grave and acute than in inguinal hernia, and gangrene develops earlier. These manifestations develop more gradually in the aged, but are not less sure in their lethal tendencies. Stomach contents are first ejected, then follow large quantities of bile-stained mucus, which in turn is followed by the classic stercoraceous vomiting. The colicky pains are relieved in a measure by pressure from distention; bowel paralysis and toxemia supervene; the temperature, which has been subnormal a few hours since, now begins a gradual rise, reaching 103° or104° F., at which time a profuse perspiration covers the the body. The temperature again recedes to subnormal, the sensoria become blunted, the symptoms all cease, and the patient rapidly passes into the inevitable collapse which presages the end.

The pulse is a reliable index to the patient's resistive powers, and will tell much of the future when carefully considered in these critical cases. Remember strangulated hernia as one of the urgent surgical emergencies in which taxis and delay have a greater mortality than a well-timed operation.

In a given percentage of young children cure may be effected by the wearing of a well-adapted support and measures which will improve the general condition, rest, diet, sunshine and pure air. The subcutaneous introduction of irritating fluids with a view to obliterating the hernial sac by inflammatory exudate is not only unsurgical, but dangerous, and is mentioned only to be condemned as a method of treatment.

The treatment of strangulated hernia is one of the most important problems in the whole domain of medicine and surgery. The time element bears a direct ratio to the mortality. The rule formulated many years ago by Dupuytren is a good working basis: "If the strangulation takes place after sundown it should be relieved. before sunup; if it occur after sunup, it should be relieved before sundown."

The employment of the ice-cap and position have been rewarded by success, and possess the additional recommendation of simplicity and freedom from danger, if not persisted in beyond a reasonable time. This treatment will succeed best when applied immediately after the accident and before the irritating influence of displacement, exudation and increased hernial contents have rendered the return of the hernia a mechanical impossibility.

Taxis, when used, should be gentle in character and short in duration. Some one has described a method of steadying the neck of the tumor between the finger and thumb of one hand and gently pressing on the base of the tumor with the palm of the other hand with a view to reducing, first, bowel contents, then the bowel itself, and later the fluid contents and the sac. This may be possible if the case comes under observation ere the landmarks have been distorted by gas and exudation.

General peritonitis complicating strangulated hernia is followed by high mortality. In neglected cases of strangulation, where great distention of bowels from gas and feces exist and gangrene of the protruding gut has taken place, the one indication for treatment overshadowing all others is drainage of the bowel. This is best accomplished by rapidly forming an artificial anus at the site of strangulation under local anesthesia. In doing this temporary operation one is rarely called upon to stitch the bowel to the margins of the wound, as sufficient inflammatory adhesions are usually present to keep the bowel from sliding back into the abdominal cavity. If the hernial contents are in good condition and the patient's condition will permit, do a radical operation at the time; if in doubt, relieve the constriction, cover the parts with moist gauze, and, if necessary to determine whether the gut will live, permit it to remain several hours or over night.

Strangulation occurs perhaps more frequently in femoral than in inguinal hernia. Thus Bryant found fifty of ninety strangulations to be of the femoral variety, and Gosselin, Maydl and Henggler all report a slightly increased ratio of frequency in femoral strangulation. The point of strangulation is usually at one of the rings. Bassini showed by plaster that the saphenous opening was really the narrowest part of the tract through which the gut must pass. Conclusions based upon this finding would be manifestly unfair, as, inferentially one would conclude this to be the more frequent site of strangulation; but one should remember that all cases strangulated at the femoral opening are wholly eliminated from this equation, hence any deductions based on such findings would be necessarily faulty.

While it is essential to know the various layers covering a hernia, in most instances it is impossible to demonstrate them. Again, the number of layers vary;

the hernia does not push all layers in front of it, but rather separates the tissues, and one sometimes comes very unexpectedly upon the gut after incising the skin, hence a good working rule would be to expect the hernial sac to appear immediately after the skin is divided. A mass of fat, or even a bursa, is occasionally encountered in old or truss-wearing cases.

