Byrd, to the changes made in the Code of Medical Ethics by the New York State Medical Society; and after a full and free discussion of said changes and detractions, on motion of Dr. P. R. Ford, the President appointed a committee of three, consisting of Drs. A. A. Homer, F. N. Burke, and Peter R. Ford, to draft appropriate resolutions in regard thereto; who, after a short recess, presented the following: Whereas, We, the members of the Philips County Medical Association, have discovered with great mortification, among a portion of the members of the medical profession of New York since 1876, a growing dissatisfaction with the Code of Ethics of the American Medical Association, which culminated in the adoption by the New York State Medical Society, at its meeting in February last, of a code which is in direct conflict with a most important part of the law established by the American Medical Association. Therefore, Resolved, first, That all the infringements and additions to the fundamental law of the American Medical Association are unnecessary and mischievous, and deserve the censure and condemnation of all true men in the medical profession. Second, That the rule adopted by the New York State Medical Society, governing its members in consultation, in which they declare the right to meet in consultation legally qualified practitioners of medicine, irrespective of any further qualification or restriction, is in direct opposition to the code established by the American Medical Association, and in its operations and bearings tending to destroy the line of distinction that has so long existed between the honest, educated physician and the charlatan. Third, That the Code of Ethics is a part of the organic law of the American Medical Association, and is above and beyond State organization, and can only be changed by resolution offered in open session to lay over for twelve months, and then by a vote of threefourths of the members present, and that all the members of the American Medical Association, or members of societies in affiliation therewith, are bound by its obligations, and amenable thereto for all violations, and that in this action of the New York State Medical Society they have offered a gross indignity to the parent association. Fourth, That the Code of Ethics of the American Medical Association, in its provisions and restrictions, is comprehensive and liberal, and we see no necessity for a change; that the action of the New York State Medical Society, in its abrogation of our law, is hasty, ill-timed, and without a precedent, and deserves the condemnation of the American Medical Association in vindication of its own dignity. Fifth, Having passed through a similar ordeal in our own State organization, we can most truly sympathize with the just and loyal men of the profession in New York who raised their hands and voices in protest against this effort to throttle organized medicine. Dr. D. A. Linthicum seconded the resolutions, and they were unanimously adopted, and it was directed that they be forwarded to THE MEDICAL NEWS for publication. WHAT IS SAID of the NEW YORK CODE OF ETHICS. The action of the New York State Medical Association, sanctioning consultation with all legalized practitioners, has aroused a perfect whirlwind of indignation in medical circles throughout this country and Canada. The condemnation on the part of the medical journals is almost unanimous, and the various State and county medical societies express their dissent in no uncertain tones.-Mississippi Valley Medical Monthly. We are satisfied to regard those who associate with | homoeopaths, eclectics, and other irregulars as men of the same stripe, cast in the same mental and moral mould. Birds of a feather flock together and aliens are driven out; just upon the same law of kindred association "a man is known by the company he keeps," and those who are not of his kidney shun his contact, and purge themselves of his offending presAmongst the American journals the Record stands almost alone in its advocacy of the new departure, and we regret to say, judging by its last issue, seems to glory in its shame.-Canadian Journal of Medical Science. ence. RESOLUTIONS of the MEDICAL BOARD OF Bellevue HOSPITAL ON The Death of JAMES R. WOOD, M.D.— At a special meeting of the Medical Board of Bellevue Hospital, called on the occasion of the death of the late Prof. James R. Wood, and held on the 6th of May, 1882, it was resolved: 1. That by the death of our late associate the Board has lost a member whose services for a period of thirtyfive years as an attending surgeon to this hospital, and whose labors as a clinical teacher, have contributed largely to the usefulness of the institution in the relief of suffering and in the diffusion of the practical knowledge of surgery. 