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tinctly remittent type of the temperature curve suggested the possibility of the presence of the malarial organism, but upon a microscopical examination of the blood, no malarial parasites were found, but another very significant fact was noted, i. e., the presence of a marked leucocytosis; and upon a blood count it was found that there were present about 25,000 leucocytes per c.m. of blood. It was found upon examination of the urine that no albumen was present, but that a large increase in the amount of uric acid existed, an observation entirely in accord with that of many investigators, which is to the effect that a permanent or even a temporary increase in the number of the white corpuscles is always attended by an increase in the amount of uric acid. A trial of Ehrlich's test proved negative. In typhoid fever, as is well known, there is little, if any, increase in the number of white corpuscles in the blood, so that notwithstanding the presence of the time-honored clinical signs of intestinal gurgling, the step-ladder elevation of temperature, and the characteristeric tongue, which were present in this case, the diagnosis of enteric fever was by the blood examination excluded.

Appendicitis was excluded by the absence of McBurney's tender point, by the disappearance of the pain from the ileo-cecal region, and by the absence of physical signs of a tumor. That it was a distended gall bladder was rendered improbable by the fact that a tumor the shape of the gall bladder could not be made out, although the liver at that time projected about 5 cm. below the costal margin. The presence of a sub-diaphragmatic abscess was thought unlikely, because no increase in hepatic dullness was apparent upward.

Hence in view of the fact that the liver was enlarged with swelling below the right costal border, the peculiar temperature and marked sweating, as well as the degree of leucocytosis, the diagnosis of hepatic abscess of course suggested itself, which, from the previous history of the patient, i. e., recurrent attacks of colic, was thought to be referable in all probability to the presence of gall stones.

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At the autopsy it was found, as has already been noted, that the liver was only slightly enlarged, while before death. there was great increase in its size. It is well known that where obstruction to circulation exists, the liver may become enormously distended, yet after death but little or no enlargement exist. Again, a rotation of the liver forward and downward, a condition frequently met with in women who have borne many children, will simulate an enlarged condition of the organ. Out of forty-two cases of cholelithiasis tabulated by Riedel, in eighteen the liver was entirely normal; in twelve cases it was enlarged as a whole, or at least in the right half, and in the same number of cases tongue-like process projected downward and forward from the right lobe beneath the costal margin. He says that as could have been forseen, the enlargement of the liver only occurred in those cases in which gall stones had migrated into the deeper ducts, or when they were located in the gall bladder had caused swelling of the biliary passages from that point. While in cholelithiasis, evidences of inflammatory processes were not infrequently seen in the serous covering of the liver, as indicated by the deposition of fibrin, the presence of circumscribed adhesions with the parietal peritoneum, the omentum, the stomach, the transverse colon and the duodenum, yet in a series of sixty-four cases recorded by him, i. e., Riedel, no case of hepatic abscess was noted.

In this connection, it may be interesting to relate the history of a case kindly furnished me by Dr. Charles E. Simon of this city, which very well shows the value of a blood examination in obscure cases of abdominal disease.

J. F., married, 30 years of age, previous history negative, except for occasional attacks of "indigestion," which were always accompanied with very severe pain. On June 9, 1893, he started with an attack of typhoid fever, which was of extreme severity, the temperature rising on one occasion to 106.5°, at 7 A. M., and reaching normal for the first time on the thirty-fifth day. During the following three days the temper

ature ranged between 98.6° and 100.6°, while the pulse during the same time ranged between 88 and 104 per minute.

On the 37th day of the disease, only 475 cc. of urine were voided, while previous to that time the amount secreted was about normal. During the afternoon of the same day, he began to vomit and to complain of pain in the lower abdominal zone, particularly in the right iliac region, which was not relieved by turpentine stupes, nor small doses (onesixth of a grain) of morphia. A few hours later, a few teaspoonfuls of paregoric were given and at 10 P. M., one-fourth of a grain of morphia, the pains at that time being agonizing. While the temperature at 8 P. M. was 100°, it steadily rose during the next few hours until at midnight it was 105.5°. The pulse made a corresponding rise from 104 to 176. At this time the patient was deeply comatose and appeared to be moribund. During the succeeding two hours three pints of whiskey and numerous injections of camphor were given. The temperature gradually decreased, reaching normal the next day about noon, from which point off, the temperature continued about normal, notwithstanding the fact that the patient was in deep stupor. The pulse varied between 120 to 140 per minute. The amount of urine voided during the 38th day was slightly in excess of 500 cc. Physical examination made on the 38th day revealed, in addition to the conditions already noted, three beginning bed sores, one upon the sacrum, and one on each trochanter. Moist rales were also to be heard at both bases. The liver was found somewhat enlarged; the abdomen tender throughout, most marked, however, in the right half. Right rectus muscle extremely tense. Although the liver was enlarged and was easily palpable, it was impossible to make out any enlargement of the gall bladder. The spleen was enlarged and had been in such condition during the course of the disease.

