SYPHILIS OF THE THORACIC ORGANS. 
Henry Alfred Robbins, M. D.} 
Washington, D. C. 
CLINICAL LECTURE DELIVERED AT THE SOUTH WASHINGTON (D. C.) FREE DISPENSARY ON MARCH 9, 1897. 
TWELFTH PAPER. 
Reprinted from the Maryland Medical Journal, November 6, 1897. 
This colored child, aged eleven years, 
makes the sixth that I have shown you 
in the last three months, who is suffer- 
ing from acquired syphilis. On exam- 
ination you notice, on the left labia ma- 
jora, an indurated papular chancre. 
The parts are not swollen, and no marks 
of any violence exist. There is no pre- 
cocious development, and you notice 
that the mons veneris is devoid of hair. 
There is a well marked bubo in the left 
groin, and well marked macular erup- 
tion over the abdomen. You will find 
on examination induration of the sub- 
maxillary, post-cervical, sub-lingual, 
post-auricular and epitrochlear glands. 
She has opaline mucous patches in her 
mouth, and she has alopecia, and she 
complains of nocturnal headache, and 
pains in her joints. 
Before dismissing the patient, Dr. 
Arwine will take her aside, and perhaps, 
with his customary tact, can obtain a 
history of how the child acquired the 
disease. He has returned alone, and 
says that this child, who is only eleven 
years old, has for the past two years 
allowed boys of all ages to attempt the 
sexual act with her. Some, she said, 
were sixteen and twenty years old, and 
these disgusting scenes occurred two or 
three times a week. It is not my pur- 
pose at the present time to dilate on the 
frightful lack of morality that exists 
among certain classes at the National 
Capital. 
The best informed know that our pa- 
tients are the poorest of the poor, lack- 
ing in food and raiment, and fuel to 
keep them warm. Still they will strug- 
gle to pay five or ten cents for medicines, 
showing that it is a base libel on the 
really deserving poor, to state that they 
are not anxious to pay. We weep over 
the sufferings of the poor in our com- 
fortable pews in a fashionable place of 
worship, as it exists in foreign capi- 
tals ; while under the shadow of the 
dome of our own capitol, there exists 
more want and disease and immorality 
than Eugene Sue described in his “Mys- 
teries and Miseries of Paris.’’ 
Before resuming the subject of syphi- 
lis of the internal organs, I can not 
refrain from quoting the following, 
which I have just read in the Medical 
Record of February 27, 1897: “ A good 
story is told of a rich manufacturer of 
foot wear and a poor (i. e., in the sense 
of not being rich) physician of a well- 
known European city. Mr. X. had a 
maxillary tumor, which, according to 
the Journal de Medecine de Bruxelles, 
a surgeon had agreed to remove for the sum of 14,000 francs. All was in readi- 
ness, when an intimate friend urged 
him to defer the operation until he 
could consult the young man who was 
fast gaining a reputation. Mr. X. con- 
sented. An antisyphilitic course of en- 
ergetic frictions and large doses of the 
iodides was entered upon, with such 
success that in a very short time the 
tumor had disappeared. In the mean- 
time the young physician, thinking to 
patronize those who came to him, or- 
dered at the establishment a handsome 
pair of shoes. On the first of the year 
the physician sent in his bill for 30 
francs for the six office visits paid him. 
By return mail his bill came back, en- 
closed with one for 50 francs for the 
shoes. The question is, whether the 
patient would not have made the sur- 
geon a present of the shoes if he had 
been cut 14,000 francs’ worth.” 
sisted that syphilitic subjects died, pre- 
senting ‘‘phthisical appearances, with 
ulceration of the lungs, situated most 
frequently in the middle lobe, but with- 
out tubercle.” Ricord and I,anceraux 
and Alfred Fournier have, by pathologi- 
cal anatomy, proved that symptoms of 
phthisis are not only possible, but very 
frequently the same as those produced 
by syphilis. 
Syphilitic Broncho-Pneumonia. Drs. 
