, and she has no lung, heart or kidney trouble. She has had no headaches, nausea, or vomiting, and her menstrual periods have always been regular and painless.

Upon examining patient I found her to be well nourished and well developed, weighing 142 pounds. Her color was good and her pupils about normal in size, reacting to light and accommodation. Both patella reflexes were absent, also Romberg's sign, and there was no enlargement of the mastoid, epitrochlear, post-cervical or inguinal glands. Her pulse was 84 to the minute, regular in rate and force. The tension and volume was good; her temperature was 98.6°. Her heart was normal in size, and on auscultation the sounds were clear and no murmurs were heard. The expansion of both lungs was good, the respirations being 20 to the minute.

Percussion and auscultation were negative; all the abdominal organs seemed to be normal. There was an ecchymotic area under her left eye, which she says was caused by her husband striking her two years ago when intoxicated.

There was a circular reddish macular papular, non-itching eruption which does not disappear on pressure, varying from the size of a bird shot to that of a nickel, and is confined to her back, chest, shoulders and arms, most profuse on the left side, and is not seen on the lower limbs at all. On her left shoulder some of these lesions have developed into pustules, which have become infected and slightly ulcerated; these give her slight pain.

In the corner of her mouth is a scar which looks like the initial sign of lues, but she claims it appeared a few weeks after the breaking out on her body. On examining her mouth no mucus patches or scars were found.

She now has an osteo-periostitis on the anterior aspect of her right tibia. It is moderately swollen, slightly reddened, and is very painful (the pain is aching, acute and boring in character) on pressure, and on tapping the bone with my finger above and below this point it caused her intense pain. (Patient claims she has never received any injury in this location.)

Upon consulting Dr. McElfresh, he remembered the case and said that he had treated her for a short time about two years ago for the initial symptoms of syphilis, but since then has never seen her.

She is now receiving the mixed treatment of protiodid of mercury, gr. ¼, with a saturated solution of potassium iodid three times a day, starting her on ten drops, then increasing it one drop each time taken. I requested her to return when the medicine is finished.

DISCUSSION BY DR. WARNER HOLT, OF WASHINGTON, OF THE PAPER ON THE CHEMICAL CO-RELATION BETWEEN THE SALIVARY GLANDS AND THE STOMACH, BY JOHN C. HEMMETER, OF BALTIMORE.

_Read Before the Society for Experimental Biology and Medicine, of New York, Meeting in the Rockefeller Institute for Medical Research, on December 16, 1908._

Dr. Holt said in part: “This experimental study by Dr. Hemmeter is not, as it might appear to be, only an inquiry into the physiology of a limited part of the digestive apparatus, but it is an attempt to solve a biologic problem and to get at the broad basic principles that underlie the chemical co-relation of the organs.

“When a worker occupies himself with the effect of the extirpation of one organ of digestion upon the organs in the next segment of the digestive apparatus, he naturally thinks of phenomena of exclusion or loss of function in one or the other of the segments following the one extirpated, but instead of phenomena of exclusion it is conceivable that those of exaggerated activity in the other segments of the digestive tube might result.

“For '_a priori_' we cannot know whether the influence that one segment of the digestive tract exerts upon the succeeding segment is that of stimulation or of inhibition, or of both, viz., of stimulation under one set of conditions and inhibition under another set of conditions. In the investigation of the problem of a chemical co-relation between the salivary glands and the stomach, Dr. Hemmeter has done meritorious work, a great part of which it has been my good fortune to observe and assist in personally; though I am a physician in the employment of the government at Washington, I consider myself a post-graduate student of Professor Hemmeter. I have seen personally four of his animals that had successfully been nursed through the Pawlow operation and extirpation of the salivary glands after months of the most trying work. It required a great deal of perseverance to persist in this kind of work, especially when some of the best animals that had emerged safely from the vicissitudes of the operation for an accessory stomach and from the removal of all the salivary glands on one side of the head succumbed to the third operation in the attempt to remove the remaining salivary glands on the other side.

“The history of these operative failures, though they will never be told, constitute a large part of the merit of those who have worked with Dr. Hemmeter in this research. No matter what the final outcome of the future investigation of this problem will be, whether affirmative or negative, the intrinsic value of such work will be appreciated by all who are to the least degree conversant with the history of physiology. Nowadays we are too liable to forget the hard plodders in experimental work who have started the solution of a problem, and when the last word has been said the worker of the beginning is generally forgotten.

“In this connection I desire to quote an expression of Prof. William H. Welch concerning the merit of the work of ex-Surgeon General Sternberg, done since the first Yellow Fever Commission was appointed, in 1879 (see Medical News. June 21, 1902. p. 1198). Dr. Welch said 'that Sternberg's work with yellow fever would stand forever; that it was a common thing in these busy days to forget the steps which led up to an important discovery. All that Dr. Sternberg had done in the study of yellow fever was necessary work, and it had to be done just in the way that he did it. The ground had first to be cleared. If it were not so, the discovery had not been possible; and later discoverers themselves would have had to hunt out the large host of microorganisms which Dr. Sternberg had described and laid aside.'