From the general symptoms described, notwithstanding the absence of the characteristic facies noted in cases of perforation, the diagnosis of peritonitis was of

course suggested. A blood examination made at this time, however, showed the existence of a slight leucocytosis and out of 500 leucocytes counted, 11.4 per cent. were of the small mononuclear variety, 1.4 per cent. transition forms, 83.4 per cent. multi-nuclear neutrophiles and 0.2 per cent. eosinophiles.

In view of the fact that the degree of leucocytosis generally stands in direct relation to the degree of local reaction, the diagnosis of peritonitis was of course abandoned and that of cholelithiasis regarded as the more probable, a view the correctness of which was later demonstrated by the fact that the urine became bile-tinged, that a distinct icterus was developed, and by the passage of a soft clay-colored stool in which, it is true, no calculi were found, but which contained a piece of inspissated bile, very much resembling a piece of indiarubber. In this connection it is extremely interesting to note that the occurrence of a piece of inspissated bile, which was regarded as the cause of the obstruction, is a condition of extremely rare occurrence.

In personal conversation with Dr. Simon, I was told that only one other case, after a careful survey of the literature, had fallen under his notice; that was a case which he had occasion to examine for Dr. Simon Flexner of the Johns Hopkins Hospital, and which was discovered at an autopsy. In Dr. Flexner's case the obstruction was about 5 centimeters long and 1 centimeter thick, while in Dr. Simon's case the obstruction was only about one-half that size. In reference to the differential diagnosis between septic infection and cholelithiasis, it seems to me that it would have been impossible at that stage of the disease to have positively decided which of these conditions was present, without an examination of the blood, as by the presence or absence of a leucocytosis, the presence or absence of septic infection is determined. When we remember the almost unvarying fatality of perforative peritonitis in connection with typhoid fever, it will not be thought strange that the hopes of the family for the recovery of the patient were resting

entirely upon the result of the blood examination.

One lesson to be drawn from the study of these two cases is the importance of an examination of the blood. By it the presence of septic infection may be definitely excluded, and in many cases a positive diagnosis made.

A second is the importance to be attached to a sudden decrease in the amount of urine secreted by the kidneys. Great stress is laid upon this condition by certain French writers, A. Robin, Gubler, Hayem, G. Sée and others, who recognized by this means the onset of many complications, before the physical signs of such changes were sufficiently advanced to be detected.

A third lesson is the necessity for greater care in the examination of the patient with reference to the diagnosis of the disease. In my case I at first believed I was dealing with a beginning typhoid fever, and not until the microscopical examination of the blood made a few days before the sudden fall of temperature revealed the presence of a marked leucocytosis, was the true condition recognized.

In reference to the relation existing between cholelithiasis and hepatic ab

scess, Frerichs states that inflammation and ulceration of the biliary passages, which may succeed upon the presence of concretions, etc., are, many times, the cause of hepatic abscess.

Dr. Osler speaks of the difficulty of making the diagnosis from intermittent fever, and states that the diagnosis must many times be made by the administration of quinine, or a blood examination. He states that where suppuration has its primary start in the bile ducts, the temperature may present an intermittent curve, there is great enlargement of the liver, and death invariably takes place early.

Bright speaks of biliary calculi associated with multiple abscess. Louis reports a case of the same kind, there being in this case some thirty to forty abscesses. Abercrombie has reported two cases. Budd reports several cases. Lebert reports a case in which the biliary passages, even down to the smallest canals, were filled with gall stones associated with suppuration. Frerichs reports a case in which the biliary passages were obstructed by calculi, causing inflammation of the same, associated with an abscess in the liver substance, the size of a child's head.

PUS IN THE PELVIS.-The inflamed Fallopian tube too often escapes detection. Dr. Grace Harrison relates a series of cases in the Alabama Medical ana Surgical Age, from which he draws the following conclusions :

1. The symptoms of pyosalpinx vary greatly according to previous condition of patient, size and mobility of the tube.

2. Complete anesthesia is essential to thorough examination of the pelvic and abdominal organs.

3. The sickening nausea and vomiting is probably due to pressure on the

ovary.

4. Pyosalpinx seldom ruptures into the peritoneum, but nature seems to guide the tear toward the vagina or more often the rectum.

5. It is probably unsafe to aspirate save through a broad adhesion and at a point of great tenderness.

6. We may hesitate to perform laparotomy when there are clearly defined broad adhesions between the tumor and bowel or vagina.

7. When rupture has occurred into the bowel or vagina, we should carefully but thoroughly cleanse the cavity. with antiseptic solutions. Preferably warm boracic acid sol. or peroxide hydrogen.

