new to their certificate will be fatal to the
end in view. — Fort Wayne Med. Jour.
Masr.
Tuberculin Test in the Diagnosis of Tuber-
culosis.
Reference was recently made in these
pages to the observation of Dr. Otis on this
subject. While not questioning the value
of tuberculin as a diagnostic aid, it seems
to the writer that it falls notably short of
infallibility both from a negative and posi-
tive point of view. Dr. Otis in a recent
paper in the Journal of the American Med-
ical Association, after studying a large series
of cases, while claiming that it is more re-
liable in the early stages where it is needed
than in the later ones where it is not, pre-
sents the following conclusions :
1. The tuberculin test indicates early tu-
berculosis by a general reaction before it
can be detected by other methods, except
the X ray, in the large majority of cases,
with a dose of from 5 to 10 mg. of Koch's
original tuberculin.
2. No injurious results occur from the
use of tuberculin in these doses.
3. Proved tuberculosis in a more or less
advanced stage may fail to give a general
reaction from doses of from 10 to 12 mg.
4. Syphilis gives a reaction in an unde-
termined proportion of cases.
5. There is a dose, undetermined, at
which a non-tubercnlous person may react
or simulate a reaction.
The value of the X ray examination in
cases of incipient tuberculosis does not ap-
pear to be fully appreciated. On this point
Dr. Otis says : "The X ray examination, in
the hands of an expert, seems to be a more
accurate and delicate test of early lung dis-
ease than even tuberculin, and without the
fear of possible injury as with the latter,
but the required technic and experience
and the expensive apparatus limits its use
to the few." The obvious objections to the
use of the X rays in the cases are growing
less and less as X ray machines become
more numerous and more frequently used.
— F'ort Wayne Medical Journal.
Teacher: "What happens when a mans'
temperature goes down as far as it can go?"
Smart Scholar: "He has cold feet,
ma'am." — Cleveland Medical Gazette.
186
THE CHARLOTTE MEDICAL JOURNAL.
A Case of Appendicitis.
A privilege of examining the early ap-
pearance of the gut after a successful end-
to-end anastomosis is unique and deemed
of sufficient interest and importance for a
detailed report.
Rupture of Gangrenous Appendix;
General Peritonitis; Incision and Drain-
age; Fecal Fistula; Resection with End-
to- End Anastomosis ; Ventral Hernia;
Herniotomy;' Recovery. — F. F., age lo,
white, male, entered St. Alexis Hospital
for operation for acute appendicitis. He
gave a history of having had the attack
seven days previous to his entrance. The
entire abdoment was greatly distended and
exquisitely tender. The pulse was 152 and
thready.
He was anesthetized and quickly oper-
ated. The pus under tension spurted out
on opening the peritioneal cavity ; the gan-
grenous appendix was readily found and
removed. The opening was made wide
and the cavity washed out with salt solu-
tion and extensive long gauze siphon drain-
age inserted.
The case seemed almost hopeless and
hung in the balance for about two weeks,
after which he slowly improved. In the
third week a fecal fistula developed, which,
on account of the intensely irritating charac-
ter of the discharge, was diagnosed as be-
ing of the ileum. Again, for about two
weeks the prognosis was most unfavorable.
After more than a month of suffering from
the extensive excoriation of the skin over
the whole area involved — it all becoming
raw and bleeding — an attempt was made to
close the opening in the intestine by lateral
suturing, but this failed. Again resorting
to all possible expedients, the mother as
well as the little patient insisted upon re-
section. I happened to have mentioned
and described this operation to a profes-
sional friend while looking at the wound
one day, and ever after on my entering the
ward the child would beg and even cry for
"resection."
Under chloroform anesthesia the intestine
was separated for some distance both above
and below the fistula, and resected near a
basal supplying artery on each side. End-
to-end anastomosis was then made using cat
gut for mucosa and silk for the peritoneum.
Both the large and small coils of intestines
were invested closely with adhesions
and these were not disturbed. The origi-
nal opening required but little modification
and was allowed to remain open as before.
Union was prompt and the abdominal
wound soon closed.
On his leaving the hospital, arrange-
ments were made for operating upon the
hernia that was sure to develop. On Sep-
tember 28, 1899, eight months after the
original operation, the hernia was closed.
At this time his condition was good, pulse
regular, rhythmic, of fair tension and
volume, rate 90. The old scar was six and
one-half inches long and three and one-half
inches wide at the widest point. The urine
was normal and bowels regular. The red
corpuscles numbered 4,860,000 and the
white 7,000.
