and a half, perhaps, to read all of that subject pertaining to appendicitis, and you would not have learned any more at the end of that time, I venture to say, than you have from the discussion which has followed the reading of this paper, because the suggestions brought out therein are more modern than textbooks; they are suggestions that come from surgeons today, and not six months or six years ago. It looks to me like the opinion of the surgeons is a unit, and I think the time is not far distant when appendicitis will be regarded the world over as a strictly surgical disease. I do not believe in operating until you have made a diagnosis, but I do believe in operating when the proper time arrives, and from my paper and from the discussion which has followed, the proper time has been brought out clearly and forcibly. Just as soon as the diagnosis of appendicitis is made, the abdominal cavity should be opened and the appendix removed, provided the case is seen within the first twenty-four hours from the onset of the attack; if later than this, conditions and circumstances, backed by experience and good judgment, must govern your course. About appendicitis in the negro, I think that is a question which is worth a word or two. The negro anatomically is a counterpart of the white man, and why should he not have appendicitis just as well as the white man? In fact, I believe they are even more liable to the disease than white men, for this reason: We all know that traumatism is one of the active causes of appendicitis, devitalizing the tissues, thereby favoring the attack of pyogenic organisms. Negroes are laborers, while white men as a rule live sedentary lives; negroes are more subject to injuries of all kinds and to the violent exercise of the iliac and psoas muscles, producing, it is claimed, trauma of the appendix, thus favoring attacks of appendicitis. I think the argument that you do not have appendicitis in the negro, is fallacious. I believe they have it, in proportion to numbers, quite as often as white men. They are not treated by the surgeon, they are not operated upon, and therefore it goes by as something else. I have operated upon a number of cases of appendicitis in negroes who have come under my care in the wards of the hospital. In conclusion, to sum up the matter, if in this disease, as in brain lesions, the profession would accept the principle that it is surgical, and that all cases of appendicitis in the onset of the attack are proper subjects for exploratory operation, death would be a rare result. How happy is he born or taught, And simple truth his utmost skill. The noblest contribution which any man can make for the benefit of posterity is that of a good character. The richest bequest which any man can leave to the youth of his native land is that of a shining, spotless example.- Winthrop. PROGRESS OF MEDICINE. MEDICINE. UNDER CHARGE OF B. F. TURNER, M.D. Visiting Physician St. Joseph's Hospital, Memphis. On a Family Form of Recurring Epistaxis, Associated with Multiple Telangiectases of the Skin and Mucous Membranes. W. Osler (Johns Hopkins Hosp. Bul., vol. 12, no. 128) reports three cases of this rare and interesting condition. The first patient was a man aged fifty-seven, who had been having attacks of epistaxis from boyhood. Seven member of his family were similarly affected with attacks of epistaxis. He had telangiectases on the skin of his face, and on the mucous membranes of the nose and mouth. A second case was a man aged fifty-five, who also had been having attacks of epistaxis from childhood. He developed telangiectases of the skin and mucous membranes, bleeding from some of the spots. Autopsy revealed cancer of the stomach, mesentery, omentum, liver, retroperitoneal glands,lungs and brain. The third case occurred in a man aged forty-nine, who had suffered from recurring epistaxis since his tenth year. There were multiple telangiectases of the skin and mucous membrane of the nose and mouth. Osler remarks that angiomata are very peculiar and remarkable structures, in which he has been interested for many years. Apart from the big nevi and angiomata with surgical relations there are: 1. The pin-point, punctiform, capillary angioma, of which few skins lack examples. They may be numerous, but they are rarely disfiguring. They appear and disappear. For ten years he had one the size of a pin's head on a finger. 2. The solid, nodular nevus, ranging from 1 to 4 or 5 mm. in diameter, forming a definite little tumor, either sessile or pedunculated, and very common on the back. 3. The spider angioma, formed by (a) three or four dilated veins, which converge to and join a central vessel; or (b) which unite at a central bright red nodule projecting a little beyond the skin. They are very common, and doctors are often consulted about their presence on the face. As examples may be found on the skin of nearly everybody, these three varieties may be regarded as almost normal struc tures. When the punctiform or spider angiomata increase greatly in numbers they are very disfiguring. In one case the skin of the face was peppered with them, and at a distance the patient looked disfigured with a bright, fresh acne rash. In another they had also proved a source of danger, as he had bled from them repeatedly. An individual spider angioma may increase in