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tures. The external wounds had become gangrenous. During my hospital experience I have seen three cases of locomotor ataxia with fractures of the leg, and all three patients were confined to bed for four, five and six months, without any union resulting, and finally amputation had to be resorted to. From lying in bed for four weeks the patient was developing paresis of the bowels, and movements were induced with difficulty. Catheterization was necessary to draw urine at all. There was not even fibrous union in the fractures.

DISCUSSION. DOCTOR WILLIAM B. PRITCHARD: There is no arbitrary rule for union in such cases. Sometimes it is impossible to obtain union, and in other cases the results are unexpectedly good. This kind of fracture is not peculiar to locomotor ataxia, but often occurs in connection with pheripheral neuritis and with multiple neuritis, and takes on exactly the same characteristics. The bones are friable, partake of the general trophic disturbance, easily fracture, and show resistance to union. These fractures do well, unless complicated. If simple, there is no external disturbance of the circulation.

ORIGINAL ABSTRACTS.

MEDICINE.

By GEORGE DOCK, A. M., M. D., ANN ARBOR, MICHIGAN.

PROFESSOR OF MEDICINE IN THE UNIVERSITY OF MICHIGAN.

AND
DAVID MURRAY COWIE, M. D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN MEDICINE IN THE UNIVERSITY OF MICHIGAN.

PNEUMOCOCCUS PERITONITIS. Max von BRUNN (Beitraege zur klin. Chir. Band XXXIX, page 57) has made a very thorough study of this disease, based upon two original cases and seventy-two reported in the literature. In all these cases the diagnosis was confirmed by finding the pneumococci. The author also discusses a few cases reported as pneumococcus peritonitis, but in which the determination of the germ was not complete.

Pneumococcus peritonitis is a relatively rare disease, though the chance of infection from pleuropneumonia must be rather common. Primary cases are more rare than such secondary cases. Next to pneumonia, bronchitis and pleurisy, middle-ear disease is an important primary source. Even in the case of pleuropneumonias, infection of the peritoneum can take place through the blood, and that by the lymph tract seems less frequent. In primary cases the gastrointestinal canal furnishes a possible source, while in some cases the female genital tract may take part. The author, however, looks on this as unlikely, and thinks pneumococcus infection of the Fallopian tubes is more likely to be due to germs in the abdominal cavity than from below. Predisposing causes for the peritonitis can rarely be found, variations in the virulence of the germs giving the most likely explanation.

The anatomic picture of the disease is striking. The exudate is usually more or less thick and creamy, of greenish or greenish-yellow color. Hemorrhages sometimes occur. There is usually no odor, but at times there is a fecal odor due to colon infection. The quantity of exudate is sometimes enormous. As is usual with pneumococcus exudates, it contains much fibrin. In consequence, adhesions soon form, binding the abdominal organs down and protecting them against extension of the disease. The intestines may be buried in a mass of false membrane, leaving their serosa smooth. Rarely is the exudate free in the general peritoneal cavity. In some cases it lies between the omentum and the anterior wall. Though complications in the abdominal organs are rare, there may be foci in the lungs, either lobar or lobular, in the pleura, meninges, pericardium or endocardium, or middle ear. Joint and subcutaneous localizations are rarer. In some cases pneumococcus peritonitis is part of general sepsis. Sometimes the exudate is less extensive, or there may be little or none, such cases rep resenting the most severe infections, in which the end comes before reaction can occur.

The clinical picture is most marked in children, in whom it is most frequent. Fifty-seven of the seventy-four cases were in persons below fifteen years. There is sometimes a prodromal stage, usually with signs in the lungs, bronchi or pleura, but often, without these, the first signs are those of severe peritonitis. Fever is usually high, pain severe, sometimes localized, sometimes all over the abdomen. The pain may be colicky, or continuous, or intermittent. Vomiting is almost constant, sometimes lasting for days. There may be diarrhea, with or without blood in the stools. Constipation is rare. The severe symptoms last only a few days. Then the fever and vomiting lessen, the pain becomes less severe or becomes localized, and a chronic stage follows that may last many weeks. The improvement may be so marked that recovery is simulated, or complications may mask the abdominal condition until some such process as perforation at the umbilicus occurs. Usually abdominal signs can be made out, such as meteorism and free or sacculated fluid. Encapsulated exudates often form between symphysis and navel, or in the navel region, but may form in the subphrenic space or the iliac fossæ. Often the abscesses extend into the true pelvis and cause severe local symptoms, such as tenesmus of the bladder. Notwithstanding extensive purulent exudates, the temperature may be normal or only slightly elevated, though septic curves may sometimes be seen. The absence of fever, like the absence of tenderness on pressure, may lead to great difficulty of diagnosis in the chronic stage. Spontaneous opening of the exudate sometimes occurs, usually in or around the navel, and is more frequent than in tuberculous peritonitis. In adults the course of the disease is usually like that of ordinary purulent peritonitis or septicopyemia.

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The diagnosis may present difficulties from the resemblance of the early stages to those of typhoid fever and appendicitis. In the chronic stage tuberculosis presents the greatest difficulty. Besides the special symptoms of the various diseases, the differential diagnosis can be assisted by recognizing the acute peritonitis, followed by evidences of local exudate. It is rendered more probable when the patient is a child, especially a girl, and when signs of pointing occur near the navel region, and when puncture reveals a greenish yellow, odorless pus. Bacteriologic diagnosis is of course essential.

