April 20, Widal test positive in twenty minutes, dilution 1 to 25. Leukocyte count Leukocyte count was 7,400. Urinalyses normal throughout the attack. No complications. Tympanites very great from the 6th to the 15th, gradually subsiding under the use of turpentine stupes and turpentine internally. Highest temperature range 103.6°. Temperature reached the normal line on the 20th, and continued near the normal line thereafter. Diet strictly fluid until the 28th, when he had one egg. On the 29th and 30th two or three eggs with a little toast. On the morning of May 1 I saw him, apparently in excellent condition. and thoroughly convalescent. Spleen almost Spleen almost normal in size, no abdominal tenderness or distension. In the evening the house physician telephoned me that the patient had, at 3 P. M., complained of sharp and severe pain in the abdomen localized about the umbilicus. Temperature had gone up to 102.6°, pulse 112, respiration 28. I telephoned Dr. Carson and we saw the case together at 8 o'clock. Temperature was then 103°, pulse 140. The facies did not express severe suffering, but he complained of pain when questioned, and there was some tenderness about the umbilicus and over the right hypochondrium. The white count, made at 5:30 P. M., was 23,600. Percussion gave resonance up to lower border of the sixth rib. The house physician thought the distension of the abdomen greater than in the early evening. The patient had urinated seven times between 3:30 and 5 P. M. Urinalysis showed nothing

abnor

There was no muscular rigidity, or at leas. so little that it had no significance. At 4:30 he had had a simple enema followed by the passage of a greenish, semi-fluid stool, with some gas.

We certainly had in this case a preponderance of evidence in favor of perforation. He had had, during the acute stage, marked tympanites, indicative of extensive or deep ulceration; now, in the second week of convalescence, sudden pain, sudden elevation of temperature, very high pulse, distension of abdomen, marked tenderness to pressure, leukocytosis, and a symptom which has frequently been pointed out as indicative of perforationfrequent micturition. On the negative side we had the absence of facial expression of extreme pain; but it must be remembered that the so-called hippocratic facies is a sign, not of perforation, but of the consequent peritonitis. Perhaps the most important negative sign was the absence of abdominal muscular rigidity. On the negative also must be counted the absence of shock, but this is a sign which is also absent in some cases of

perforation. To the resonance which obscured the normal dullness over the lower portion of the liver we attached little weight, as we believed that it was transmitted resonance from the colon, and not due to free gas in the abdomen.

In view of the great importance of early operation in perforation we believed that justice to the patient demanded that he should be given the benefit of the doubt and the abdomen promptly opened. Operation was made at 9 P. M. by Dr. Carson. The opened abdomen revealed intestines and peritoneal surfaces almost normal in appearance. A careful search of the whole intestinal tract failed to reveal any sign of a perforation, but high up in the ileum was found a kink in the small intestine, the bowel at that point, upon being drawn out through the abdominal opening, looking as though it had been compressed. There was some congestion about that area, and the bowel more distended above than below it. The patient went on the operating-table with a temperature of 102°, pulse 130. Just before the anesthetic he was given a hypodermic of morphine, grain, and atropine, 1-120 grain. At 10 P. M., after being put to bed in the surgical ward, his temperature was 97.4°, pulse 120. During the night he had one hypodermic of 1-6 grain of morphia and ten drops of veratrum viride. At 2 A. M. he had a thin, brown stool. May 2, 6 A. M., temperature 98.6°, pulse 96.

The highest temperature following the operation was 99.6°, pulse for several days ranged between 100 and 112. He made an uninterrupted recovery.

A case very similar to this is described by Dr. John B. Roberts in the Annals of Surgery, August, 1906. Dr. Roberts' case had symptoms of perforation, was operated upon and made an uninterrupted recovery. Dr. Roberts refers to two cases reported by Dr. Allan Eustis in the New Orleans Medical and Surgical Journal (1904-1905, vol. Ivii.), in which volvulus was discovered at autopsy in typhoid patients where symptoms had indicated perforation.