The relation of certain vessels are of great importance in hernia operations. The deep epigastric is given off just above Poupart's ligament and passes inward toward the median line. The superficial epigastric comes off below the ligament (the second branch), pierces the cribriform fascia, passes upward and inward to the abdominal wall. These vessels must be located before dividing the constricting ring; injury to the deep branch is likely to follow division of the femoral ring, and the superficial branch may be injured in relieving a constriction at the saphenous opening. If the deep epigastric is cut, make an incision parallel and above Poupart's ligament and ligate the vessel near its origin, and do not trust pressure to control hemorrhage from this source.

The danger of reducing a hernia en bloc is completeely obviated by opening the sac and stretching or dividing the constricting part, and as removal of the sac is the crux of all hernia operations, it becomes imperative that the sac be opened and explored to make sure it is empty before completing the operation.

After freeing the sac and ligating close to its base and cutting away the outer portion of it, the purse-string suture, which includes Gimbernat's ligament, the femoral fascia and the fascia of the pectineal within its grasp, will serve to strengthen the floor of the femoral ring.

While in the mind of most authorities obliteration of the hernial sac is the key to success, a description of the ideal operation for hernia will include the problem of correcting the faulty intra-abdominal pressure lines and devote less space to the confusing technique which abounds in articles. and text-books on closing the ring.

Finally, be prepared for a new experience in every case of strangulated hernia, and treat the individual while treating the disease.

1606 Freeman Avenue.

Basing our conclusions upon the statements found in the older text-books of surgery, we are led to believe that fractures of the carpal scaphoid are extremely rare; that this fracture, when it is met with, is an accompaniment of extensive crushes of the wrist, and that isolated fractures of this bone practically never occur.

The fact that in the past eighteen months I have observed four isolated fractures of the scaphoid, and the fact that similar cases are being almost daily recorded in the literature, would seem to indicate that such fractures are, to say the least, not uncommon. It cannot be doubted that many fractures of the scaphoid are being constantly diagnosed and treated as "sprains."

Although the scaphoid is most frequently fractured, isolated fracture of any of the carpal bones can occur. Any of the carpal bones may be involved if the fracture is due to direct trauma, the point of

application of which would determine the site of the fracture. But the most common trauma to the wrist is not direct trauma, but "strain," and more particularly "strain" due to falling upon the extended hand. Such strains are felt chiefly by the end of the radius and the scaphoid, hence the frequency of Colles' fracture and fracture of the scaphoid.

In three of the cases observed, the fracture of the scaphoid resulted from strain upon the extended hand, and in one case it followed direct trauma over the scaphoid.

Strain borne by other bones of the wrist tends to cause dislocation rather than fracture of the respective bones, the pisiform and semilunar being most liable to be dislocated.

Searching for the anatomical basis for strain fractures of the scaphoid, the fact that the scaphoid serves, for the most part, as the distal attachment of the external

lateral ligament of the wrist joint, while its proximal attachment is the styloid process of the radius, is very suggestive. It is possible that the same strain may at one time produce a fracture of the radial stylus and at another a fracture of the scaphoid.

The diagnosis of fracture of the carpal scaphoid is often not an easy one without the aid of the X-ray. Indeed, three of the four cases observed were unsuspected before the Roentgen examination. The symptcms are usually those of a sprained wrist, if the case is seen early. There is history of the strain followed by pain, swelling and disability. But if the case is seen some days or weeks after the injury, incipient tuberculosis or chronic infectious arthritis may be suspected. The causal trauma may have been slight, and little or no attention paid to it. The patient may not consult a physician until the constant pain and disability alarm him.

The pain is the most constant and characteristic symptom. It is usually more localized than the pain accompanying sprains, and is referred to the radial side of the wrist. It may persist for some time after the application of the splints. In one case more or less pain was complained of throughout the entire course of healing.