Balzer and Grandhomme have recently 
made several necropsies of syphilitic 
still-born infants, and the results of their 
examinations prove that syphilitic le- 
sions, which are caused by microbes, 
like other inflammations, do not appear 
to preserve any specific character in 
their evolutions. With regard to the 
lungs, syphilitic pneumonia may be 
classed with broncho-pneumonia, in the 
same degree as secondary pneumonia 
in acute infectious diseases, such as 
measles, or in chronic affections, like 
tuberculosis. Syphilis in the fetus as- 
sumes the different forms of broncho- 
pneumonia and other lesions, according 
to its violence and the degree of its 
chronic stage. The authors classify 
these forms of broncho-pneumonia, in- 
cluding pulmonary congestion, and le- 
sions which are not apparent on micro- 
scopic examination. 
2. Broncho-pneumonia or agglomer- 
ated nuclei disposed in a vertical band 
at the posterior portion of the lungs. 
These forms correspond, with regard to 
lesions, to subacute forms of broncho- 
pneumonia of other infectious diseases, 
and invariably assume the following 
type. 
We have called your attention to 
syphilis of the brain, and of the organs 
of sight and hearing, and of smelling, 
and of taste. Likewise we have taken 
up the buccal cavity and the pharynx 
and larynx. Now let us take up the 
lungs. Lammonier nearly a century 
ago described the existence of phthisis 
pulmonalis of a syphilitic character. 
Then followed a long series of years 
when syphilis was not recognized as at- 
tacking the internal organs, probably 
owing to the teachings of John Hunter 
and Sir Astley Cooper, who did not 
believe in any visceral complications of 
syphilis. Sir Astley and Kdward Jen- 
ner were the pet students of Hunter, 
and naturally endorsed whatever the 
great physiologist taught. Sir Astley 
in his lectures on surgery taught “ that 
some parts of the body are incapable 
of being acted upon by the venereal 
poison, such as the brain, the heart and 
the abdominal viscera.” Indeed he 
writes ; “ This poison does not appear 
to be capable of exercising its destruc- 
tive influence on the vital organs, or on 
those parts most essential to the welfare 
and continuance of life.” 
3. Broncho-pneumonia, with white 
hepatization, without dilatation of the 
bronchi, corresponding to the hepatiza- 
tion of other forms of broncho-pneumo- 
nia. It may lead to fibro-caseous or 
gummy degeneration. 
4. Broncho-pneumonia, accompanied 
b}r dilatation of the bronchi. It may be 
said that pulmonary syphilis is identi- 
cal at different ages. 
At a meeting of the Moscow Derma- 
tological Society, Pospelow and Kon- 
trim (^Monatshefie furpraktische Derma- 
tologic, 1895) each reported two cases of 
In 1826 Laennec and Vandral recog- 
nised and described syphilis of the lungs, 
identical in its symptoms to those of 
phthisis pulmonalis. Van der Kolk in- 3 
syphilitic pneumonia that yielded to 
treatment with mercurials. Hemopty- 
sis occurred in three of the cases, and 
fever with sweating was present in two. 
The lesion was localized at the apices. 
In one of the cases, tubercle bacilli 
were found in the sputum, and the pro- 
cess was believed to be tuberculous. 
Treatment with mercurial inunctions 
and sulphur baths, with a residence in 
Egypt, was followed by general im- 
provement and disappearance of fever,- 
cough and expectoration. The patient 
had been well for three years at the 
time of the report. In this case it is 
believed that the tuberculous affection 
was implanted upon the syphilitic pneu- 
monia, disappearing with the latter. 
its complete disappearance without leav- 
ing any traces, and its prompt cure 
by mercury. The lecturer is inclined 
to believe that the so-called secondary 
fever of syphilis may be in many in- 
stances explained by the existence of 
this kind of pleurisy, which in the pres- 
ence of indubitable signs of lues venerea 
is not suspected or sought for. In one- 
half of the cases bronchitis is present 
as well, this complication being probably 
due to the outbreak of a syphilide on 
the bronchial mucous membrane. 