2. The memory of our late associate will ever be gratefully cherished as the founder of the pathological museum connected with this hospital, which he enriched by the gifts of his large and valuable private collection, and which deservedly bears his name. 3. The members of this Board feel that by the death of the late Prof. Wood they have individually lost a generous, warm-hearted, and steadfast friend, as well as valued associate; and that his death leaves a void which must remain unfilled, not only in the hospital, and in the relations of friendship, but in the medical profession and in social life. 4. The Medical Board tenders the heartfelt sympathy of all its members to the family and relatives of the late Prof. Wood in the loss which they have sustained, together with the hope that they may derive consolation from his merited professional eminence, his long life of usefulness, his unblemished character, and his private virtues. OFFICIAL LIST OF CHANGES OF STATIONS AND DUTIES OF OFFICERS OF THE MEDICAL DEPARTMENT, U. S. ARMY, FROM MAY 2 TO MAY 8, 1882. KING, WM. S., Colonel and Surgeon.-The extension of his leave of absence, on account of sickness, granted him in S. O. 251, November 7, 1881, from A. G. O., still further extended six months on account of sickness.-S. O. 104, A. G. O., May 5, 1882. WILLIAMS, JOHN W., Major and Surgeon.— Granted leave of absence for six months.-S. O. 101, A. G. O., May 2, 1882. COWDREY, S. G., Captain and Assistant Surgeon.-Now awaiting orders, to report to commanding general, Department of the East, for assignment to duty at Fort Monroe, Va.-S. O. 103, A. G. O., May 4, 1882. HOFF, J. V. R., Captain and Assistant Surgeon.-To be relieved from duty in Department of the East, and report in person to commanding general, Department of California, for assignment to duty. -S. O. 103, c. s., A. G. O. PORTER, JOS. Y., Captain and Assistant Surgeon.-The extension of his leave of absence, granted him in S. Ó. 17, c. s., Military Division of the Atlantic, is further extended twenty days. — S. Ö. 99, A. G. O., April 29, 1882. CARTER, E. C., First Lieutenant and Assistant Surgeon.-To be relieved from duty in Department of California, and report in person duty.-S. O. 103, c. s., A. G. O. to commanding general, Department of Arizona, for assignment to RAYMOND, H. I., First Lieutenant and Assistant Surgeon.— To be relieved from duty in Department of California, and report in person to commanding general, Department of Arizona, for assignment to duty.-S. O. 103, c. s., A. G. O. VOL. XL. A WEEKLY JOURNAL OF MEDICAL SCIENCE. SATURDAY, MAY 20, 1882. ORIGINAL LECTURES. MÜTTER LECTURES. ON THE HISTOLOGY OF INFLAMMATION. Delivered before the College of Physicians of Philadelphia, May 8, 9, and 12, 1882. BY E. O. SHAKESPEARE, M.D. ABSTRACT OF LECTURES VIII.-X. INFLAMMATION IN THE BLOODVESSELS. GENTLEMEN: I next ask your attention to the inner surfaces of the blood vessels. They present structures which are very similar in many important points to the serous surfaces, and their minute anatomy and pathology should very properly occupy a place in these lectures immediately following that of the serous membranes. You are, of course, so familiar with the normal histology of the bloodvessels that I can very well dispense with a detailed description of them. I wish, however, to impress upon you the fact that, in the larger arteries in particular, the tunica intima, so far as its relation to the vasa vasorum is concerned, is a nonvascular membrane. It contains no blood vessels. Indeed, the elastic layer of the tunica intima seems to form, in health, almost, if not quite, always an impenetrable barrier both to blood vessels and to lymphatics. It appears to be a sharp line of division between those structures of the vessel which receive their pabulum from the vasa vasorum, namely, the tunica adventitia and the tunica media on the one hand, and those of the tunica intima, which, on the other hand, are directly supplied from the lumen of the vessel, through the mediation of its juice-canals or lymphatics. The latter pervade the tunica intima as they do other fibrous membranes, and they receive the fluids of the blood, and return their lymph through minute stomata between the endothelia lining the inner surface of the bloodvessel. Others have succeeded in injecting these lymphatics from the lumen of the vessels, and so have Ithus demonstrating a communication with the blood, which, although usually very sluggish, notwithstanding the nearness to the rapidly circulating vital fluid, is nevertheless direct. There are various means of showing the lymphatic radicles of the tunica intima. Perhaps one of the best is the interstitial injection of nitrate of silver, by means of a hypodermic syringe. Figure II reproduces very poorly the appearance of the