size, or, as in the cases here related, they may become very numerous. Angiomata have a curious relationship with affections of the liver. In cirrhosis, in cancer, in chronic jaundice from gall stones, spider angiomata may appear on the face and other parts. They may be of ordinary stellate variety, like the stars of Verheyen on the surface of the kidney, or the entire area of the star may become diffusely vascularized, so that there is a circular or ovoid territory of skin looking pink or purple, owing to the small dilated venules. A dozen or more of these may appear on the trunk, or even large ones may disappear. And lastly, in a few cases of disease of the liver he has seen large, mat-like telangiectases or angioma involving an inch or two of skin, looking like a very light birth-mark, but which had appeared during the illness. The skin was not uniformly occupied with the blood vessels, but they were abundant enough on the deeper layers apparently to give a deep change in color and to form very striking objects. The dilated venules on the nose, and the chaplet of dilated veins along the attachment of the diaphragm, are not infrequently accompaniments of the spider angiomata in cases of disease of the liver. Osler has recently seen the spider angiomata appear in the face in a case of catarrhal jaundice. Character, like porcelain ware, must be printed before it is glazed. There can be no change after it is burned in.—Beecher. SURGERY. UNDER CHARGE OF W. B. ROGERS, M.D. Professor of the Principles and Practice of Surgery and Clinical Surgery, A Case of Suture of a Stab Wound of the Heart, with Remarks on, and a Table of, Cases Previously Reported. G. T. Vaughan (Med. News, vol. 79, no. 23) reports a case of stab wound of the heart operated upon by him, in which, however, the outcome had been fatal. The entire literature reveals reports of 26 cases sutured, with a mortality of 76.93 per cent. Without doubt the greatest immediate danger is from hemmorrhage, next from shock and entrance of air into the heart. Then comes the danger from pericarditis, empyema and pneumonia. Of the 26 cases, 1 had pericarditis; 2 empyema; 2 empyema and pericarditis; 1 empyema and abscess of right lung, and 1 bronchopneumonia-7 cases with infection, all of which were fatal except the 2 cases of empyema only. The urgency of the symptoms and the necessity for prompt and rapid action often prevent the observance of proper aseptic precautions a fact which probably accounts for the frequency of infection. The author feels that a review of these cases justifies the following conclusions: 1. The time has arrived when a wound of the heart should be operated on with as little hesitation as a wound of the brain, with the expectation under corresponding conditions of getting equally good results. The mortality must inevitably be high -not from the operation but from the injury-especially if all cases including desperate ones be undertaken. Selection of cases who have survived five or more hours after receiving the wound would give a good percentage of recoveries, but such selection is not to be recommended. 2. In all cases of wounds in the region of the heart, with symptoms threatening life, an exploratory operation should be done by making an osteoplastic flap by dividing the fourth and fifth costal cartilages at their attachments to the sternum and the ribs about one inch external to their attachment to the cartilage, somewhat according to the method of Roberts. This flap turned up as a door on a hinge gives a good view of the pericardium and can easily be enlarged upward if more room is required. 3. While early and speedy operation is often essential to success, yet the importance of asepsis cannot be too strongly emphasized on account of the great danger of pericarditis and empyema. If there has been much hemorrhage a quantity of physiological salt solution, approximately equal in amount to the blood lost, should be injected into a vein while the surgeon is operating on the heart, if it has not been done sooner. The Treatment of Aortic Aneurism by Means of Silver Wire and Electricity. L. Freeman (Amer. Jour. Med. Sc., vol. 27, no. 7) says: 1. Considering the inefficiency of medical treatment, and the comparative efficiency of the use of silver wire and electricity, it is probably better to proceed to the latter at once without wasting valuable time upon the former. This seems all the more desirable when we consider that wiring is not a very dangerous process, and that it is in the early stages of an aneurism, when the sac is still firm and the patient is in good condition, that the best prospect of cure exists. 2. Soft, undrawn, unalloyed silver wire devoid of springwire just as it comes from the shop-is preferable to the hard, highly drawn wire alloyed with copper and full of spring. It is hardly necessary to previously coil the wire. 3. It is still an open question as to which is preferable, a large amount of wire or a small amount, with the theoretical advantages in favor of the former. 4. A strong electric current is apparently preferable to a weak one. 5. The canula through which the wire is introduced should be inserted just within the sac, and no further. 6. There is little if any danger of bursting the aneurism from increase of pressure due to coagulation in a portion of the sac only. |