Dr. Rendu, at a recent clinical lecture, 
presented an old woman who had for 
a long time been emaciated and cachec- 
tic, but without fever. The symptoms 
were ill-defined, some pain, stiffness of 
the limbs, without marked weakness or 
paresthesia, dyspnea on exertion, and 
for a short time a dry cough without 
expectoration. The respiratory and 
auscultatory phenomena were found nor- 
mal, anteriorly, but behind there was 
dullness over the right apex, with 
roughened prolonged expiration. There 
was a loud, rough, systolic murmur, 
together with a softer and more super- 
ficial one, but no symptom of cardiac 
insufficiency. The arteries were appar- 
ently healthy, the liver normal in size, 
and there was no albuminuria. There 
was a diffuse and characteristic syphi- 
litic melanodermia, and iritis of two 
years’ standing, nocturnal bone pains 
and headache. Her only previous ill- 
ness had been measles. It was pointed 
out that against tuberculosis was the 
long duration, the absence of expectora- 
tion, of rales, and of concomitant symp- 
toms. Syphilis does not usually attack 
the apices, although cases of this occur- 
rence are recorded. Syphilis and tuber- 
culosis may occur in association, and 
tuberculosis may attack a lung previ- 
ously syphilitic. From the absence of 
a history of acute pneumonia an indu- 
rating pneumonia could here be ex- 
cluded, The attack of measles was not 
considered adequate cause. As there 
were no other etiological factors, the 
changes in the heart and lungs were 
probably syphilitic. Great improve- 
ment followed the exhibition of mercury 
and iodide of potassium. 
Syphilitic Pleurisy. In the Presse 
Medic ale, of the 20th ultimo, M. Chan- 
temesse publishes a clinical lecture on 
the complication of constitutional syphi- 
lis. The subjects of the lecture were 
two men who presented the usual stig- 
mata of syphilis in the eruptive stage. 
In both there were discovered the phys- 
ical signs of pleurisy with effusion, 
and in one aspiration with a hypodermic 
syringe yielded a quantity of straw- 
colored serum. Both had rales, due 
probably to an eruption of roseola on 
the bronchial mucous membrane. M. 
Chantemesse had succeeded in col- 
lecting twelve similar observations of 
syphilitic pleurisy. Most of them were 
cases of dry pleurisy, but in either case 
the prognosis is favorable, resolution 
and absorption being the _ rule un- 
der specific treatment. M. Chantemesse 
treated his patients with intravenous in- 
jections of corrosive sublimate ; he 
nevertheless does not recommend this 
method, but would prefer intramuscular 
injections of red oxide of mercury dis- 
solved in sterilized olive oil. He says 
that he has never noticed any stomatitis 
during a treatment of several months, 
consisting of daily doses of four or eight 
milligrammes of the salt dissolved in 
one or two cubic centimeters of the oil. 
The specific character of the pleurisy is 
plain to M. Chantemesse from the fol- 
lowing peculiarities : Its bilaterality, 
the small amount of effusion, its con- 
comitance with the secondary eruption, 4 
In lecture No. VIII, I referred to pa- 
tients of Abrahams and Bratnbilla and 
Fournier .and Ross. These patients 
were undoubtedly far advanced in pulmo- 
nary tuberculosis, when they acquired 
syphilis. They were put upon energetic 
anti-syphilitic treatment, which cured 
not only the syphilis, but the tubercu- 
losis. You will naturally ask if I do 
not think that the treatment destroyed 
the toxines of both syphilis and tuber- 
culosis, and the same treatment is indi- 
cated for both diseases. I have put 
this same question to eminent throat 
and lung specialists, and have been in- 
formed that the treatment has been 
tried, and the effects were baneful, un- 
less the patient had syphilis complicat- 
ing the tuberculosis. 
Syphilis of the Heart and Arteries.— 
Virchow describes syphilitic growths in 
the substance of the heart, and refers to 
those recorded by Ricord and Lebert. 
Ricord, in his Atlas, calls them “syph- 
ilitic muscular nodes in the substance 
of the heart.” They were found in 
the substance of the ventricles, and con- 
sisted of firm, cheese-like masses. There 
was a history of chancres and ulcerated 
tubercles of the skin. Debert reports 
that gummata were seen at a com- 
paratively early stage of development 
in his case, and were found in the wall 
of the right ventricle. There were tu- 
bercles of the skin, of the subcutaneous 
tissue, genital organs and bones of the 
skull. In Virchow’s case there were 
syphilitic gummata in the testicles. 
A few months ago, I visited the 
United States Army Medical Museum, 
and Dr. D. S. Damb showed me a path- 
ological specimen of a heart in which 
a syphilitic gumma was imbedded in the 
wall of the left ventricle. This speci- 
men was exhibited in Baltimore, at the 
Johns Hopkins University, and its 
nature verified by the pathologists there. 
For the clinical record, Dr. Damb re- 
ferred me to Health Officer W. C. 
