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of development, and their slight degree of motility, as well as by the preservation of the red blood-corpuscles, these forms remind one of those of slow development in birds.

In the fevers of tertian type, there are at first small amoeboid forms that grow and become laden with pigment, while they remain in active movement; the pigment-granules, which are usually fine, are also in active movement; the blood-corpuscle swells, the hæmoglobin is altered, losing its color, or becoming the color of old brass. Sporulation may take place prematurely in the medium-sized forms, and more frequently in the large forms that occupy the entire blood-corpuscles; in such a case there is an aggregation of from fifteen to twenty spores, and in the other of from fifteen to twenty surrounding the mass of black pigment usually in the centre. The adult forms that do not undergo sporulation, and that pass from the red corpuscles into the plasma die, i. e., they become larger, apparently hydropic, present vacuoles, extend flagellæ, and extend masses with granules in active movement. The analogy with the form of moderate rapidity of development in the lark is striking; amoeboid movement only is wanting.

In fevers of the true quotidian type there are at first small intra-corpuscular forms, with active amoeboid movement, which become round and pigmented immediately before the onset of a new paroxysm; the pigment is collected at the centre, and the surrounding parasitic mass breaks up into spores. Fortunately all do not undergo sporulation-a portion die in the shrunken red blood-cell that has become brass-colored; others continue to grow, remaining round and becoming free; more frequently they become extended, and distribute themselves at the periphery of the red blood-corpuscle; they continue their extension, and curve round to form crescents. Meanwhile the red blood-corpuscle has become paler, and finally disappears; at most there remains a margin at the concavity of the crescent, and almost always a layer of hæmoglobin surrounding the parasitic mass. Recent observations have failed to confirm the occurrence of sporulation. The crescents degenerate more slowly at ordinary temperatures than in the thermostat, while those of the rapid cycle, which have begun to sporulate in the circulating blood, complete their sporulation. The crescents become egg-shaped or round; the movement of the pigment-granules may be very active, but only very rarely are flagellæ extended. In the course of from five to ten days, sometimes earlier, the phases of another kind of degeneration may be observed. The red blood-cell in which the parasite develops again becomes more distinctly visible; the layer of hæmoglobin surrounding the parasite disintegrates, and then the parasite itself disintegrates. Thus, pale fragments of the red blood-corpuscle with the hæmoglobin-colored parasite-mass, and with accumulated or disseminated pigment-granules, may be seen. The hæmoglobin-colored crescent may also be seen immediately after the removal of the blood-from which it must be concluded that the degeneration has taken place in the circulating blood. Slowly the hæmoglobin color fades, and of the whole mass only the black granules remain.

Inoculations with blood containing crescents and parasites in sporulation respectively were attended with negative results. Inoculations with splenic fluid obtained several hours after death from cases of pernicious fever of two spleenless guinea-pigs, two normal guinea-pigs, two spleenless white rats,

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three normal white rats and two kept on ice, a porcupine and a bat, two doves, two turtle doves, and numerous frogs and tortoises and other coldblooded animals, were all negative.

In the various classes of vertebrates, the parasites considered have the following common characters: 1. A seat in the red blood-corpuscle, in which they remain during the entire intra-corpuscular stage, which may normally advance to sporulation; those forms that after a longer or shorter residence in the red blood-corpuscles do not undergo sporulation, have a more or less short free stage in the plasma. So that the analogy, but not the identity, of the various intra-corpuscular parasites in the various animals, would be the following: For the intra-corpuscular stage, between the respective small, medium-sized, and large forms, to the stage of sporulation in batrachians, reptiles, birds, and man; for the free stage, in the blood-plasma between the drepanidium of batrachians and of reptiles, the free forms in the blood of birds, the quartan, tertian, and quotidian preceding the free phase; the forms that do not sporulate have an intermediate stage of intra-corpuscular existence in which the forms correspond in the various animals examined. 2. Endogenous reproduction through gymnospores without preceding encapsulation. 3. A structure composed of two substances, of which one takes up much and the other little color, and a vesicular nucleus.

One differential character resides in the fact that in cold-blooded animals the hæmoglobin is not reduced, and, as a rule, the red blood-corpuscle is not destroyed. In birds and in man, on the contrary, the blood-parasites are sustained at the expense of the hæmoglobin, which is converted into melanin -whence results the melanæmia. Ascending from the lower animals to man, the free phase in the plasma is seen to progressively diminish, and the intracorpuscular stage to increase in importance; at the same time, the parasitic activity increases in correspondence with the rapidity of reproduction. In man, before sporulation takes place, all forms display active amoeboid movement, of which only indications are present in lower animals. The relationship between the parasites of birds and those of man is so close that the forms of slow, rapid, and accelerated development correspond with the quartan tertian, and quotidian.

