DOES INTERNAL MEDICINE TEND TO ABORT OR CURE ABSCESS AND THE TENDENCY THERETO?-Robert E. Coughlin believes that if individuals predisposed at all times to the development of abscess were examined carefully at different times when supposed to be in a condition of health they would undoubtedly show some abnormality in their makeup that would give some light on the etiology and predisposing factors. Abscess of the appendix may be anticipated by attention to the etiological factors. The use of serum to produce immunity in typhoid and the antiseptic treatment of the disease may prevent extension into the gall bladder and a subsequent abscess. Internal medication in the case of pyelitis may abort a suppurating kidney. Internal medication in a case of dysentery, malaria, or tropical fever may prevent a liver abscess. Vaccines have been used with some success in pyemia, pyosalpinx, and tube-ovarian abscess by indicating opsonins, etc. Following out this line of reasoning abscesses of the skin, boils, furuncles, furunculosis, and carbuncle are due to a disordered condition of the system, and in the latter staphylococcus serum has worked well along with supporting treatment; as for instance, strychnine as a stimulant with opium to relieve pain. Calcium sulphide is effective in modifying all suppurative processes in a most decided manner, the dose used being one-half to one grain three times daily in adults, and for children one-tenth to one-twentieth of a grain three times a day. When indicacations have been carried out in the manner suggested one cannot fall to be convinced that internal medication does tend to abort or cure abscess.-Medical Record.

PHYSICIAN AND PATIENT. A little pamphlet called "Treatment" has just been received by the Gazette. In it we find a quotation from the New York Evening Sun for October, 1910, that discusses a problem frequently encountered by us all and one which demands our attention. It deals with the relation of the physician to his patient, and is as follows:

"The unusual case of Dr. Merriam, the Washington physician who is sued for $5,000 by a patient for being absent in time of need, raises interesting points. The relations between physician and patient as to these points it would profit both parties to have cleared up.

A great many patients are much inclined to impatience over the fact that their physicians are not available when called for. A rather large number of physicians suffer in health, once they attain to what is called a successful practice, owing to their overexertions in trying to answer all their patients' calls. Each party naturally feels that the other is somewhat unfair to him.

The patient's point of view is typically this: "I don't know anything about medicine, but I know my physician, and have confidence enough in him to intrust my health to his keeping; when I deal with a grocer or a butcher, I expect to find him at his stand whenever I need him; so when I call upon the only physician that I deal with, I expect to find him at his stand."

The physician's way of looking at it is somewhat different: "I appreciate the confidence of my patients, but I deplore their lack of understanding of my limitations; they seem to think that I can be in several places at a time; they demand the same prompt service of me that they do of their telephone exchange; they don't realize that a physician cannot devote himself to a single patient; they are foolishly touchy about anything that they can construe as neglect; and yet they are just as touchy if in case of emergency I send them a substitute or an associate." The solution, as it will be applied in the future, no doubt, is contained in the recourse to a substitute. There seems no other alternative. Patients do not want a physician who has no other patients. Yet an overworked physician cannot answer their needs either. Whether he is

away on some other case or whether he attends a patient while himself under the stress of overwork and over-hurry, the medical attention is inadequate.

Abroad there is a tendency in some lines of practice for physicians to form firms. The patient receives the service not of the individual practitioner but of the partnership. The arrangement requires each of the firm to know the history of each of the firm's cases, and incidentally it gives each case the benefit of two or three medical heads instead of one. The fact that the junior partner is a partner and not a mere assistant gives him a greater share of the confidence of the patient. Division of labor makes it possible for the firm to attend to routine calls and emergency demands with a fair degree of certainty, and with much more comfort to the hard-worked practitioner.

If the public would learn, from the present case in hand and from such others as occasionally may come up, the advantages of tolerating an alternate physicians, it might make for good all around."

