tender on pressure; in two others there was slight pain with some fulness in the scar, and in the fourth there was a definite hernia at the site of operation as large as a hen's egg. (3) Those patients operated upon during a subacute attack or in a quiescent period were thirty-two in number, and furnished the following replies: Twenty expressed themselves as being better in every way and much benefited by the operation; nine could find some symptoms which they thought possibly due to the scar for example, four had noticed slight occasional pain on exertion or on coughing, one suffered from constipation, one from "flatulent dyspepsia," another from tenderness in the scar, and three thought that the scar showed more prominently than before. Medical Record.

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ACUTE PANCREATITIS.

Wm. S. Thayer (Johns Hopkins Bull., Nov., 1905) reports five most interesting cases of acute pancreatitis, in all of which where operation took place, and in all of which the diagnosis was established, from the clinical course of the disease, and from the physical examination.

Thayer calls attention again to the experimental work that has been done by Koerte, Flexner, Opie, and others, and mentions the important observations of Opie and Halstead on the retrojection of bile as a causative factor in pancreatitis complicating gall-stones. Lately there has been noted the fact that a large number of cases of acute pancreatitis occur during pregnancy and the puerperium. According to Thayer, glycosuria is of little diagnostic assistance in pancreatitis. The examination of the feces often leads to more definite aid, but to do this work thoroughly, the patient must be most carefully fed, and this is not possible with patients that are as ill as patients of this class usually are. Opie and Hewlett have both demonstrated the importance of lipase in the urine.

The most important point brought out by the review of these cases seems to be the favorable result of early operation. Three of the four cases of suppurative pancreatitis operated upon recovered. St. Louis Medical Review.

DEATH FOLLOWING SCOPOLAMIN-MORPHIN ANESTHESIA,

Sexton's patient, aged 47, had been in poor health for five years, principally on account of excessive bleeding from the uterus. A diagnosis of fibroid was made and operation was advised. The patient was anemic and had a weak heart, but otherwise presented no evidence of disease, except of the uterus and ovary. She was prepared for operation as usual, and at 7:30 A. M. a hypodermic of scopolamin hydrobromate, 1-100 grain, and morphin sulphate, 1-6 grain, was given. The patient was sound asleep in fifteen minutes. At 8 A. M. she was found unconscious, slightly cyanosed, pulse 120 and throbbing, respiration 20 but very shallow, abdominal muscles and intercostals rigid, so that it was impossible to compress the lower chest and epigastria. The muscles were contracted markedly. The jaw dropped, the mouth was open, and the eyeballs were turned up. All efforts at resuscitation failed and the patient died at 9:15 A. M. without the least response to stimulants, pain, heat, flagellations, or changing posture.- Jour. A. M. A.

ETIOLOGY OF APPENDICITIS.

Professor Lucas Championnere (International Journal of Surgery) formulates the following theory, in regard to the etiology of appendicitis: The great frequency of appendicitis is promoted by influenza, but the foundation for this influence has been previously laid by excessive meat consumption.

After all, then, we return to the point from which we started, that appendicitis is primarily dependent upon digestive disturbances, since the preponderance of animal food predisposes to putrefactive processes and also to constipation, owing to the inadequate supply of those vegetable constituents which afford the necessary ballast and stimulate peristalsis. From a prophylactic point of view these observations are of great significance, for there is no doubt that appendicitis has increased in frequency during recent years, and the influence of a more luxurious diet as an etiological factor is deserving of careful investigation.

It is not difficult to understand why influenza should predispose to appendicitis, since the gastro-intestinal form of la grippe is not uncommon. Although appendicitis is the result of an infection, no specific microbe has been isolated, and there is every reason to believe that various organisms may give rise to its development. If this be true, not only rheumatic fever and influenza, but any constitutional infection may be concerned in its causation, provided the appendix offers a favorable soil for the growth of the invading germs.

But there is another way of looking at the subject. Every severe general infection is accompanied by more or less disturbances of the digestive apparatus, and if these persist they may furnish a soil favorable for microbial activity. It must be borne in mind that the healthy intestinal tract swarms with micro-organisms of various kinds, which, like the bacterium coli, may under certain circumstances, acquire a virulency which they previously did not exhibit, and then become the source of inflammatory processes in the appendix.-Louisville Monthly Journal of Medicine and Surgery.