"In doubtful cases it is best to operate, as experience shows that patients stand an exploration very well." (Osler.)

In an article in the Journal of the American Medical Association (1905) Manges says it is far better occasionally to make the mistake of operating without there being any perforation than of operating after the clinical picture has become so clear that the patient has no chance of recovery.

Robert B. Preble, in Progressive Medicine, March, 1906, collects ten cases diagnosed as

perforation and the diagnosis proved wrong either by autopsy or by operation. In two cases appendicitis was mistaken for perforation; in two cases gastritis and entero-colitis were causes of error; in two cases left basal pneumonia was the correct diagnosis; in two cases no cause was found for the symptoms; in one case Zenker's degeneration of the right rectus was found, and in one a healed ulcer with secondary rupture. Seven of the ten cases were operated upon with three deaths, none of the deaths being attributable to the operation.

CASE II.-The history of the other case referred to, in which operation was not made, was as follows:

C. W., aged thirty-six, entered the hospital March 25, giving a history of having been ill for some five weeks previous. This illness, as described, corresponded with the course of a moderately severe typhoid. His symptoms, on admission, were those of the declining stage. The Widal test was negative, white count 4,900, urinalysis normal. The temperature gradually declined, and on the morning of April 12 was 99°, pulse 98. On the 9th he had complained of pain in the left shoulder; on the 12th this pain was more severe and there was a little tenderness about the shoulder. At 3:30 P. M. of the 12th he complained of severe abdominal pain and the temperature rapidly rose to 103°, pulse to 120. The pain, which came on suddenly, seemed to increase toward evening, and there was tenderness and general abdominal rigidity. He was examined at 8 P. M. by Drs. Greiwe, Carson and myself. At this time the temperature was 102.6°, pulse 116. Face not expressive of great pain. The tenderness and rigidity were over the upper portion of the abdomen, extending to the left and to the back over the region of the left kidney. Liver dullness normal. The white count made in the early evening was 12,300. The Widal test showed partial clumping in one hour. Nothing abnormal was found in the examination of the chest. Urinalysis was normal (chemical and microscopical). It was decided that the symptoms were not sufficiently definite to warrant operation at that time. On the next morning the temperature was 98.2°, pulse 80, general condition good, rigidity somewhat relaxed; still complained of pain over the epigastrium and the left hypochondrium. The pain gradually disappeared. With occasional fluctuations of temperature the patient made an uninterrupted convalescence and was discharged well on May 8.

These cases would seem to show that little reliance can be placed upon the white count as indicative of perforation. In both a moderate leukocytosis was found very soon after the onset of symptoms.

DISCUSSION.

DR. B. M. RICKETTS: I am glad to hear these reports, because of their bearing upon a most desperate condition-one that about 50 per cent. recover from when treated surgically. It is better to err in opening the abdomen in typhoid when perforation does not exist than to delay or not open it when perforation does exist.

Rigidity may or may not be present in typhoid perforation or any other intra-abdominal lesion in the right lower belly area. However, it is usually present when the head of the cecum is especially involved, as in typhoid fever and appendicitis, but it may exist in diseases of the ovary, tubes or uterus. The causes of this rigidity are not known or understood, and while Byron Robinson gives reason for the referred pain in the upper abdomen in lesions about the head of the cecum, he does not attempt to do so for rigidity of the right rectus muscle.

The cecum from its head to the splenic flexure is dominated by a branch of the diaphragmatic plexus, hence the pain in the epigastrium. Perforations, one or more, may have been present even though they were not found. Some are so small that it is almost impossible to detect them with the best light and opening. In such cases it is best to be content with simple drainage; even when the openings are large, single or multiple, this is best, as it has been found unnecessary to suture the perforation.

Successful results are proportionate with successful drainage, and it is better to operate in ten cases without perforation than to not operate in one that has perforation. The good results in the first will far exceed the latter instance.