Celli and Sanfelice are unwilling to state whether or not various forms represent a single variable parasite or definitely different varieties. All of the intra-corpuscular organisms are conceded to be sporozoa, divisible into three classes: 1. Gregarina; 2. Myrosporidia; 3. Sarcosporidia; to which may be added a fourth-hæmosporidia. The last are characterized not only by their seat in the red blood-corpuscle, but also by their mode of development. In addition to the differences in the developing and the adult forms, the hæmosporidia do not become encapsulated before they form spores, and their spores contain no sickle-shaped bodies, as do the coccidia and gregarina, nor polar bodies, as do the myrosporidia. Hæmosporidia may be divided into three genera: Hæmo-gregarina (batrachia and reptilia); hæmo-proteus (birds); plasmodium (man). The chief characteristics of the three genera are respectively as follows: 1. Inabilty to reduce hæmoglobin and to destroy the red blood-corpuscle; the free stage in the blood-plasma is well organized and reminds one of free gregarina. 2. Conversion of hæmoglobin into melanin; the free stage is insignificant. 3. Active amoeboid movement preceding sporulation.

SURGERY.

UNDER THE CHARGE OF

J. WILLIAM WHITE, M.D.,

PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE
UNIVERSITY AND GERMAN HOSPITALS;

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THE OPERATIVE TREATMENT OF THE ENLARGED PROSTATE. KEYES (Medical Record, vol. xl., No. 18) arrives at the following conclusions in regard to the treatment by operation of prostatic hypertrophy: 1. Prostatectomy is justifiable, and does what nothing else can. 2. The perineal operation is somewhat less severe, but decidedly less reliable than the supra-pubic; it should rarely be preferred, unless there be urethral complications. In very feeble men it may still be elected. 3. The operation is not justifiable, with present statistics, if the patient can be comfortable in catheter life. 4. No physical condition of the parts or of the patient short of a practically moribund state contra-indicates operation. By it in desperate cases life is often actually saved, although the operation is a grave one and its mortality high. 5. With the rongeur-better than any instrument— the bladder outlet can be lowered, and polypoid or interstitial growths jutting into the prostatic sinus can be removed, and these points are more essential to a successful operation than is the taking away of a large portion of the prostatic bulk. The instrument next in value is the curved scissors, but the skilled finger is most important of all. Most of the work has to be done by the aid of touch, as the bleeding soon becomes free and renders visual inspection impossible. 6. Diuretin, perhaps, is of value when the kidneys are damaged, It certainly does no harm. 7. Chloroform alone should be used as an anaesthetic, for the sake of the kidneys.

ACTINOMYCOSIS HOMINIS.

DR. JOHN B. MURPHY (North American Practitioner, vol. iii., No. 12) reviews the history of actinomycosis, 251 cases of which have been reported up to January, 1891, adds 5 cases of his own, and comes to the following conclusions:

1. The treatment consists of a radical extirpation of the entire mass, as can frequently be done in a case where the lower jaw is attacked primarily and where the disease has become detached from the bone by the reparative process, as in one case of mine, and in many reported by other observers. Where radical extirpation is impossible curetting is very efficient, if care be

taken to follow all sinuses to their extreme ends. As this disease attacks the muscle or bone only superficially-i. e., the periosteum and the inter-muscular, connective, and fatty tissues-it can be removed without any considerable amount of destruction of these tissues by the curette. The surrounding tissues are thoroughly protected from injury by the diffuse induration which extends far beyond the site of coagulation necrosis. The walls of the vessels stand out for several inches with all the surrounding tissue eaten away. They should be ligated at both ends and cut out, otherwise they are liable to rupture and cause fatal hemorrhage. Simple drainage of an actinomycotic cavity is not sufficient, as the germs continue to invade the walls, and many sinuses are found leading from the cavity and forming new foci, which are not drained. The limit of invasion can be recognized by the golden-yellow or orange-colored slough produced by the disease; this is particularly well marked where suppurative infection is absent. The process of repair after operation is very rapid. So far, medical treatment has been of no avail. The vast majority of cases, not accessible to surgical eradication, terminate fatally, the exceptions being rare cases where the disease seems to die of inanition. 2. The growth of the disease is very indolent and sluggish, except in the peritoneal cavity. 3. It is accompanied by very little pain. 4. The microbe does not produce a ptomaine that has the effect of causing an elevation of temperature. 5. Pure infection by the actino-cladothrix is not accompanied by pus. Pus is present only after a secondary infection with the streptococcus pyogenes. 6. The amount of infiltration around each nodule of granulation and its sero-purulent contents is very great compared with small contents. 7. The greater the amount of suppuration the more malignant and rapid is the progress of the disease. 8. Diffusion of the actinomyces in loco or by entrance into the blood-stream is the mode of extension-never along the lymphatics and glands. Its extension is greater in opposite directions to the course of lymphatics. 9. After evacuation of contents the nodule heals rapidly, but in a few weeks or months reappears, if all germs were not removed. 10. Fatal symptoms are very tardy in appearing, due principally to the very great connective tissue infiltration, barring the progress of the dis