The pain is accompanied by exquisite tenderness in the anatomical snuff-box. This tenderness is often so sharply localized over the scaphoid that fractures of the radius may at once be ruled out and the diagnosis of fractured scaphoid established.

The great tenderness and persistent pain in these fractures has been attributed by Downes to the close relation of a branch of the radial nerve with the scaphoid. Codman and Chase and Eisendrath have referred to the slight tenderness found normally in the anatomical snuff-box, due to a small branch of the radial nerve which passes over the radius and scaphoid.

There is practically no bony deformity with these fractures. There may be considerable swelling, especially to the dorsal and radial aspects of the wrist. This absence of bony deformity and absence of displacement of the hand at once rules out typical Colles' fracture, but in those cases of Colles' fracture in which the displacement of fragments is slight and deformity absent, the location of the point of tenderness is the differential feature. In fractures of the lower end of the radius,

the point of tenderness is above the radial stylus, while in fractures of the scaphoid the tenderness is below that landmark.

The radial and ulnar styloids maintain their normal relations in fractures of the scaphoid.

All movements are painful, especially extension, which may be limited to a few degrees.

Crepitus is difficult to obtain in these cases; moreover, the force and manipulation necessary to elicit this sign may dis

Fracture of Carpal Scaphoid.

place the fragments and interfere with the functional result.

In recent typical cases, the diagnosis may be made by considering the injury, the pain in the anatomical snuff-box, the swelling over the radial side of the wrist, the exquisite tenderness over the scaphoid (below the radial stylus), inability to extend the wrist, and possibly crepitus. Of the four cases observed by the writer, one presented the above typical signs, the remaining three being recognized only by an X-ray examination. In one of these three, however, the condition was obscured by a secondary infection which caused a diffuse swelling of the joint. The remaining

two were seen late (four to six weeks after the injury). But the history of these two cases would lead one to believe that a fracture of the scaphoid may result from a very slight trauma, and that the initial acute symptoms may be so modified and insignificant that the patient will not seek medical aid. In both of these cases the causal strain was slight, and the patients applied for treatment some weeks later because of continued pain in the wrist, which interfered with their occupation.

The treatment of this fracture1 is very simple, following the general lines of treatment of a Colles' fracture. The forearm, wrist and hand should be encased in plaster or splints with the hand perfectly straight, the splint reaching just to the distal end of the metacarpals in order to allow free movements of the fingers. Readjustments of splints may be made once a week, and during the third week the splints may be removed fifteen minutes daily and massage and passive movements instituted. At the end of the fourth week the splint may be taken off, although some pain and limited extension may persist for some time. If the fragments are widely dislocated and cannot be replaced, excision is indicated.

CASE I.—J. B., a scene-shifter at a local theatre, while at his work received a sharp blow over back of wrist inflicted by a piece of falling scenery, applied at Cincinnati Hospital for examination. All of the typical signs of fractured scaphoid, as outlined above, were present, the limited extension and point of tenderness being especially marked. A skiagram verified the diagnosis. The part was put in wooden splints for four weeks and made a good recovery. Throughout the treatment the patient complained of pain and tenderness over scaphoid, the pain at one time being so severe as to lead to suspicion of some infectious condition in the joint. Some tenderness and limited extension persisted when patient was discharged from

treatment.

CASE II.-Hand was caught in a steam wringer and severely wrenched. Swelling and pain in wrist was at first sight and patient resorted to rubbing the parts with liniments. After a few days, swelling, pain and tenderness became so severe that he was referred to the Cincinnati Hospital for examination. The joint was found to be diffusely swollen, hot and tender, and all movements painful. The skiagram showed a fracture of the proximal end of the scaphoid, with a cracking off of the tip of the radial sty

1. Downes: Annals of Surgery, January, 1908.

lus. It showed, further, an erosion of the ad jacent articular surface of the radius, in the light of which bone change a diagnosis of infcctious arthritis of the wrist following fracture of the scaphoid was made. The case was subsequently lost sight of.