DR. W. E. KIELY: How soon after perforation should one expect to find rigidity? Is rigidity not due to peritonitis?

DR. RICKETTS: No, no; many times we find rigidity without peritonitis. We have rigidity before or after perforation, but it is more intense in perforation.

DR. EARL HARLAN: I merely wish to commend Dr. Mitchell for having presented these cases tonight. I believe, with Dr. Ricketts, that it is better to err on the side of early operation in cases like the doctor has presented, giving the patient the benefit of the doubt, than to have done no operation at all. The consensus of surgical opinion is that early operation should be done in all of these cases where perforation is suspected; and especially is this position recently reinforced by the knowledge gained that the mortality of exploratory laparotomy is nil in these cases. Both surgeon and internist should follow the example indicated by Dr. Mitchell, as has been indicated by the case reports this evening.

DR. MITCHELL (closing): I have little more to say. It is a revelation to find from experience how well the typhoid fever patient endures a laparotomy. A priori, one would suppose that opening the abdomen either in the course of the disease or early in the convalescent period would precipitate a fatal issue. Since we have learned that a skillfully made operation adds very little to the danger, and in cases of perforation gives the patient one chance out of four for recovery, whereas without operation he probably has not more than one chance in a hundred, it is certainly an imperative duty to give the patient that

better chance. In doubtful cases the fact that the opening of the abdomen adds so little to the danger should encourage us to give the patient the benefit of the doubt by operating early.

In diagnosis no one symptom is pathognomonic, and the decision must often be made by the preponderance of evidence. Other conditions sometimes most closely simulate perforation. On the other hand, perforation may occur with very few symptoms. I am sure that every man who has had the opportunity of following numerous cases from the hospital wards to the post-mortem room has had the surprise of finding perforation as the cause of death in cases where it had hardly been suspected.

In the second case reported the preponderance of evidence was against the existence of perforation, and a few hours' delay made it practically certain that there was not. The issue in this case justified withholding the knife, as the issue in the other case justified its early employment.

Barton's Fracture.

DR. EARL HARLAN reported the following

case:

Col. J. E. F., male, aged forty-five years. Occupation, theatrical owner and manager.

The two negatives, taken by Dr. Juettner, which I will pass among you, present a beautiful illustration of the value of the X-ray as utilized in connection with the diagnosis of fractures. The pictures were taken through the dressings. They show a typical Barton fracture of the radius, presenting the separation of the anterior and posterior radial lips obliquely from the joint cavity to the external surface of the shaft. The styloid process of the ulna is probably separated also, but the picture fails to show this feature. There is a T-shaped separation of the end of the bone, with the horizontal arm of the latter situated in the shaft and the vertical portion running longitudinal and communicating with the joint. In this instance the wrist was sprained, with a consequent enlargement of the bursal sac posteriorly and a jammed displacement of the carpus forward and upward. These latter features, with the protruding bursa, gave to the injury the typical silver-fork deformity of Colles, and but for a very careful manual examination might have led to an excess of misguided efforts, with consequent injury to the joint, in the matter of correction. The fracture was produced by the sudden reversal of the engine of the victim's automobile while attempting a sudden stop of the machine, the fracture representing the destruction resulting from the kick of a thirtyhorse power engine. These fractures were formerly supposed to be of extreme rarity, but will probably prove of more common occurrence, with the advent of the automobile in aiding their production, and the aid of the skiagram in the matter of diagnosing wrist injuries.

The treatment employed in this instance was the free application of the hot bath, three times daily, with removal each time of the bandage and the application of massage and Weaver's iodine. Movement was instituted from the time of fracture. In a week's time, under the above treatment, the discoloration, swelling and soreness about the joint (all except fracture-line tenderness, which latter was the particular feature which led to the diagnosis of Barton's fracture when the case was first examined), disappeared, and the arm was placed in a permanent bandage, which latter will be allowed to remain a week or ten days.

Skiagrams of this case will be presented later, showing, by comparison with the two presented this evening, what the result will be.