PUS IN THE ABDOMINAL CAVITY.-Deaver of Philadelphia, in the Annals of Surgery, contributes an important article upon this subject. Among other things he says:

"What is to be our attitude towards the pus already present within the abdominal cavity? I am certain that I drain less

and less every year. Where I once said, 'When in doubt, drain,' I am now likely to say, 'When in doubt, don't drain.' I do not hesitate to close up any case which shows only a small amount of seropurulent fluid within the abdomen.

Thick, vicious-looking pus in considerable amount, especially if it be foul smelling, is in my mind still an indication for drainage. I waver somewhat even in certain of these cases, and I have closed a few of them without ill effect. Sodden, pus-soaked gauze is an obstacle to the flow of secretion instead of a conductor. As I remarked long ago, a cigarette drain is an excellent thing when there is nothing to drain.

The advisability of washing away the exudate at the time of operation is, of course, another point to be considered here. My objections to irrigation in brief are that:

1. It consumes time that we cannot afford to lose.

2. It diffuses infectious material, a serious matter in generalizing peritonitis where there may be extensive areas of peritoneum as yet unaffected.

3. By causing us to manipulate the bowels it has a tendency to promote paresis.

4. My own experience, and I believe the combined experience of operators all over the world, show a higher percentage of cures without irrigation.

I do believe it to be good practice to aspirate any collection of fluid in the pelvis, or elsewhere, that is accessible, or to absorb gently with gauze any highly foul or purulent exudates about the source of infection, but to wash extensively or to go on any extended tour of the abdomen seeking for exudate to clear away, I believe is wrong."

THOUGHT IT SOMETHING DREADFUL.

Old Lady: "Doctor, do you think there is anything the matter with my lungs?"

Physician (after a careful examination): "I find, madam, that your lungs are in a normal condition."

Old Lady (with a sigh of resignation): “And about how long can I expect to live with them in that condition?"-Pharmaceutical Era.

Professor of Surgery Reliance Medical College; Adjunct Professor of
Surgery University of Illinois; Surgeon of Grace Hospital and
to Cook County Hospital, Chicago.

Atrophy of the Quadriceps Femoris Muscle.
(Continued from June Number.)

This atrophy is due, partly to disuse, partly to extravasation of blood in the substance of the muscle, partly to associated injury to the muscle and to its contained nerve filaments. By the aid of the open operation all blood extravasates can be removed, fascial tears can be sutured.

The patients regain the use of their limbs in a comparatively short period of time; the period of immobilization is markedly shortened. Active use prevents and overcomes atrophy attendant upon disuse. It is said that "an ounce of voluntary exercise is worth a ton of massage in the treatment of muscle atrophy." The early removal of all extravasated blood, liquid or clotted, from the articular cavity and from the peri-articular tissues, limits the liability to the formation of adhesion, intra- and extra-articular in

nature.

By the employment of the open operative method all the above mentioned obstacles to restoration of functional integrity can be more rapidly, more effectually overcome than by resorting to non-operative treatment, separate or combined. The open method makes possible the removal from the joint cavity of detached bony fragments; it enables the operator to absolutely prevent the union of the fragments in a faulty position, that is, in a position mechanically interfering with the proper function of the joint; the tendency to adhesion of the upper patellar fragment to the femoral condyles is lessened. Increase in the dimensions of the patella following the open operative treatment is a rarity. Any increase in the dimensions of the patella is very liable to interfere with the adaptability of the patella and femoral articular surfaces. Is operation at times contraindicated? If so, when?

Under what conditions is the open operative treatment of doubtful propriety or not indicated?

In formulating indications and contraindications for the open operative treatment of fractures of the patella, we give only slight consideration to age, sex and occupation. Individuals of either sex, at all periods of life and in all walks of society, need a good patella. However, in this, as in all other operations, the state of the tissues and the viscera must not be ignored. Such anatomical and physiological deterioration of the tissues may be present, as to compel us to regretfully substitute inferior therapeutic measures to operations of election. The facts can be stated to the patient and he can select between functional integrity and functional disability. We do not advise the open operation:

I. In fractures of the patella that occur in a diabetic patient. The tissues of diabetics offer very little resistance to infection. They are tissues of impaired regenerative power. Nevertheless, an absolutely bad prognosis need not be given in these cases.