Woodward, M. D., as the specimen was 
obtained from him when he was serving 
as coroner of the District. Dr. Wood- 
ward kindly sent me the following re- 
port : “ The patient came under my 
observation after death. The history 
was vague. Colored, male, thirty-three 
years old, a native of Virginia ; was 
found dying in bed about 5 o’clock 
one morning by his wife, who had been 
sleeping by his side. He had com- 
plained for some time of shortness of 
breath, and is said to have had night- 
sweats just previous to his death. 
There was, further, a history of con- 
tinued ill health, not borne out by the 
condition of the body, attributed by 
his family to a hernia. There was 
no external evidence and no history 
of syphilis. Deceased was a huckster 
by occupation.” 
At a recent meeting of the Clinical 
Society of Don don (British Medical Jour- 
nal), Dr. Duckworth reported the case 
of a strongly-built man, 35 years old, 
who, while walking in the street carry- 
ing his little boy, suddenly fell down 
and expired. Only a meager anteced- 
ent history was obtained, but there was 
evidence of old syphilitic disease on the 
tongue and on the glans penis. A 
small gumma was found in the left 
lung. The heart weighed twenty-two 
ounces, and was bound by firm adhe- 
sions to the pericardium, both at the 
apex and the base. The ventricles were 
hypertrophied -and dilated ; the valves 
were normal. In the wall of the left 
ventricle, above the apex, was a round 
depression, nearly an inch in diameter, 
and covered by long adhesions. This 
was due to a thinning of the wall, with 
much endocardial thickening. A large 
aneurismal pouch was found behind the 
In the Museum of the British Army, 
Medical Department at Netley, there 
are two preparations which show such 
gummata in the substance of the heart. 
“ One occurred in the case of a soldier, 
twenty-four years of age, under treat- 
ment for venereal ulcers, of nine month’s 
duration, in various parts of the body. 
He had lost his palate, and eventually 
sank from exhaustion, with symptoms 
of phthisis. Sections of the muscular 
substance of the heart showed several 
isolated deposits in its substance and 
beneath its serous covering, and isolated 
portions of the lungs were converted 
into a substance of the consistence of 
cheese.” 5 
posterior cusp of the mitral valve. This 
appeared from without as a tumor grow- 
ing from the base of the heart, and com- 
pletely covering the left auricle. Its 
walls were half an inch thick, and the 
pericardium was closely adherent over 
it. On section the muscle was replaced 
by tough, fibrous tissue, with foci of 
gelatinous matter. The endocardium 
was greatly thickened and fibrous. Mi- 
croscopic examination proved the for- 
mation to be gummatous in nature, 
with patches of caseation. The smaller 
vessels showed signs of endarteritis. 
These appearances were taken to indi- 
cate a recent gummatous growth at the 
base of the left ventricle, and a similar 
but older one near the apex of that 
cavity. 
second and third intercostal spaces, with 
an accentuated second sound. There 
was no clinical evidence of syphilis. 
Eight days after admission, there was a 
profuse and fatal hemorrhage from the 
stomach. The autopsy showed the 
heart to be hypertrophied, but only 
slightly dilated. No circulatory obstruc- 
tion could be proved at the mitral ori- 
fice. Islets of fibrous tissue were pres- 
ent at the base of the papillary muscles, 
and the muscles themselves had under- 
gone fibrous changes. Fine strands of 
fibrous tissue were seen in the slightly 
brown cardiac muscular tissue. The 
dilated left auricle presented peculiar 
appearances. The wall was rigid, with 
only the remains of a few yellowish- 
brown muscular fibers. The auricular 
appendix was greatly shrunken. Very 
irregular and easily detached excres- 
cences were found in the inner wall of the 
auricle, and were especially marked well 
on the upper surface of the mitral valve 
segment. The gummatous formation 
in the heart muscle could only be due 
to syphilis. In the liver fibrous changes 
with the remainsofgummata were found. 
There was induration of the uterus with 
chronic endometritis, also of syphilitic 
origin. 
Investigation showed that in fourteen 
similar cases death occurred quite sud- 
denly in eight. But one case in the 
whole number was in a woman. The 
mean age of all the patients was 32 
years. Many of the cases seemed to have 
been devoid of urgent symptoms. In 
some there had been pericardial pain. 