Apposition and position were maintained in this instance by the free and careful application of the lint bandage, no splint having been used, except a small bit of cigar-box lid to steady the arm in case of accident from contact of the hand unexpectedly with other objects.

Correspondence.

"SOLUBLE IODINE."

COLUMBUS, O., July 17, 1907.

EDITOR LANCET-CLINIC:

I note the review in THE LANCET-CLINIC, July 6, 1907, under the caption of "Soluble Iodine." It is a pity that so scientific a man as M. I. Wilbert should get his name so sadly mixed with (to use a mild term) doubtful pharmacy. Iodine with resorcin reacts to form the nearly insoluble resorcin iodide. The writer sees no reason for thinking it more efficient than sodium iodide or the other frauds-"colorless iodine" (resorcin "decolorizes" a solution of iodine).

Ammonium iodide is more expensive than potassium iodide, and does the work no better in making a solution. A "2 per cent. alcoholic solution' may be used, but has no advantage over plain water. (See Lugol's solution, liquor iodi compositus of the U. S. Pharmacopeia.) The main point is to use very little water at first, then dilute as desired.

I presume this letter will go to the wastebasket. Doctors don't like to be told things. That is a fundamental reason why these "ready made" pharmaceutical houses continue to thrive at the physician's expense. Very truly,

E. N. WEBB.

THE irritation induced by imperfectly digested food may result in dilatation of the stomach in children.

THE

EDITOR MANAGING EDITOR

News-Items of interest of a medical nature will be appreciated.

Original Papers-Articles are accepted for publication with the understanding that they are contributed solely to this journal.

Correspondence on all matters of clinical interest will be welcomed. Anonymous communications, whether for publication, for information, or in the way of criticism, are consigned to the wastebasket unread.

Remittances should be made by check, draft, registered letter, money or express order. Address

THE LANCET-CLINIC PUBLISHING CO. 317-319 W. SEVENTH ST. CINCINNATI, OHIO

SATURDAY, JULY 27, 1907.

THE REVIEW OF MEDICAL LITERA

TURE.

Matthew Arnold defined literature as a criticism of life. There is an inherent force in everything, in every one, that strives for expression. Every word we speak, no matter how haltingly, is an effort to express a secret we prize. And yet perfect and adequate expression is rare. To some it is given to publish their thoughts properly and all the world listens. Thus great literature is born. These epics, These epics, these discoveries, these original thoughts, are pounced upon with avidity, and they give life and sustenance to starving minds. But these great thoughts may be published but once in a century or a generation; and so they percolate through every gradation and stratum of society by successive interpretations given by critics. It is within the province of criticism to present a truth in everyone of its kaleidoscopic variations; for truth is as varied as human nature. To each it brings a message, and the critic is the interpreter.

In medicine, epoch-making books are rare, but the really important works, dealing with matters of deep concern to the progressive scientific physician, are more numerous than we surmise. "Of the making of many books there is no end"-to find the best, and to select what is needful, we require the aid of competent critics.

Criticism of medical and scientific works is taken very seriously in Europe. Each book is given to an expert, to a specialist along the

of careful study are given to it.

Hours References

are made to authorities, comparisons instituted, citations proved or disproved; and the result is a very adequate review. This renders publishers more careful in undertaking the promulgation of facts; and the authors, knowing what an ordeal is before them, are extremely circumspect in making assertions which are not substantiated. Continental critics are à power to reckon with in medical literature. It is a continuation in medicine of what during the nineteenth century was of immense influence in England in reference to literature, when the serious quarterlies made and unmade reputations.