8. By proper care an artificial anus may be relieved without operation, if seen in time.

9. In debating an operation we should banish all hope of establishing or fear of injuring a good reputation and consider the patient's good, and his alone. If an operation offers one chance in a thousand it should be given. Not our interests, but the patient's, first, last and

all the time.

WHY BALTIMORE IS A HEALTHY CITY.

READ AT THE FORTY-SIXTH ANNUAL SESSION OF THE AMERICAN MEDICAL ASSOCIATION, HELD AT BALTIMORE, MD., MAY 7-10, 1895.

By D. W. Cathell, M. D.,

Baltimore.

BEFORE presenting a few statistics which aid in proving that Baltimore is a very healthy city, a brief synopsis of its location, climate, etc., seems proper. Baltimore lies in latitude 39° 18', longitude 76° 36'. It is situated on the Patapsco river, one of the tributaries of the great Chesapeake Bay, which divides. the State of Maryland into two portions -eastern and western, the city of Baltimore being on the western portion, about fourteen miles from the junction of the Patapsco river with the bay. We have an excellent and large harbor for our shipping.

Baltimore covers an area of 311⁄2 square miles and, like Rome, may be said to lie on seven hills. Its soil is both healthy and favorable for building. The city has 99,987 houses, with an appraised value, including the ground, of $274,000,000. Its population, as ascertained by the police census of 1894, is 496,315, of whom 422,568 are white and 73,747 are colored. It has 780 miles of paved streets, with 234 miles of rapidtransit street railways, running 785 cars, some cable, some electric, each car being provided with a fender in front for the protection of life and limb, and all stop to take on or let off passengers at the near side of streets, instead of crossing the street before doing so, and each must come to a full stop before crossing any intersecting railway. By these rules our street railway accidents are reduced to a minimum. Besides business, carriding for pleasure is a source of both recreation and health to our people.

Our city has an inexhaustible supply of excellent water, chiefly from the Gunpowder river, kept in 8 separate storage reservoirs, which have a total capacity of 2,274,000,000 gallons, the daily consumption of water being 45,000,000 gallons, while the daily capacity of supply

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The rich and diversified soil, the swarming waters, and the teeming forests about Baltimore furnish an unsurpassed abundance and variety of food. Added to these, we have an unequalled climate for permanent residence, for neither the cold of our winters nor the heat of our summers continues long enough to entail deleterious effects on the general health. Our snows end with March and our autumn frosts begin with November.

Baltimore is chiefly surface-drained, and although it has about 35 miles of underground sewers, the function of most of these sewers is to carry off stormwater from certain localities. The city has no slums, and comparatively few tenement houses, although, like all large cities, there are many thickly populated neighborhoods where many poor people live too closely huddled. The mean temperature for 1894 was 55.9°; the highest temperature of summer was 98°; the lowest in winter was 7° above zero. Our average annual rainfall is 44 inches. The number of days on which rain and snow fell in 1894 was 134, and strange to say, the greatest monthly precipitation was in May, 7 inches, and the least was in March, 14 inches. The total mortality in the city of Baltimore for the year 1894 was 9486, of which number 7242 were white persons and 2244 colored, being a marked decrease in comparison with the five preceding years, notwithstanding a decided increase in population. Our death rate for 1894 was 20.84 per thousand, but if the death rate per thousand were computed as in other cities, upon an estimated population, instead of the U. S. census of 1890, it would show a rate of only 19.04 per thousand for the whole.

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1894

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Total number of deaths.

10, 198

10,073

10,582

9,554

9,486

Ratio per 1000

22.41

22.13

21.77

20.99

20.84

The ratio of deaths of children under five years of age to the total mortality was 39%. In addition, there were 721 still-births during the year.

The death rate among our colored population is always greater than that of the whites. This I attribute chiefly to their meager comforts and lack of opportunities for advancement, compared with those of the whites, coupled with their relative lack of knowledge of sanitary laws. Thus, in 1894:

The annual death rate per 1000 white population was 18.85.

The annual death rate per 1000 colored population was 31.60.

The vital statistics of our race tell us that the average duration of human life is about 37 years. Up to 1875 there were no reliable vital statistics kept in Baltimore; and I am ashamed to tell you that even now, almost at the dawn of the twentieth century, we have no complete record of the births; but of the 174,923 deaths that occurred in Baltimore during the twenty years ending December 31, 1894, we find the following large number of aged decedents:

12,651 were between 40 and 50 years of age.

12,752 12,800

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13 were above 110 years of age.

Nature has done a bountiful share for Baltimore, and man has done much to aid her, and of this her physicians have done their full share. We have about 450 regular practitioners in the city, besides quite a sprinkling of irregulars of all shades and colors. We now have laws regulating medical practice, which bid fair to be of great benefit to the community. Besides the great Johns Hopkins Hospital, we have scattered through the city numerous other and well managed hospitals and homes, some for the

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