stellate lymph spaces in the intima of an ox treated in that manner. It also indicates another effect of the silver salt thus applied. I refer to the smaller bundles of fibres seen to constitute the larger bundles which, by crossing in various directions, form lymph spaces of the most varied outline, just as they appear elsewhere. The large bundles of fibrous tissue in the inner coat of these vessels often possess the same characters which have been described in other locations. They may be composed of smaller bundles, which are partially enwrapped with very small flat cells closely applied to their surface, and the stellate lymph spaces, and the flat cells which they contain, have the same relations to the larger bundles and to the smaller ones that were pointed out when speaking of the cornea. But in the intima of the vessels the primary bundles may not always be grouped into larger groups. I should say just here that the minute elastic fibres which are usually No. 20. present in large numbers in the larger arteries, can be proved to be partly covered by small flat cells in a manner identical with that of the primary bundles of fibrillæ. FIG. II. X 400 There is, particularly in the larger vessel, a lamellar condition of the tunica interna, which can be demonstrated in various ways. The lamella which are parallel with the surface of the wall can be separated more or less easily by use of the sharp-pointed forceps. But one of the easiest and best methods of showing the thickened lamellar sheets of fibrous and elastic bundles is that of excising a small square of the whole thickness of a large vessel, and placing it upon the freezing microtome with the inner surface up. This surface of course cannot be mathematically level at all points. Consequently in the act of making frozen sections parallel with the surface, at some places the knife passes through the lamellæ slightly obliquely, and in consequence the edges of the extremely thin lamellæ are often turned back. Figure 12 very fairly represents such a section of the human aorta, where c and d were two lamella whose planes were not quite horizontal at this place, but were slightly oblique to the plane of the knife. The knife passed in the direction from b to d, and turned back the edges of the lamellæ at a, at the same time slightly raising up the lamella d, and exposing to the action of the silver salt, in which the section was subsequently placed, the adjacent surfaces of these two lamellæ. At 6 the action of the silver marked out the boundaries of endothelial cell-plates which at that place existed in a single layer between the two lamella. The aorta from which this section was cut was obtained ten hours after death, and was first treated with solid lunar caustic. At a and at various other points the minute flat cellplates which have been already referred to as partly enwrapping the primary bundles and the small elastic fibres are quite distinct. We have, therefore, in the tunica interna very much the same order of cells present, and much the same relations of cells, lymph spaces, and fibrous bundles as hold in other fibrous tissues. Before leaving the normal histology of the vessels, I would particularly direct your attention to a physiological function which seven years ago I recognized in These views, and the observations upon which they were based, were first expressed in an essay on the "Nature of Reparatory Inflammation in Arteries after Ligature," in January of 1877, for which I obtained the Warren Triennial Prize. They were first printed April, 1879, in a lecture on "Reparatory Inflammation in Arteries after Ligature, Acupressure, and Torsion," delivered in June, 1878, as Lecture VII., in the course of Toner Lectures, at Washington, D. C., and published in the Smithsonian Miscellaneous Collections, No. 321. The same opinions and observations were also recorded in the editorial addenda in the American translation of Cornil and Ranvier's "Pathological Histology," published January, 1880. I am thus explicit, for the reason that in 1881 appeared in New York, under the editorial direction of Dr. Satterthwaithe, a Manual of Normal Histology, of which the chapter on blood vessels came from the hand of Dr. Wendt, of that city. The latter gentleman makes the assertion, in a manner which would lead one to suppose it to be unquestionable, that the endothelia of bloodvessels regularly desquamate, and may give origin to white blood corpuscles; and yet, when upon the next page we read a paragraph printed in small type, it would seem that this statement is only an inference insecurely based upon a supposed analogy of function, perhaps existing between the endothelia of the bloodvessels and the endothelia of the peritoneum. Possibly the authors cited were not aware of my observations, notwithstanding