In this country, where everyone is in a rush to succeed, without taking the trouble of learning the intermediate steps to success, superficiality is the order of the day in every aspect of life. This truth is unpalatable, but it is the truth. Many of our books are mediocre, and hastily written, quite a number of fair average worth, a few are solid, serious, scientific. Who has the leisure and the inclination to sift the chaff from the wheat? Not the busy practitioner, who has the time only for a more or less cursory glance through his medical journals and an occasional hour for his books. So he good-naturedly relies on the reviewers to inform him what is worth while. Then it is a case of the blind leading the blind. The sort of insipid stuff found in medical journals passing current as review is sufficient to upset the stoutest gastric viscus. Puerile reviews," of which those found in the Cleveland Medical and Surgical Reporter and in the Medical Herald are fair samples, are kindergarten criticisms. A member of a New York publishing house told the writer of this recently that it was a serious question whether it is worth while to send books to medical journals for review, since adequate treatment seems impossible. The review department is in most instances a matter of graft, a sop, where the perquisites are distributed to a few disgruntled physicians to gain their good will, or to pay some debt, social or financial, of the editor, or perhaps his better half. The great publishing house.

66

The fulsome remarks, perfunctorily written, ungrammatically expressed, to the brainracking extent of half a dozen lines, are sorry things to offer an author for the child of his brain, born with so much travail and anguish of spirit; they are sorry things, indeed, to the publishers, who have sometimes spent a fortune to bring to the notice of the profession these publications.

The correct interpretation of medical literature for the busy practitioner may be difficult. To properly weigh and classify and compare may require a greater natural talent than that necessary to write the original book. The The advice, "if you haven't anything to say, for heaven's sake, don't say it!" may with advantage be given to many who pose as critics. Let them write a good prescription after making a painstaking diagnosis. The art of imparting knowledge by criticism is not theirs.

With pardonable pride and with becoming modesty THE LANCET-CLINIC points to the revived department of book reviews in its own columns. The busy man may turn with confidence to these pages for an adequate treatment of the books he needs. Criticism must be disinterested if it should be true. Our reviewers are not compelled to rely on publishers for gratuitous copies to fill their libraries. Fear or favor are both unknown. Specialists in their departments take the time to read a book in their line, to write as well of the shortcomings as of the excellencies. Hence our reviews are reliable.

Medical literature is an expression of our progress in the science and art of medicine. Let us treat it seriously; let us read it understandingly at least that much of it which is worth while.

MEETING OF THE OHIO STATE
PEDIATRIC SOCIETY.

During the last decade pediatrics has assumed increasing importance. The number of men who are devoting themselves to this specialty is quite large and is growing constantly. Great strides have been made in it; indeed, it is not too much to say that pedia

trics has advanced more since it has become a special department of medicine than any other part of the science.

It is a pleasure to direct attention to the remarkable programme which the Ohio State Pediatric Society has arranged for its forthcoming fifteenth annual meeting at Cedar Point, Wednesday, August 28, 1907. Prominent names are everywhere apparent, and the titles of the papers to be read cover practically everything of importance in this specialty. The Nestor of them all will be present-Dr. A. Jacobi, of New York Ah! there is a name to conjure with. It is safe to say that he will have a large and interested audience.

The banquet of the society will be the social event of the session. There'll be wit and wisdom and btilliant repartee, and there'll be enough to fill the inner man to repletion. After the banquet, to be held promptly at 7 P. M., the members will listen to the aforementioned special address by Dr. A. Jacobi, entitled "Doses of Diet and Drugs."

The Ohio State Journal, quite inadvertently, to be sure, stated that the meeting and banquet would be held on August 27, and that Dr. Jacobs would address the meeting. THE LANCET-CLINIC cheerfully makes the correction for it contemporary.

The following is the programme. Each subject is an inducement for everyone to attend:

MORNING SESSION-9:00 O'CLOCK.

1. Cerebral Pneumonia. S. P. Wise, Millersburg. 2. How Best Preserve the Child at Birth. D. S. Hanson, Cleveland.

3. Lipomatosis. J. J. Thomas, Cleveland. 4. Rachitis. C. L. Patterson, Dayton.

5. Infant Feeding in Health. H. B. Martin, Springfield.

6. Deferential Magnesium. Park L. Myers, Toledo.

7. Lukemia. E. W. Mitchell, Cincinnati.