The operation consisted in dissecting out
the entire scar and all the cicatrical tissue.
The edges of the fascia were retracted far
from the margins of the wound — this was
especially marked on the inner side. On
exposing the intestine the point of resec-
tion was found the lumen was narrowed to
an appreciable degree only, the most dis-
tinguishing mark being the whitish line at
the point of union. The blood vessels
which had served as landmarkg for the point
of resection were easily identified and their
branches were richly anastomosing. The
extensive adhesions among the intestines
observed at the time of resection had al-
most disappeared. Primary union followed
and the boy is now well.
The reason that almost all of the bowel
contents escaped during the existence of
the fistula was on account of a valve-like
reduplication by partial prolapse of the
mucous membrane, thus shutting off the
distal bowel. — Crile, in the Bulletin of
the Cleveland General Hospital.
The Nutrition of the Lens and Its Relation
to Cataract Formation.
(Strieker.) The lens is practically im-
mersed in its nutrive supply, and the fluid
which has passed through the capsule by
osmosis permeates all the inter-fibrillar
spaces ; hence, literally, the fibres are bathed
in nutrive fluid, a condition more perfect
in the cortex than in the nucleus, where
the fibres are more closely packed. Dur-
ing each accommodative act the fluid in the
inter-fibrillar spaces must change its posi-
tion, and in this manner currents are set
up, by means of which the fluid which has
served its purpose is forced onward, and
fresh fluid enters the lens, the accommo-
dative efforts producing an effect which
may in the lens be likened to the diastole
and systole of the heart. Later in life,
when the nuucleus has become less resilient,
and its lamellaj denser, and the nucleus, as
a whole, no longer gives during the ac-
commodative efforts to the same degree as
the cortex does, this leads to the formation
of splits and fissures, in which the nutritive
fluid stagnates and is subsequently not
THE CHARLOTTE MEDICAL JOURNAL.
187
pressed out. In consequence the neigh-
boring fibres undergo degenerative changes.
The aqueous obtained from patients having
cataract contained more albuminous sub-
stance than the aqueous of the normal
eye.
Though no analysis has been made of
the vitreous during the progress of cata-
ract formation, attention has been called to
the fact, clinically noted, that opacities ap-
pear in the vitreous, indicating a degenera-
tion of the same. The increase of albumen
in the acqueous is a result of the cataract,
as cataractous lenses contain less albumen
than healthy ones. It is a well-known fact
that the direct contact of normal aqueous
and vitreous with the lens fibres causes these
to swell up and dissolve in the living eye.
Hence there must be something present in
the aqueous and vitreous which, with a per-
fect integrity of the lens existing, is pre-
vented from entering the capsular sac.
There are conditions, in which nutritive
disturbances may only be active for a cer-
tain period of time, not only affecting the
growth of the fibres, but also their trans-
parency. Subsequently a normal nutritive
supply is again supplied, and the epithelial
cells produce normal fibres, which are ap-
plied over the affected lamellae, and thus is
explained the zonular or lamellar cataract
— "journal of the Eye, Ear and Throat
Diseases.
The Gallinger Bill.
Certain changes have been made in the
Committee on the Di&trict of Columbia
relative to Senator Gallinger's bill for the
"Further Prevention of Cruelty of Animals
in the District of Columbia." The Com-
mittee, as it now stands, consists of Sena-
tor James McMillan, Michigan, Chairman,
and Senators J. H. Gallinger, New Hamp-
shire ; H. C. Hansborough, North Dakota;
R. Redfield Proctor, Vermont; J. C.
Pritchard, North Carolina ; Lucian Baker,
Kansas; George L. Wellington, Maryland ;
S. R. Mallory, Florida ; W. V. Sullivan,
Mississ.ippi ; W, A. Clark, Montana ; Thos.
S. Martin, Virginia; Wm. M. Stewart,
Nevada ; and Richard Kenney, Delaware.
Personal letters may be addressed to them
or other Senators. Petitions should be ad-
dressed to the Senate of the United States.
— Boston Medical and Surgical Journal.
Now the osteopaths are going to close all
the state hospitals for the insane by resett-
ing the bones of the neck upon which in-
sanity depends. What marvels are being
accomplished at the close of this nineteenth
century ! — loiua Medical Journal.
Inflammability of Celluloid Hairpins to the
Static Breeze.