2. In fractures of the patella, occurring in patients having advanced tubercular disease or suffering from well developed cardiac, renal or hepatic disease.

3. In closed longitudinal fractures, with no displacement or with but slight lateral displacement. In fractures of this type recovery almost invariably follows the combined use of such measures as massage, immobilization, full extension of leg on thigh, coaptation of the fragments by retentive apparatus.

4. Fractures of the patella in which the separation of the patellar fragments is so slight as to be barely detectable, do not call for the open operative treatment. The same applies to fractures in which the injuries to the accessory patella ligaments are unimportant.

5. Do not operate on patients who prefer to pass their lives. partly disabled rather than to run the minimal dangers of an operation.

If operation is not always indicated, when is it indicated?

The popularity of the open methods is increasing. In careful and skillful hands, the dangers formerly incident to their employment can now be said to be non-existent. Kocher himself has become an earnest advocate of the open operative treatment. In von Bergmann's clinic, it is regarded since 1893 as the routine. treatment for transverse fractures of the patella.

With increasing familiarity with the successive steps of the operation and a better appreciation of a judiciously carried out. after-treatment, the results atending its employment are becoming more and more satisfactory.

For this very important addition to our surgical resources we are chiefly indebted to Lord Lister-Lucas-Championniere, one of the pioneers and also one of the most enthusiastic advocates. of the open operative treatment for fractures of the patella, who states that the first antiseptic operation of patella suturing was

performed by Cameron of Glasgow in 1877. Lister reported his first case in 1877. In 1883 he reported six more cases and then showed clearly that this new method of treatment was followed by perfect recovery, while previous to that time the condition had been looked upon as being, of necessity, followed by lameness. The adoption of this form of treatment, among German-speaking surgeons, is largely due to the efforts of Hackenbruch, Trendelenburg and Koenig. Trendelenburg performed the first open operation in Germany in 1878. Among the French-speaking surgeons: Charput, Berger, Lejars, Mayer, Lambotte, Vallas, are some of the ardent and most prominent supporters of the open operative treatment.

It was Berger who introduced cerclage.

It is our belief that, after ample preparation of patient and of the operative field, the open operative treatment is positively indicated:

I. In all fresh fractures of the patella in the absence of contraindications.

a. If the surroundings are favorable..

1. An aseptic operating room.

2. Skilled surgeon, and assistants having "an aseptic conscience."

3. Dependable suture material, rubber gloves, etc. b. If the patient is in the best possible condition.

c. If the fracture be of such a nature that a disabling defect is to be expected if one resorts to non-operative

treatment.

d. When the bony fragments cannot be returned exactly by manipulation to their normal position and retained therein by retentive apparatus.

2. In all compound fractures.

3. In all cases associated with considerable intra-articular effusion. The separation and tilting of the fragments is partly produced and partly maintained by the intra-articular effusion, be the latter hemorrhagic or inflammatory in nature.

4. In all cases associated with marked laceration of the periarticular tissues (ailerons, reserve extensor apparatus). After fractures of the patella a great distention of the joint capsule is suggestive of noticeable peri-articular lacerations.

5. In all cases in which the inter-fragmentary space or diastasis has at any time exceeded 3 cm. This extent of separation. cannot occur without laceration of the accessory patellar ligaments, without rupture of the overlying fibro-periosteal tissues.

6. In such fractures as are very liable to cause serious functional joint impairment; among such may be cited cases in which bony fragments have escaped into the articular cavity; cases in which lower or upper fragment or both are completely inverted, or other such anomalous cases.

7. In all fractures of the patella occurring in individuals