far the larger number of cases the specific micro-organisms were present. In one rabbit a film was made of the exudation from the iris; this showed the micrococci to be present, and cultures were obtained in a pure state from it.

This investigation shows that the three different streptococci isolated by Wassermann, Poynton, and Walker, from cases recognised clinically as undoubted rheumatism, all reproduced fully the stigmata of rheumatism in the rabbit and monkey. In no single case, among a large number of experiments, was there any abscess formation, though infarcts were often found. On the other hand in corresponding experiments with organisms isolated from cases of pyæmia in man, abscesses were found in the experimental animals and cardiac lesions were comparatively rare.

The micro-organisms, obtained in different ways from cases of rheumatic fever, are shown in this investigation to be able to produce arthritis, iritis, pericarditis, myocarditis, endocarditis, and pleurisy, with visceral infarcts, in animals, both rabbits and monkeys. "From this it naturally follows that the particular micro-organism in question, called the micrococcus rheumaticus by Walker, the diplococcus rheumaticus by Poynton, and the streptococcus aus chorea by Wassermann, is the actual infective and causal agent of acute rheumatism. Acute rheumatism is therefore of microbic origin, and the acute causal agent is a micrococcus closely resembling the streptococcus pyogenes in its chief characteristics."

JAMES E. H. SAWYER.

SPONTANEOUS GANGRENE OF THE

HOLLOW VISCERA.

A STUDY OF MESENTERIC OCCLUSION.

By ROSWELL PARK, M.D. (Annals of Surgery, April, 1904).

PARK begins an important paper on this subject by relating details of two cases. The first was that of a man, aged 45, who, while in apparently good health, was suddenly seized with severe abdominal pain. At the end of twenty-four hours the abdomen was rigid and distended, and the patient was collapsed and was vomiting a material, which had a coffeeground appearance; his pain, which had been very severe, was less. Abdominal section was performed, and it was found that the whole small intestine, from stomach to cæcum, was gangrenous; that there was gangrene of a part of the large intestine, and that the parietal peritoneum seemed almost as much involved as the visceral. Death occurred two or three hours after operation.

The second case was that of a woman, aged 33, who was suddenly seized with severe abdominal pain and vomiting. Park saw her at the end of thirty hours, when her abdomen was distended; she had fæcal vomiting and there was no passage of fæces or flatus. The abdomen was opened, and the whole small intestine was found to be gangrenous. The patient died at the end of forty-eight hours. No post mortem examination was allowed in either case.

Mesenteric occlusion was first described by Virchow in 1859. Occlusion of the mesenteric vessels is not easy to explain; but it must be remembered that, while the veins of the mesentery have no valves, the arteries, like those in the brain, are terminal, and collateral circulation is therefore not prompt or complete. After tying the superior mesenteric artery, the blood supply of the intestine is at once cut off. According to Gallavardin, the most frequent cause of mesenteric occlusion is mitral stenosis, the next most common cause being probably arterio-sclerosis. Falk collected records of seventeen cases of embolism of the intestinal arteries, and for purposes of

diagnosis it is important to remember that in every one of them there was evidence of embolic disturbance elsewhere. Thrombosis of the mesenteric vessels is nearly always an extension of a primary lesion in the veins of the kidney, intestine or pelvis. It occurs after acute appendicitis, pyelophlebitis, intestinal ulceration, &c.; but, curiously, it is rare after typhoid ulceration. In typhoid the veins are often affected, but much more often those of the lower limbs than those of the intestine. It is not necessarily a main mesenteric artery that is occluded. The blockage may occur in a branch, and then results in an annular necrosis of the intestine over a greater or less area. As soon as the artery supplying a particular part of the intestine becomes plugged, there promptly ensues an anæmia of the gut, venous stasis and loss of contractility following. The extent of the gangrene may vary from a slight annular gangrene to a gangrene of a great portion of the bowel, as in the cases which Park describes.

Symptoms: The first symptom is, as a rule, an absolutely sudden and very severe abdominal pain, sometimes paroxysmal, sometimes continuous. Vomiting occurs early; the vomited matter being bloody and often, after a short time, fæcal. There may be diarrhoea at first, but symptoms of obstruction more common. The abdominal wall is rigid and meteorism soon makes its appearance. The patient's general condition is one of collapse.

are

When mesenteric embolism or thrombosis is suspected, one should search over the rest of the body for similar lesions elsewhere, as their discovery would add to the certainty of diagnosis.

Differential diagnosis is difficult or, indeed, almost impossible. A suddenly occurring gangrene of any abdominal viscus gives rise to practically the same symptoms. As examples may be cited gangrenous appendicitis, acute necrosis of the spleen, acute necrosis of the gall bladder. Perforative lesions, too, as for instance perforation of a gastric ulcer, give rise to much the same symptoms. Hence Roswell Park lays stress on the importance of obtaining, if possible, an accurate

history of the previous condition of the patient, as this is almost the only thing that will aid in making a differential diagnosis.

Treatment is of no avail in cases of such severity as those detailed by Park, but operation has been successful in cases of more limited gangrene.

It is interesting to note that in 1868 Chiene, of Edinburgh, recorded an instance of mesenteric occlusion not proving fatal. This was in the case of a dissecting-room subject, in which the branches of the cœliac and mesenteric arteries were found filled with the injecting material, while their main trunks were completely occluded by an old embolic process The coeliac axis was changed into a cord, and both mesenteric arteries were obliterated.

LEONARD GAMGEE.

REVIEWS.

A Text-Book of Surgery for Practitioners and Students. Edited by WILLIAM W. KEEN, M.D., LL.D., F.R.C.S., and J. WILLIAM WHITE, M.D., Ph.D. Fourth Edition. Royal octavo; pp. 1,363; 39 plates; 590 illustrations. Thirty Shillings. W. B. Saunders and Co. 1903.

DR. KEEN and DR. J. WILLIAM WHITE have presented in their American Text-Book of Surgery a work which has attained a great popularity during the two years of its existence, no less than 40,000 copies having been disposed of. The book is compiled on the modern plan of the "system" by many contributors, and has the inequality and want of continuity inseparable from works of this type. After a careful perusal of the book, we are not sure whether the editors intend it to compete with the year-books of surgery or to be a presentation of modern surgery based on well-weighed evidence of widely-accepted theories and practice. The most recent, up-todate, and most advanced of work is included, but at times in a somewhat sketchy manner which detracts from its value. Chapter II., on the examination of the blood in its relations to surgical diagnosis and treatment, is an example of what we mean: reflections are made on the value, and conclusions are drawn from the results, of estimations of, the hæmoglobin value, the leucocyte ratio, iodophilia, freezing point of the blood (and urine) from the kidneys, and the coagulation time of the blood; but no description of the methods by which the student or practitioner undertakes these proceedings is given in the text.

The book deals with general, special, regional, and operative surgery. In the first part the subject of syphilis is very satisfactorily presented. Rickets, scurvy, and tetanus are very cursorily dealt with. In the chapter on Tumours, Cohnheim's views as to their origin from embryonic rests" are favoured by the writer. The classification of an English surgeon is more or less closely adopted. The illustrations in this section are not typical; they represent what is unusual, monstrous, and often horrible.

Part II., Special Surgery, contains a good chapter on diseases of bones, and fractures. The operative treatment of recent fractures is deprecated, and the use of massage and passive movement is alluded to with scepticism. Orthopædic Surgery is briefly dealt with, and then chapters on