The editor of the Journal of Electro-Ther-
apeutics reports a disagreeable experience
while, administering the static breeze to a
young lady who had fastened her hair with
celluloid hairpins. During the administra-
tion of the breeze from an ordinary static
head crown which was about eighteen in-
ches from the hair and attached to the neg-
ative pole of the batiery, the young woman
suddenly gave a scream and a column of
smoke was seen to arise from the patient's
head. The motor was at once disconnected
and the examination disclosed three cellu-
loid hairpins which had been ignited, and
had each burned away the hair for a space
the size of a quarter of a dollar. The scalp
was quite seriously burned in one place.
He recommends that the hair should always
be examined for celluloid pins before ad-
ministering the static current. — Bulletin of
the Cleveland Hospital.
The Plague.
In Honolulu, up to January 24th, there
had been fifty five cases of plague with
forty-one deaths. The health authorities,
soon after the disease appeared in the city,
adopted the radical plan of destroying by
fire every infected building, but on January
20th the fires got out of control and spread
from one building to another in the native
and oriental quarter, until nearly the entire
district was in ruins. Four or five thousand
persons were rendered homeless and China-
town was wiped out, but it is believed that
the advance of the plague was stayed. — It
is stated, apparently officially, that Rio de
Janeiro and Santos, in Brazil, are now
entirely free from the disease. A few cases
of plague have occurred at Ensenada, Ar-
gentina, and the ships of the United States
South Atlantic squadron under Admiral
Schley were quarantined on that account
when they arrived at Montevideo from
Ensenada. — Medical Recoad.
First Aid to the Injured.
Customer (emerging from bargain coun-
ter) — Help! My leg is broken.
Floorwalker — You will find the crutch
department, sir, on the fourth floor, in the
rear. — Judge.
In wounds necessitating the ligation of the
brachial artery it is well to remember that
while the inner edge of the biceps is the
guide to this vessel, the edge of the mussels
slightly overlies the artery, and must be
lifted up a little to expose the vessel.
THE CHARLOTTE MEDICAL JOUR15AL.
Joint Affections in Gonorrhoea.
B. G. Moynihan (Lancet, November, iS,
1899) in a clinical lecture describes the vari-
ous forms of joint disease connected with
gonorrhoea. He adopts Konig's classifica-
tion of four varieties : (i) hydrops; (2)
sero-fibrinous ; (3) empyema; (4) phleg-
monous. Attention is drawn to the chronic
course which is run by most cases, and to
the severity of pain compared to intensity
of local inflammation. A typical case of
each variety is described as follows :
I. Hydrops is the least severe form. A
patient with (usually) a slight attack of
gonorrhoea chances to observe tliat his knee
is swollen. There is no fever, no ill-health,
little or no pain or tenderness, merely an
increase in the circumference of the joint;
The capsule is not thickened, and there
are no inflammatory changes noticeable in
the skin. The effusion generally disappears
quickly, and the function of the joint is not
permanently disabled. Recovery is usually
only a matter of a few weeks. The author
says that this variety has been observed only
in the knee-joint.
2 and 3. The sero-fibrinous form and
empye?na are anvanced and moie intense
forms of inflammation. The joint in hy-
drops contains a thin, almost clear, pale,
yellowish-green, limped effusion. In the
sero-fibrinous form the fluid becomes
thicker, more viscous, and turbid. In the
fluid are shreds and cloud-like masses of
fleecy lymph. Turpidity increases, and
finally pus is formed. Tallying with these
pathological changes are corresponding al-
terations in the clinical symptoms. The
capsule of the joint becomes thickened and
swollen. The temperature of the joint is
raised, manipulation and gentle movement
are exquisitely painful, and swelling and
redness are strikingly apparent. The mas-
sive deposit of lymph may cause eventual-
ly some adhesion in the joint, and then a
more or less firm and permanent ankylosis
results. The general health of the patient
does not, as a rule, suffer very seriously.
4. The phlegmonous form is the most
serious. Effusion is small in quantity, and
varies from densely turbid serum to pus.
Fluid as such may even be absent, the joint
being filled with jelly-like masses of fibrin.