ease.

THE TREATMENT OF ABDOMINAL WOUNDS.

MICHEL WASSILIEFF, discussing the treatment of these wounds (Revue de Chirurgie, 1891, No. 11), says: "The position of the surgeon is very difficult in doubtful cases. How shall he act when he is ignorant of the condition of the viscera? To make a laparotomy immediately is a serious step, perhaps useless, for the viscera may not be injured. On the other hand, to postpone operation and wait for more serious symptoms is to endanger the life of the patient." He then quotes Augagneur, who claims that the three dangers to life-internal hemorrhage, shock, and peritonitis-do not justify laparotomy, the first and second because they may of themselves cease, and the third because it has no definite symptoms, for those usually ascribed to it may be due to shock. The grounds on which Reclus and Nogués justify operative interference are as follows: Internal hemorrhage; issue of fecal matter and

gas from the wound or the distending of the abdomen by gas; and symptoms of peritonitis. They would prefer systematically no operation to always operating immediately, supporting their opinion by statistics. With no operation they find a mortality of 12 per cent. in punctured wounds and 25 per cent. in gunshot wounds, against 24 and 63 per cent., respectively, where there was operative interference. Wassilieff says, however, that the majority of surgeons prefer operating, and that promptness has much to do with success. He cites six cases of his own, four of which recovered without fever after laparotomy, washing with a 1: 8000 sublimate solution, and tamponing with iodoform gauze. All were punctured wounds, with injuries of the viscera. The fifth and sixth cases-both without early dangerous symptoms, one a punctured wound, the other a contusion-died without operation, and section showed peritonitis due to wounds of the viscera. These cases lead him to believe that in all cases where there is a perforating wound-or, as he puts it, where a laparotomy has been begun-it should be completed; but he finds it difficult to decide the question in cases of contusion such as the last. Where there exists the least suspicion of a visceral wound he advises immediate operation. He says: "Certainly we would have obtained better results in these last two cases by operating, and therefore my advice is, that it is better to operate without finding visceral lesions rather than commit the fault of neglecting a case that has internal injuries."

He discredits the authority of the statistics quoted, both on the ground of the period that they cover, and also the unwillingness of operators to report unfavorable cases.

TREATMENT OF SOME DISLOCATIONS OF THE ELBOW.

STIMSON (New York Medical Journal, vol. liv., No. 17) calls attention to an error very commonly made in the examination of old unreduced luxations of the elbow. This consists in mistaking certain outgrowths of bone which appear promptly after dislocation for displaced fragments, or exuberant callus in fracture. The surgeon, supposing the lower end of the humerus to be irremediably deformed, refrains from attempting what he supposes to be an impossible reduction. In reality the articular surfaces have undergone no change in shape, and so far as they are concerned a restoration of the normal relation is possible. In these cases reduction of the dislocation and restoration of function are absolutely impossible excepting by an arthrotomy with removal of the bone outgrowths.

Eight cases are recorded, six of whom underwent operation. In all but one case the dislocation was backward. In one it was backward and upward. The age of the dislocation varied from three weeks to five months. In all, flexion and extension were entirely, or almost entirely, lost, the limb being fixed at an angle of about 145 degrees. Rotation of the forearm was preserved in all but one. The feature of interest was the prominent mass of bone seen and felt above the displaced head of the radius and continuous with the back of the external condyle. This mass was broadly attached to the back of the condyle, and its free end extended forward, almost completely covering the upper surface of the radius and forming a new articulation with it. The

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