CASE III.-Dr. M. S. Patient suffered slight strain upon extended wrist six weeks previous, but because of its insignificant nature paid no attention to it. Complained of dull pain to outer side of wrist, which was aggravated by use of same, and very much worse in the evening when fatigued. There was slight tenderness, a little swelling, but no redness, over inner side of wrist. Little or no interference with movements. Incipient tuberculosis was suspected. The skiagram showed a fractured scaphoid.

CASE IV.-Patient suffered a fall upon the extended hand four weeks previous to presenting himself at the Cincinnati Hospital for examination. Patient's occupation necessitated use of wrist in pasting labels, and because of pain in wrist was compelled to stop work. Pain was elicited especially by the flexion and extension movements necessary to his occupation. The joint was slightly swollen, not red; slight tenderness over outer side of wrist, with limitation of extension. Rheumatism was the diagnosis advanced by his physician. The skiagram showed a transverse fracture through the middle of the scaphoid.

In examining for fracture of the scaphoid, the possibility of a congenital bipartite scaphoid must be borne in mind. The uninjured wrist should always be skiagraphed for comparison.

THE

A Weekly Journal of Medicine and Surgery.

SUBSCRIPTION:

THREE DOLLARS PER YEAR EDITOR MANAGING EDITOR

A. G. KREIDLER, M.D.
G. STROHBACH, M.D.

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 11, 1908.

THE ACTION OF TUBERCULINS.

As generally understood, the term tuberculin applies to products of the metabclic activity of the tubercle bacilli or to somatic extracts of the bacilli themselves. The term was formerly limited to the crude tuberculin of Koch, but recently has been given a wider meaning. It was originally assumed that the bacilli in the course of their metabolism excreted certain toxic principles into the culture medium, and that the activity of the substance was due to these. The injection of ordinary broth which had not been used as a culture medium proved the fallacy of this position, inasmuch as it occasioned a reaction characteristic of tuberculin, although larger doses were required. There have been many modifications of the original tuberculin, the discoverer or inventor of each making wholly unjustifiable claims for the superiority of his product. During the last ten years there have been numerous attempts to extract the supposed active principle from the bodies of the tubercle bacilli, and the methods used are as various as the bio-chemists engaged in the research. On the whole, these "tubercle bacilli products" have given greater satisfaction than the bacterial free filtrate of culture media. The English bacterio-therapeutists find the T.R. most effective, and present an inspir

their position. In this country there appears to have been an increasing tendency to make use of the watery extract of the tubercle bacilli, which has proven itself highly effective in the hands of many practitioners.

In spite of extended investigations on the part of eminent bacteriologists, the action of these substances in the lung tissues has never been satisfactorily explained.

Koch held that the crude tuberculin increased the necrosis around the disease area, and thus established a line of demarcation between healthy and diseased tissue. The position was found to be untenable. Behring held that the phenomenon was due to the existence of precipitins in the arterioles contiguous to the disease area which occasioned intravascular coagulation when the tuberculin acted upon them. The existence of precipitins at the disease foci has not been demonstrated, nor if they had is it clear how intravascular coagulation would occasion the reaction. Hueppe held that tuberculin and allied products stimulated tubercle bacilli and aggravated tissue destruction when the series of reactions ensued. This seems to harmonize best with the observed facts, although not free from objections. It may be laid down. as a rule that colloids injected into a diseased body stimulate or act upon the diseased areas; that the action is upon the body cells in dis-equilibrium, and not upon the invading organisms; that the primary action is distinctly harmful, as it disarrays the lines of defense and gives the invading organisms temporary advantage. If the nutrition of the body is of such a character that recovery from this disorganization can occur there is a determination of body energy to the focus which expresses itself generally in the subjective symptoms of the reaction and locally increased cell proliferation and hyperemia. Obviously this increased proliferation is an advantage, better enabling the limitation of the disease foci.