The important points, pathologically, are
the fierce intensity of inflammation and the
extension of the process beyond the limits
of the joint c;\psule. As a result of this
extension the capsule and its surroundings
are fused and soldered into one turgid in-
flammatory mass. The skin is red, tense,
shining, and oedematous. The contour of
the joint fades gradually away. The symp-
toms are exquisitely defined Pain is agon-
izing, even to torture; the tenderness is ex-
cruciating, even the pressure of the bed-
clothes cannot be borne, and the mere sug-
gestion of movement is intolerable. Mus-
cular wasting is unusually rapid and se-
vere. The disorganization of the joint may
become riotous, and within two or three
weeks dislocation may occur. When the
process subsides the massive flakes of lymph
become organized into adhes'ons which ham-
per or prevent the movements of the joint.
In the knee-joint there is a striking tenden-
cy for the patella to fuse with the lower
end of the femur. The rapidity and com-
pleteness with which this ankylosis can
occur in gonorrhoeal arthritis is quite char-
acteristic. In this form, in spite of appear-
ances, abscess formation is most unusual.
The severity of the symptoms and the ex-
tent and intensity of the pathological pro-
cesses are liable to considerable variation.
It is not uncommon for the acute condition
gradually to subside and to merge into an
exceedingly chronic condition.
It is not unusual for the joint affections
of gonorrhoea to appear in some such man-
ner as this : several joints are — simultane-
ously or almost so — affected with aching,
boring pains, and difficulty of movement
with slight limitation. No obvious physi-
cal change is anywhere present. These
"flying" pains, irregular in appearance,
sudden in onset, and seemingly capricious
and irresponsible, vanish, and one joint
becomes then more acutely affected with
one of the varieties of inflammation above
described. In the latter stages of gonor-
rhoea, when the "gleet" stage has been
reached and the discharge is almost gone,
there may be any of the joint affections
peculiar to gonorrhoea. But in this stage
it is most usual to find two or more joints
affected with, in each, a different intensity
of the inflammatory process. The disease
is, in fact, polymorphous. One joint may
be in a condition of hydrops, another may
be affected with the phlegmonous form of
inflammation, and so on. It is worthy of
note that it is especially in this later stage
of gonorrhoea that inflammations of the se-
rous membranes, e.g., pericarditis, pleurisy,
etc., are liable to develop. As a general
rule, however, the joint affections at this
time are of a mixed type, but are long pro-
tracted.
As regards treatment, Moynihan advises
rest at first, but, owing to the great ten-
dency to ankylosis, the rest must not be too
prolonged. Internally he has had good re-
sults from mercury and the iodides. If the
joint is very tense and the pain acute, relief
is obtained by incision and antiseptic
flushing.
THE CHARLOTTE MEDICAL JOURNAL.
189
An examination of reported cases shows
that the lower extremity is affected about
twice as often as the upper. The knee is
most often attacked, then the hip and el-
bow. In twenty-seven cases in which the
fluid was examined gonococci were only
found in eight ; hence the infection is prob-
ably a mixed one. — Treatment.
An Early Sign of Pregnancy-
Braun-Fernwald (Wien. klin. Woch.
March 9, 1899), while discussing the early
signs of pregnancy, refers to the well-recog-
nized fact of the change of consistency of
the uterus. He has also observed a signi-
ficant difference in the anterior-posterior
diameter of the uterine body. This thick-
ening is usually located upon one side.
This enlargement corresponds to the posi-
tion of the ovum. This also brings into
tactile prominence a sort of central groove
in the corpora. He explains this condition
by calling attention to the rarity of the cen-
tral attachment of the ovum and the early
growth of which nearly always takes place
in or near one of the other of the cornui.
Observation has convinced him that this
sign is more constant and confirmatory th
any other one of the signs or symptoms of
pregnancy described. He was able to con-
firm the greater majority of his diagnoses
by subsequent observation of the cases. In
cases of abortion in which the ovum has
been expelled, he found the central groove
of the lateral thickening absent. On the
other hand, if the ovum was still attached,
he found both signs to obtain. He looks
upon this as a very certain and important
diagnostic. He also believes that cases of
extra-uterine gestation which present the
ordinary signs of pregnancy are discover-
able by the absence of the central groove
and the lateral thickening of the corpora
uteri. — Bulletin, of Cleveland Hospital.
Diffuse Gonococcal Peritonitis.