the fact that they had been made known five years ago, and had been more or less widely brought to the notice of the American profession on three different occasions since. At any rate, the author quoted makes no reference to my observations, or to any others directly bearing upon the blood vessels themselves. And yet some of his reviewers award him what credit there may attach to an original positive observation. Now, gentleman, we take up the question of the his tology of inflammation in bloodvessels. In discussing it, time will not allow us to consider all the phenomena which they may present under the stimulus of inflammation. Only a few of the more important changes will be noticed here. The portions of the walls of larger vessels most remote from the source whence comes the pabulum necessary for the life and activity of the elements, are the most external layers of the tunica intima, and the most internal layers of the tunica media. Naturally these parts should of all others be most liable to necrobiosis. It is just here that the ordinary atheromatous degenerations of the arterial tunics are seated, usually first beginning as a small focus of fatty degenerated cells in the outer layers of the intima, which, in some way, has had its naturally scant supply of nutritive fluid much lessened or entirely cut off. This little focus of fatty degenerated cells acts upon the surrounding elements as a foreign body, and excites perhaps a slow destructive inflammation by which the area of the minute focus spreads. The atheromatous softening may gradually wear away the dense barrier of elastic fibres which separates the intima from the media, as well as extend inward toward the lumen of the vessel. In this manner, the tunica media, as well as the dense layers of the tunica intima of arteries, may be eaten away, and the wall of the vessel prepared for the establishment of an aneurism. In this process of destruction, the minute flat cells which cover the small bundles of fibres, and normally exist dormant in the tissues in immense numbers, no less than the common stellate cell or connective tissue corpuscle, work the destruction of the surrounding tissue. Primary arteritis in which the pathological changes are of an active proliferating character are on the contrary seated nearer to the supply of pabulum. A chronic endarteritis affects the investing endothelia, and the layer of stellate cells directly beneath. They can be seen to present changes of growth and multiplication identical in appearance to those which have been already mentioned for the serous surfaces. The fixed cells of the layers affected, both the ordinary stellate cells and the minute flat cells, are active in this process of inflammation, whether it result in softening and destruction of the fibrous ground substance, or in a proliferation and new formation. At the same time that the activity of these various fixed cells is unquestionable, it cannot be denied that lymph corpuscles or white blood corpuscles also play a similar part. FIG. 13. In this chronic proliferating endarteritis it is probable that all the fixed cells (including of course the investing endothelia, which are nothing more than connective tissue corpuscles somewhat modified in shape) play the most active rôle, whilst on the other hand in the acute inflammations the superficial changes may be mainly wrought by the white cells of the blood. of the media; i sections of the intima, which even at One of the effects of inflammation involving the inner surface of the blood vessels is the swelling, proliferation, or desquamation of the endothelia. Figure 13 is borrowed from the illustrations of the Toner Lec-proliferated, in the midst of which lacunæ (v) appear. ture already mentioned. The same cut also appears upon page 58 of the American edition of Cornil and Ranvier's Pathological Histology, It represents a capillary in the mesentery of a frog a few hours inflamed. The endothelial cell b was observed to become detached from its bed in the manner explained in the place cited, and to be borne off in the circulation. I was fortunate enough to make a similar observation on one other occasion (1. c.). In the lecture above referred to, I pointed out the fact that arteries are permanently healed after ligature, acupressure, and torsion, by means of a proliferating endarteritis, and that the new tissue which effects the permanent obliteration of the lumen of the vessel is a granulation tissue which springs from and is formed by a proliferation of the tunica intima, and that the blood clot, which is sometimes formed and sometimes not, is merely a foreign body, which, when present, aids in exciting a slow proliferating endarteritis, but which itself is never organized. Fig. 14 is a sketch of a cross-cut of a small artery