The valves were not usually involved, 
and hence murmurs were not to be 
heard. The ventricles and their septa 
were the common sites of the growth. 
The tendency to fatal and sudden syn- 
cope was probably attributable in part 
to endarteritis affecting the coronary 
vessels, and possibly to the formation 
of embolisms in the branches of the coro- 
nary arteries, as a result of the dislodg- 
ment of fragments from the interior of 
aneurisms. 
At the Berlin Medical Society, Dr. A. 
Fraenkel recently demonstrated a speci- 
men of cardiac syphilis from a woman 
36 years of age. When first seen last 
year she had aortic regurgitation and 
suffered from frequent headaches, which 
were occasionally associated with faint- 
ing attacks. The heart disease was 
supposed to be consequent on acute 
rheumatism. The husband was syphi- 
litic and the woman herself had suffered 
from swellings on the head, which had 
ulcerated and left scars. She improved 
at first and left the hospital, but was re- 
admitted this year with severe attacks 
of angina pectoris, in one of which she 
died. At the necropsy the left coronary 
artery was found quite permeable, but 
the orifice of the right coronary was 
completely obliterated by a process of 
arterio-sclerosis, which in excess of the 
patient’s years and its proper position 
could only be determined by probing 
backward along the lumen of the artery. 
During a recent meeting of the Mon- 
treal Medico-Chirurgical Society, Dr. 
Finley presented the report of a case of 
syphilitic gummata of the heart and 
liver, and exhibited the pathological 
specimens showing the characteristic 
lesions. 
At a late meeting of the Charitfe 
Aerzte of Berlin, Dr. Israel exhibited 
pathological specimens, and gave the 
following clinical history ; During life 
the patient, aged 47, had presented the 
appearance of hepatic cirrhosis. The 
pulse, 136, was small and irregular at 
first, but improved under digitalis. A 
svstolic murmur was heard in the left, 6 
There was a gummatous tumor, four 
and a half centimeters long, in the sep- 
tum ventriculorum, and Fraenkel thinks 
this shows that the arterial changes 
were really of syphilitic nature. The 
arterio-sclerotic changes in the aorta 
reached down to the bifurcation. Fraen- 
kel, moreover, remarks on the part 
played by syphilis in the etiology of 
aneurisms. Walsh thought that sixty 
per cent, of true aneurisms were due to 
syphilis ; others think still more. 
Fraenkel himself, during the last four 
years, has seen nineteen cases of aneu- 
rism of the thoracic aorta in which there 
were necropsies. Three cases were in 
women, sixteen in men. Of the nine- 
teen patients, nine, that is forty-seven 
per cent., had had syphilis and these 
were all under fifty years of age. The 
case illustrates the relation of precocious 
arterio-sclerosis and syphilis. Mracek 
{Medico- Chirurgisches Centralblatt, 1895) 
refers to authors and states that, espe- 
cially just preceding the roseola, in the 
second stage of syphilis, disturbance of 
the heart’s action is not uncommon. 
He quotes Fournier to the effect that 
these troubles are functional and not de- 
pendent upon distinct lesions of the 
heart itself, and that they are distinctly 
transitory by nature, disappearing with- 
out leaving a trace, occurring much 
more frequently in women, and com- 
monly associated with nervous disturb- 
ances. The later forms of heart syphilis 
appear, however, as distinct pathologi- 
cal changes. The symptoms of the af- 
fection are those of degeneration of the 
heart-muscle or interference with the 
valves, whatever is the cause of these 
pathological conditions. 
but rather a slow transformation in the 
fibrous tissue. Judging from reported 
cases the prognosis is extremely bad, 
death coming suddenly and often in the 
midst of apparent perfect health. In 
sixty-three cases collected by the author 
(Semnola), this suddenly occurred in 
one-third of the number. Jullien and 
Mauriac stated that this end is observed 
in fifty per cent, of cases. Death comes 
after a heavy meal, or from drinking 
or straining. Often the patients are 
found dead in bed. Many cases perish 
in coma from heart failure. 