Muscatello (II Policlinico, August 15,
1899) reports the case of a woman, aged
forty-eight, admitted into hospital March
16, 1899, with a history of gonorrhoea ac-
quired twenty-five years previously, and
persisting more or less since with periods
of quiescence and of exacerbation. For
the last twenty days, and without any defi-
nite cause, the patient had suffered severe
pains in the pubic and right iliac region,
accompanied by fever. On examination
per vagitiam pyosalpinx with parametritis
was diagnosed, and the pus was let out per
vaginam on March 19. Three hours after
the operatien great restlessness and pain in
the hypogastric region, severe collapse, cold
sweats, and vomiting occurred. March 20.
the collapse continued, but there was no
tympanites. March 21 laparotomy was per-
formed, and a considerable quantity of yel-
low, inodorus, seropurulent"; fluid let out.
The intestines were distended and non-ad-
herent. Part of the distended ileum was
drawn into the upper part of the wound,
and opened so as to let out some of its con-
tents. The patient never rallied, and died
shortly afterwards. No post-mortem ex-
amination was allowed. Bacteriological
examination of the pus in the pyosalpinx
and in the peritoneal cavity showed the
presence of gonococci. — Treatment.
Cases of Intractable Syphilis.
Fournier (Ann. de Derm, et de Syph.,
July, 1899) reports the case of a woman
who, two years and a half previously, had
contracted syphilis from her husband.
During the whole of that period she had
suffered from severe syphilitic symptoms,
notwithstanding the most varied treatment
— mercury, iodide, iron, etc. He also refers
to a similarly obstinate case in a man. The
mercury in both was used in every possible
way — by mouth, by inunction, and by in-
tramuscular injection. An interesting
feature about both was the fact that the
woman had had forty calomel injections,
and the man no fewer than 120, without
any curative effect up to date, demonstrat-
ing most clearly how little foundation
there is in the dogmatic statements put for-
ward by some observers that syphilis could
not resist calomel injection. In the case of
the woman, her mother had died of phthisis,
and her father from absinthe — facts which
might to some extent explain the want of
success ; but Fournier states that he has
come across similarly obstinate cases in
which there was no such history, and
which could not be explained. He obtain-
ed a certain amount of benefit from serum
injections. — Treattnefit.
Havana's Vital Statistics.
A report on the vital statistics qf Havana
for the year 1899, compiled by Major Davis,
chief sanitary ofiicer, shows 8153 deaths
from all causes in an estimated population
of 220,000. Of these deaths 1 163 were from
enteritis and 1367 from tuberculosis. There
were but 103 deaths from yellow fever.
Eleven deaths were due to leprosy. The
number of contagious and infectious dis-
eases reported was 6442, of which 284 were
yellow fever. There were recorded during
the year 4181 births, of which 1516 were
illegitimate. — Medical News.
190
THE CHARLOTTE MEDICAL JOURNAL.
Intense Heat in the Southern Hemisphere.
At Buenos Ayres on Saturday and Sun-
day last the thermometer registered i30
degs. F. in the shade nearly all day. On
Saturday there were one hundred and two
cases of sunstroke, of which ninety-three
w^ere fatal, and on Sunday there were two
hundred and nineteen cases, of which one
hundred and thirty-four were fatal. In
Melbourne, as we noted last week, the
weather has been extremely hot, and in
South Africa the British troops have suf-
fered exceedingly from the unbearably high
temperature. Indeed, the entire globe ap-
pears to be warmer than usual, for the win-
ter in this country has been far from se-
vere, in the Klondyke the weather is re-
ported to have been almost mild, and at
Davos Platz the season has been ruined by
the warm weather, which has turned the
snow into slush and has housebound all the
guests with pulmonary and bronchial af-
fections. — Medical Recoi'd.
The omnipresent and iconoclastic bacte-
riologist is again on the warpath. The
most sacred of institutions and customs
seem not to be exempt from his assaults.
Recently a health officer in Turin, Italy,
has m-ide an examination of the holy water
provided in the cathedrals of that town.
He finds them badly contaminated ; as many
as thirty-eight species of bacteria in a single
repository. It is stated that the water is
renewed in these places and it is rare that
they are cleansed. It is the opinion of the
health officer that they may be an impor-
tant means of communicating disease. He
therefore recommends a weekly washing
and the addition of some disinfectant to the
water. — Medical Review.
Smallpox is spreading in Oklahoma, and
and it has been necessary to close the post-
offices in several towns because of it. In
the northwest also the disease prevails, and
friction has arisen between the authorities
in British^ Columbia and those in Washing-
ton over the disinfection of the mails from
Spokane. It is reported from Louisville
that smallpox is prevalent in about thirty-
five counties of Kentucky, and the State
board of health finds itself without the
necessary means to fight the disease. The
secretary has received the resignations of
the county boards of health in at least a