“And similarly I can say of Dr. Hemmeter's efforts that, no matter what the eventual outcome of this problem will be, all that he has done was necessary work, and it had to be done just in the way that he did it.

“Just one more idea and I shall have finished. It concerns the demonstration of such research work in places at a distance from the experimentor's laboratory. Such demonstrations are always attended with great difficulty. They usually require four animals, two or three janitors to transport them, and as many laboratory assistants as the director of the laboratory can manage to take with him. The technique of these operations, the high-grade sensitiveness of operated animals, the refinement with which chemical tests should be made, all require for their safe conduct that the experimentor should work only with those men who are used to his system. The animals themselves are always influenced in one way or other by the presence of strangers. I remember in one animal which was demonstrated on March 17th, at the University Hospital, the demonstration at which Dr. Satterthwaite was present, a most unexpected change in the quality of the gastric secretions took place. This was a control animal which had undergone no operation whatever. He was simply taken along to show the proteolytic power of a normal dog and compare it with the operated dogs. His gastric juice had been previously tested on several occasions, and always found to be of regular standard, but on the night of the demonstration before the Medical Society this animal's gastric juice was practically inactive, containing no HCL nor pepsin.

“Dr. Hemmeter has already informed you that in some animals the loss of gastric juice after extirpation of the salivary glands is only temporary, and that in varying time—in some cases three weeks, in other animals three to four months—there is a gradual resumption of gastric secretion. This resumed secretion, however, never becomes as effective as it was in the same dog before an operation. The question when to begin to make observations on an operated animal depends entirely upon the state of this animal; if the dog eats his food with appetite, he has no fever, and his digestion appears to be satisfactory; then the observations may be begun, even if it is only one week or ten days after the last operation. One of the most valuable animals that was used in this series of experiments was so injured in the effort to transport him to another laboratory that he could not be used for further experimentation. The dog struggled so in his holder while he was being transported in a wagon that the partition of true mucosa which separates the accessory from the plain stomach was broken through. This had happened once before in transporting a dog from the laboratory to Dr. Hemmeter's country place, and his associates in the Medical Faculty, becoming aware of the great labor and cost involved in such operations, and the rarity with which they succeed, advised that no further Pawlow dogs be sent to other laboratories.”

AN INTERESTING CASE OF SCROTAL HERNIA.

BY G. E. BENNETT, '09.

_Senior Medical Student._

_Patient_—George Kolubaher.

_Age_—Sixty-six years.

_Occupation_—At present a farmer; formerly worked as laborer in stone quarry.

_Complaint_—Patient entered the hospital on January 21, 1909, complaining of great pain and discomfort in the right inguinal region and in the scrotum of the same side.

_Physical Examination_—Inspection showed an enormously enlarged scrotum, more marked on the right side, and a prominent swelling along the right inguinal canal, which was most marked when standing. Marked discoloration on the skin of the scrotum and inner side of both thighs, probably due to use of counter-irritants.

_Palpation_—Mass soft and freely movable, showing no skin attachments; slight impulse on coughing. Slightly painful on pressure. Some gurgling when manipulated.

_Percussion_—Slightly tympanitic.

_Remarks_—Contents of the sacs were forced into abdominal cavity after prolonged manipulation, returning to original condition as soon as pressure was taken away.

History of patient shows nothing of interest except that of the present condition, which began suddenly twenty years ago. While lifting a heavy block of stone had a feeling as though something had “given away” in his right side. This sensation was immediately followed by one of intense pain and general discomfort. The day following the patient noticed a small lump in the right inguinal region that disappeared on pressure, returning when he lifted any heavy object.

For eighteen years the condition gave him no serious discomfort except for the wearing of a truss and becoming larger. Two years ago the truss was discarded as being useless.

One week ago conditions grew suddenly worse, and patient was confined to bed. Has suffered a great deal of pain and has been unable to sleep.

On January 22, 1909, patient was operated upon by Professor Winslow. Operation as follows:

Patient was brought to the operating room at 11.30 A. M., anesthetized and prepared for an aseptic operation.

Incision about five inches in length was made parallel to Poupart's ligament and immediately over the inguinal canal, passing through the skin and subcutaneous fat. The external ring having been exposed a grooved director was passed into same, passing under the aponeurosis of the external oblique muscle; fibers of same were split, using the director as a protective guide. The sac was exposed and carefully dissected free from its surrounding tissues, and upon examination was found to be continuous with the covering of the testacle (giving the appearance of a congenital hernia). The sac was next opened and found to contain small intestines and a Meckel's diverticulum. Following this the intestines were replaced in the abdominal cavity. Digital examination through the internal ring showed the bladder to be adherent to the peritoneum at the margin and toward the median line. The sac was tied close to the internal ring, cut free. The distal portions of the sac were drawn upward, bringing the testacle into view; sac was cut close to same and sutured so as to enclose the greater part of it.