in the lung of a dog, the section being one of a large series made under the direction of my friend, Dr. H. Formad, Assistant Demonstrator of Pathology in the University of Pennsylvania, with the object of elucidating the etiology of tumors. In this particular case some chopped periosteum had been injected into the circulation. The animal was killed after 55 days, when numerous minute nodules of bone were found scattered through the lungs. The artery cut was in the neighborhood of one such nodule of bone located near the pleura. FIG. 14. a m Figure 16 shows, as seen under a high power, the constitution of the inflamed and proliferated tunica intima. The drawing was made from the portion marked x. The proliferated intima i is seen to consist of a mass of endothelioid cells, which, when seen in profile, as in the figure, appear spindle-shape. The lacunæ (v) are lined with a single layer of endothelial cells; m represents an outline sketch of the tunica media. FIG. 16. Դ a is the tunica adventitia, and b the tunica media. cand e are granulations of the tunica intima projecting into the lumen of the vessel. d is a complete bridge of similar tissue extending from wall to wall. Here also the same process has been at work which effects the closing of the lumen of an artery after ligation or torsion. In this case we have a proliferating endarteritis established by the presence of an embolus. Whilst studying experimentally the process of reparatory inflammation in arteries, numerous opportunities presented themselves of observing the method by which a vein closed, for it frequently happened that the needle or the forceps or the ligature included with the artery the accompanying vein. These accidental preparations afforded the most convincing evidence that at least in these cases the lumen of the vein was obliterated by precisely the same process, namely, that of a proliferating inflammation of the inner coat of the vessel. Figure 15 represents under a low magnifying power a portion of a longitudinal section of a jugular vein of a goat, which, some days before the animal was killed, had been ligated. Two ligatures were applied a little distance apart. The figure represents at c the lower ligature; a are sections of the adventitia; m sections m I am indebted for the use of the section from which tion, read a most interesting and instructive paper I have made use of the section and the drawings, which I myself sketched, in order to show one more example of a proliferating inflammation of the tunica intima bringing about the closure of a vein after the application of a ligature. GENTLEMEN: At length we have reached the last lecture of this course. I shall occupy the hour by a general review of the salient points presented during the course of the nine preceding lectures. You will remember that in the lectures on the cornea I described the ordinary fibrous bundle known to authors as composed of small intermediate or primary bundles of ultimate fibrillæ; and stated that each of these primary bundles possesses an average diameter about equal to that of the red blood-corpuscle, and is partially invested by minute, thin, flat, or spindle-form cells, closely applied to its surface, in this particular confirming the statements of Thin. The fibrous ground substance is actually teeming with myriads of these minute cell-plates, which ordinarily are no more visible than the cells which constitute the shaft of a hair or the corneous part of a finger-nail, but require special treatment for their demonstration in healthy adult tissue. The so-called corneal corpuscle is a complete analogue of the flat-tendon cell-plate of Ranvier, or the branched connective tissue corpuscle of the ordinary fibrous tissues. It is applied to the surface of the ordinary large fibrous bundles of authors, and usually in part lines one side of a lymph space formed by the crossing or apposition of these bundles. These larger bundles are frequently grouped into broad thin bands or ribbons which correspond to the groups of bundles in tendons, and which like the latter have a complete investment of flat endothelial cellplates. It is these broad bands of fibrous bundles which constitute the lamellæ of the cornea. Between some of the lamellæ exist more or less complete sheets of endothelial cells. In the normal cornea, beside the two classes of cellular elements known to exist therein, namely, the lymph or wandering cell, and the branched corneal corpuscle or common fixed cell, there are, then, sheets of ordinary endothelial cells and millions of minute flat cells enwrapping the primary bundles. the lymph vesicle of Klein. And I endeavored to show that the so-called cartilage cell presented the form and characteristics of the flat endothelioid cell-plate which in one place constitutes the