BULLET WOUND OF THE HEART.

A most interesting case of this kind is communicated by Professor Manteuffel. The patient, a girl, 21 years old, on September 12th, at about 3 P. M., was shot with a revolver, the weapon being placed against her naked breast. She became unconscious and on awakening vomited, and about 4: 30 got up and rang for a servant. A friend of the patient, a sister of charity, was summoned, and gave an injection of camphor, and not until 6:20 was Manteuffel consulted. At that time she was pale and cyanotic, the pulse 80 and scarcely perceptible. The vomited matter contained no blood, and there was no effusion in the pleural cavities. The opening of entrance of the bullet was close to the margin of the sternum; the area of cardiac dulness was not increased. Although believing that the patient would not long survive, Manteuffel had her transported to the clinic, and at midnight, 9 hours after the injury,

she was etherized. On opening the pericardial sac, which was filled with blood, there was found in the right ventricle, 6 cm. from the apex, a perforation, from which during diastole a column of blood spurted to the height of half a meter. This opening was at once closed with silk sutures, and the bleeding arrested. The bullet could be felt in the posterior wall of the right ventricle. The heart was held up, the bullet cut down upon and extracted, and the wound sutured. The pericardial wound was then closed with four sutures. Immediately after the removal of the blood from the pericardium the pulse improved, and with the exception of a light serous pericarditis recovery was uneventful, the patient being able to leave the bed on the 20th day. Manteuffel prefers a longitudinal incision with an adequate resection to the flap incision.International Journal of Surgery.

MEDICAL

DIET IN NEPHRITIS.

Grube (Deutsche Medizinal Zeitung, May 9, 1905), in discussing the dietetics of nephritis, sides with Rosenstein and von Noorden against Senator and Grainger Stewart in advising a mixed rather than a purely milk diet. Some cases of chronic nephritis are benign, others severe, and results are often ascribed to diet which are in reality dependent on the mildness or otherwise of the case. The alleged advantages of milk are that it diminishes the albumin, does not irritate the kidneys, contains no toxic substances, favors diuresis, and is entirely assimilated. Grube points out that to diminish albumin is not, per se, of great moment, that other diets are equally non-irritant, free from toxic substances, and assimilable, and that diuresis is not always desirable. The principal draw-back to an exclusively milk diet is that it is insufficiently nutritious. He advises that red and white meat and eggs be given in the same proportions as in an ordinary mixed diet, especially when edema develops. in consequence of cardiac feebleness. Details in support of this

view are given briefly as follows: In interstitial nephritis the quantity of urine is greater on a milk than on a mixed diet, but when the ratio of excretion to intake of fluid is considered, it is greater on a mixed diet. The specific gravity is higher on mixed diet. Albumin is on the whole less on mixed diet. In parenchymatous nephritis the results are much the same. In an instructive paper (Jour. Am. Med. Assoc., Chicago, 1905, June 24) Croftan discusses inter alia four new points in the treatment of Bright's Disease: (1) Decapsulation he condemns absolutely. (2) Liberal feeding. Starving may suit acute cases; when the disease is chronic, full nutritive diet is required. Milk is insufficient both in general nourishment and in iron. (3) Restriction of fluid. It is unnecessary to urge the patient to drink largely. (4) Withdrawal of chlorides. If the edema increases, chlorides should be tentatively withdrawn.- Edinburgh Medical Journal, November, 1905.

DEPLETION BY MEANS OF SALINE PURGATIVES.

Saline purgatives are used to lower the blood pressure and thus prevent the rupture of a blood-vessel, and consequent apoplexy, or to prevent further extravasation in a case in which the vessel has already burst. Lauder Brunton says that the regular use of aperients is especially necessary in gouty persons with contracted kidney and high blood pressure. How far their utility is to be ascribed, however, to their direct effect in lowering the blood pressure, and how far to the removal of waste products which might raise the pressure, it is impossible to say. The utility of purgatives after apoplexy has occurred may be doubtful, and though usually administered, they probably do no good if the arterial tension is abnormally high; purgatives, especially the salines, lower it, as the sphygmographic tracings show. When a considerable quantity of serum is withdrawn from the intestinal vessels, the blood pressure is necessarily diminished elsewhere. Free transudation from the blood-vessels to the intestinal canal lessens the amount of work which the kidneys have to do, and if these organs are hyperemic, removes the congestion.