Dr. Fisher, in the Bristol Medico- Chi- 
rurgical Journal, summarizes as follows 
the articles of Hektoen (Journal oj Pa- 
thology and Bacteriology) and Jacquinet 
('Gazette des Hopiiattx, 1895): “Hek- 
toen records a case of interstitial myo- 
carditis due to syphilis in a child six 
weeks old and mentions that only eleven 
other cases have been recorded. In two 
of these eleven cases sudden death oc- 
curred when the children were consid- 
ered to be in good health, a noteworthy 
fact, siiice it shows that this disease in 
the child may lead to the same abrupt 
arrest of heart action that frequently oc- 
curs in the adult when the heart is 
affected with syphilis. 
“Jacquinet treats the subject of syph- 
ilis of the heart very fully. In connec- 
tion with the above remark it may be 
mentioned that he quotes Mracek as 
saying that of fifty-eight cases of syphi- 
lis of the heart, twenty-one ended in 
sudden death. Others terminated in 
what French writers call acute asystole, 
where severe dyspnea ushers in the rap- 
idly approaching end. Jacquinet quotes 
as an example the case of a prostitute 
who was dining in a beer-house with 
some of her companions, when she com- 
plained of pain in the stomach and ab- 
domen. The pains increased and palpi- 
tation of the heart was added. She 
was removed to a hospital and died of 
“ advanced asphyxia ’’ after a few hours. 
The pain mentioned in this case suggests 
angina pectoris, which may sometimes 
be epigastric in situation. Jacquinet 
comments upon this point and refers to 
the possibility of cardiac pain being a 
symptom of syphilis of the heart. He 
Semnola holds as pathognomonic a 
persistent arhythmia, either existing 
alone or accompanied by tachycardia, 
respiratory troubles coming and going, 
resistance to all ordinary methods of 
treatment, and a history of syphilis. 
Through syphilitic stenosis of the coro- 
nary artery the symptoms of angina 
pectoris may be caused. Exceptionally, 
murmurs are developed. The course of 
syphilis of the heart is extremely slow 
and insidious. There is rarely any acute 
process, such as a softening of a gumma, 7 
mentions that one of the recorded cases 
of sudden death occurred in a sailor, 
who died putting his hand to his heart 
as if he suffered pain in that region. 
Huchard is quoted as saying that of no 
cases of angina pectoris, in 32 a history 
of syphilis was obtained, and other ob- 
servers are mentioned as having noticed 
severe cardiac pain in syphilitic subjects. 
This point is of some interest, since po- 
tassium iodide is recognized as of value 
in angina pectoris. The drug is not gen- 
erally given, however, with the idea of 
combating syphilis, but of influencing 
the diseased condition of the coronary 
arteries that often exists. Yet a satis- 
factory result naturally suggests that 
this disease of the coronary arteries may 
be sometimes syphilitic, like aortitis of 
the intra-pericardial portion of the aorta 
with which cardiac pain is also often 
associated.” 
that did not terminate suddenly were in 
young prostitutes. One of these died 
with intense dyspnea and c}?anosis ; the 
other was admitted to the Bellevue Hos- 
pital for lobar pneumonia, which ended 
fatally. Dr. Loomis emphasizes the 
point that the question of syphilis as a 
probable cause of heart disease should 
not be overlooked. He says : “ When 
symptoms of cardiac failure occur dur- 
ing the prime of life, for which no cause 
can be ascertained, such as rheumatic 
history, valvular disease, arterial changes 
or kidney complications, especially in 
one with a syphilitic history, these 
should always suggest syphilis as the 
cause of the condition.” 
The same author published in the 
American Journal of the Medical Sciences, 
October, 1895, a very able and instruct- 
ive article, giving in detail his services 
as curator for ten years for Bellevue 
Hospital, New York City. Fifteen 
hundred or more autopsies came under 
his personal observation, where certain 
pathological changes, “ which were un- 
questionably of syphilitic origin, yet 
which failed in spite of marked symp- 
toms to be diagnosed during life as man- 
ifestations of syphilis.” 
We propose in our next lecture to 
take up syphilis of the liver, spleen, 
kidneys, and conclude with a lecture on 
treatment. 
Dr. H. P. Loomis has reported fifteen 
cases of fibroid disease of the heart, 
three of which were considered beyond 
all doubt to have been of syphilitic ori- 
gin. He has also seen four cases of 
gummata of the heart wall. Sudden 
death occurred in two of these cases. 
Notes are given of one. An apparently 
healthy man, aged 35, was found lying 
dead on his bedroom floor, with his hat 
in his hand, having obviously fallen 
immediately after entry. The two cases