branched connective tissue corpuscle; in another place the flat cell-plate of Ranvier; in still another the fat vesicle, and in yet another the lymph vesicle of Klein. And I indicated the method of successive formations of capsules and of so-called daughter cells. I attempted to trace out an arrangement of the fibrous ground substance or intercellular matrix, very similar to that of the cornea, and stated that there were strong evidences of the existence here also of the minute flat cells, partly embracing the surface of primary bundles. More sweepingly than in the cornea, but even with much more confidence, I claimed for the fixed cells of the cartilages the sole agency, up to a certain point in the process of inflammation-admitting the possibility of interference by the emigrant cells of the blood only after great changes had already been wrought. When discussing the serous membranes, I spoke of certain physiological functions of lymph and blood formation, which the fixed cells of certain portions of the peritoneum seemed to possess, and alluded to the fact that in these structures we often have areas of greater or less extent which may be regarded as nonvascular. In considering inflammation of these surfaces, I pointed out evidences of the active agency of all the fixed cells in the inflammatory process. It is unnecessary for me to refer again to what I have so recently said concerning the bloodvessels. In the course pursued in these lectures, I have purposely avoided as much as possible the examination of inflammation in tissues where the influence of the bloodvessels may be said to be dominant. In the first place, I wished to escape, as much as possible, the confusion which the presence of emigrant white blood corpuscles throws over the changes which are passing in the tissues affected by the process of inflammation; in the second place, I did not see the utility of again going over ground which has been so admirably studied by Cohnheim and some others. I do not question the fact, indisputably demonstrated again and again, of emigration of the white elements of the blood in inflammations whose influence reaches the walls of the bloodvessels. I have often observed the phenomena of emigration myself. The chief issue I join with Cohnheim and others of that school is, that the fixed cells of the connective tissues, under the stimulus of an irritant, return to the condition of embryonal cells, and give birth to embryonal cells, contributing to the mass of embryonal elements by which tissues are destroyed in the process of inflammation, and by which also tissues are regen Under the stimulus of irritation the endothelial cell plates, and the myriads of little dormant cells resting upon the surface of the small primary bundles of fibres are awakened to their primitive activities no less than the long known corneal corpuscle, all tend to return to their embryonal state, and when thoroughly rejuven-erated when the damage of injuries is repaired. ated seem to be rehabilitated with their original powers, both of destruction and of repair. Often in slight injuries to the cornea the inflammatory process commences and proceeds to the complete repair of the damage done, without the intervention of the emigrant cells from the blood at the limb of the cornea, the various fixed cells and their offsprings being entirely capable, in such cases at least, of performing the work of reconstruction. You will recollect also that I claimed for the so-called homogenous, structureless, intercellular matrix of hyaline cartilage a positive fibrous constitution, in this agreeing.at some points with a few histologists who have recently examined these tissues. Furthermore, your attention was called to the analogies which exist between the so-called cartilage cell and the connective tissue corpuscle in other locations, particularly to the metamorphoses of the fat vesicle in the connective tissues, to those of the cartilage cell, and to those of It is, as I believe, the most unwarrantable exercise of dogmatism to assert that the fixed cells can give rise only to cells endowed with iconoclastic powers, whilst it is the emigrant cells of the blood or their direct progeny which solely possess the power of reconstruction. There are no facts which, when crucially examined, can give support to such a belief, for it is a mere hypothesis. In closing, I thank you, gentlemen, for your attendance and attention. My acknowledgments are also due, and are thus publicly and heartily rendered to my friend, Dr. J. H. C. Simes, who has kindly assisted me in some of the preparations which I have exhibited under the microscopes; to my friends, Carl Seiler, M.D., Henry Formad, M.D., and George Piersol, M.D., who have kindly extended me various facilities for the illustration of these lectures. |