1913 Journal of the American Medical Association  
one in which the cerebrospinal fluid was sterile through¬ out the course of the disease. He remarks (January, L911) : "We are accustomed to place so much reliance on lumbar puncture that the possibility of the existence nf acute meningitis with a normal fluid is rather difficult in grasp." In casting about for an explanation of the failure of the cerebros] lina I fluid to show the characteristic changes, it would not be necessary to assume a shutting off of. the spinal canal. The thick and
more » ... The thick and tenacious char¬ acter of the pseudomembrane covering the brain with almost no liquefaction of this exúdate is sufficient to ex¬ plain the reason for the failure of the cerebrospinal fluid to reveal the actual condition. From what has been said above, the following conclu¬ sions seem justified: 1. The positive diagnosis of pneumococcus menin¬ gitis may be impossible during life. '.'. A normal cerebrospinal fluid may be obtained throughout the disease. ,"i. Anatomic changes (encephalitis, meningitis) occur offener than usually believed and are the explanation of symptoms from the side of the nervous system which we have regarded in the past a-functional (ineningisnius). The use of this tissue for grafting to denuded areas finds its justification in that it is essentially an embryonic offshoot of the skin and is histologically built up of dermal elements. It is more logical for this purpose than tissues of other animals, being "human" and, as just stated, of skin derivation and hence homologous. It also seems better than freshly cut skin-grafts, eliminating the use of the razor and anesthetic as well as the entailed secondary wound with its numerous inconveniences. Besides these advantages, should this method be found as useful to others as I have found it, there is a negative advantage of inestimable value in that there is no harm done should there be no "take." Dr. Nicholas Sabella, who cooperated with me in my early efforts to perfect this plan of treatment has been using the amniotic covering of the umbilical cord and that portion of the amnion immediately adjacent to its fetal attachment where it is found to present "amniotic caruncles" which comprise islands of stratified epithelia closely resembling true skin. His results have also been gratifying in the extreme. The histology, in brief, is that of a smooth, glistening membrane made up of two layers loosely connected and freely movable between the thumb and index-linger. Tim outer layer, of chorionic origin, is mucofibrous, and the inner, of true amniotic origin, is made up of a single layer of cuboidal epithelia. It is this side of the sac with which we are most concerned, as it is the one which will adhere to the denuded surface, being simply an extension of embryonic skin. The technic of preserving and fixing the grafts was suggested to me by Dr. Alexis Carrel, who also described his method in a recent paper.3 In this paper he deals with the preservation in latent life of various tissues, including skin-grafts removed from an infant which had died (luring labor, and describes his experiments with various mediums such as isotonic sodium chloral solution, Locke's and lunger's solutions, delibrinated blood, serum, confined human air and petrolatum. The last and lunger's solution were chiefly employed, ami in these mediums the tissues were phu-ed immediately aller their removal from the organism and maintained al a temperature between -1. and -|-7 C. (between 30.2 and I l.ii !•'.). The color and consistency remained normal for several weeks and even after from seven to ten months the microscopic appearance of the arteries was not markedly modified. In my experiments I have adhered to the above technic lui t have em ployed pel rolaltim and also liquid pet rola 1 um for jais from which paris of an entire aninintic sac were being cut from day to day for cases as they presented, 'thus avoiding the necessity of reheating the jars after each session, which would have been necessary were I using the thicker medium. Individual lubes of petrola¬ tum containing small specimens are, however, belter for slock purposes keeping much longer, as they are exposed to the air for the first time except before their immersion-just when needed. Another imporlanl aid from the same source was the recommendation of a wax dressing-mixture of paraffin, beeswax and castor oil-to bold the graft in close appo¬ sition to the granulátory surface ami cause it lo con¬ form accurately to the minute inequalities thereof. The freshly obtained amniotic sac is washed of all blood in a normal saline solution, dried between layers of sterile gauze and immediately immersed in petrolatum which has been raised to the melting point over a waterbath. Liquid petrolatum will serve well when a spéci¬ men is to be cut, many limes and used up within a lew weeks. The receptacles are stored on or near ice as soon ¡is possible. When the denuded surface has been thoroughly cleansed of all secretion and bits of 1 issue, a seel ion of the graft is spread smoothly, care being taken to press nut all air-bubbles. Care should also be exercised that the amniotic or glistening side he placed in apposition to tin.' wound. The wax. having been warmed to just the degree necessary to liquefy, is now applied with wooden appli¬ cators wound with cotton so that a whisk of nearly an inch in length may be saturated and then drawn across the graft without disturbing its position. A fresh applicator is used for each dip lo prevent contain ilia j ing what remains, and also because Ihe wax hardens imme¬ diately mi exposure, and the collón would soon become covered with hard wax and no longer be a soft brush. An (inter dressing of cotton and bandage is all that is necessary for protection and absorption. Alter two days when the dressing is removed it is found that what seems lo be the entire graft is adherent to the wax. This, however, is not what happens. On microscopic examination of this adherent, tissue it is found that only the outer or chorionic layer has come away. The two layers have Beparated and the inner or 1. Carrel, Alexis: The Preservation of Tissues and Its Applications [ill]n Surgery, The ournalL A. M. A., Aug. 17, 1912, p. 523.
doi:10.1001/jama.1913.04340130021008 fatcat:d3xoqo4wczdlvmbgpdzywsab6e