The prognosis is relatively good in children, if an operation is done in time. Out of fifty-seven children, laparotomy was done in fifty. Of these, ten died. In adults, the prognosis is as unfavorable as in other kinds of peritonitis. Spontaneous recovery has not been observed in adults.

The treatment consists in laparotomy with drainage. Even in general peritonitis of pneumococcus origin recovery has followed operation in two cases.

G. D.

SURGERY.
BY HENRY O. WALKER, M, D., Detroit, MichigAN.

PROFESSOR OF SURGERY AND CLINICAL SURGERY IN THE DETROIT COLLEGE OF MEDICINE,

AND

CYRENUS GAVITT DARLING, M. D., ANN ARBOR, MICHIGAN.

LECTURER ON SURGERY AND DEMONSTRATOR OF SURGERY IN THE UNIVERSITY OF MICHIGAN.

THE OPERATIVE TREATMENT OF CHRONIC BRIGHT'S
DISEASE: A SECOND COMMUNICATION BASED
ON REPORTS OF ONE HUNDRED AND

TWENTY CASES. RAMON GUITERAS, New York (New York and Philadelphia Medical Journal, November 7 and 14, 1903). The article is based upon the replies to one hundred fifty letters of inquiry, addressed to various surgeons, who expressed themselves about equally for and against the operation.

The following questions are discussed:
What is chronic nephritis ?

In what does the operation consist that is supposed to cure or relieve it?

The arguments pro and con as to this treatment.
The symptoms which have led the various surgeons to operate.
The results which they have obtained from the procedure.

Chronic nephritis means inflammation or degeneration of the blood vessels, the interstitial tissue, glomeruli, or the epithelia lining the tubules of the kidneys. Both kidneys are always affected but not to the same degree. An examination of the reports of five hundred autopsies for chronic Bright's disease showed both kidneys involved in all cases.

Movable kidney may give the usual symptoms but is not true Bright's disease, the symptoms disappearing when the kidney is fixed.

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Pousson noticed a sympathetic relation between the kidneys, an operation on one frequently relieving congestion in the other.

Two kinds of operation are advocated. One is partial decapsulation of one or both kidneys and suturing the capsule propria to the abdominal wall. The other consists in removing the capsule propria and placing the kidney in the fatty capsule. Ferguson punctures the kidney after decapsulation. Other operators make incisions and leave them open for drainage. Hemorrhage rarely causes annoyance, although Rockey, of Portland, was obliged to remove the kidney to prevent fatal hemorrhage. The size of the kidney gives little indication of its condition unless it is small. The removal of a V-shaped piece from the kidney, as introduced by Ferguson for diagnosis, is advised.

An argument for operation is that the circulation of the kidney is increased by anastomosis with tissues of the abdominal wall and capsule. New epithelia are formed to carry on the function of the organ. Experiments on animals are opposed to this statement, however. Not only is the blood supply not increased but the destroyed capsule may regenerate and contraction still further limit the blood supply of the organ. This may account for some of the fatal terminations two or three months after the operation. While the patient is comfortable, the operation should be delayed, but when the heart is overtaxed and the process is advancing rapidly, it is time to operate.

The symptoms given by the various surgeons which lead them to operate are too many to mention. Nearly all cases had uremic symptoms and edema, while a number had general anasarca. Those having uremic symptoms and chronic edema, should be operated upon when medical treatment fails. It is difficult to decide the question of operation in bad cases, as fifty per cent die and only twenty-five per cent are improved or cured. When the patient is passing little urine or none at all, operation is imperative. The most favorable cases are those of movable kidney with nephritis, the most unfavorable are those with chronic diffuse nephritis.

Results.—Favorable cases recover and are in perfect health for months or years after operation. The urine may return to a normal condition or be only slightly improved. In movable kidney only the displaced organ should be operated upon. Statistics of one hundred twenty cases show sixteen per cent cured, forty per cent improved, eleven unimproved, and thirty-three per cent deaths. Death after operation may be due to exhaustion, uremic coma, edema of the lungs, acute dilatation of the heart, or myocardial thrombosis. The operation is new and requires modification. Further experience may remove the danger to a great degree.

Conclusions.—Chronic nephritis should not be operated for, until medical treatment is of no avail. It is time to operate when the process is advancing rapidly, and fear is entertained that the heart will soon be overtaxed. The operation which has proved least dangerous and given the best results is nephropexy, performed on a single movable kidney. Cases of general anasarca with a bad heart action

should not be operated upon; if the heart action is good an operation performed as a dernier resort may give the patients a few extra months of life provided they survive it. When there has been a marked destructive process in the kidneys as a result of a nephritis, the operation may relieve them for a number of weeks or months, but they generally fail again and die when the new capsule begins to contract.

GYNECOLOGY.

BY REUBEN PETERSON, A. B., M. D., ANN ARBOR, MICHIGAN.

PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

AND

CHARLES LANPHIER PATTON, M. D., ANN ARBOR, MICHIGAN.

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FIRST ASSISTANT IN GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

A NEW TREATMENT FOR DYSMENORRHEA. EMIL RIES, M. D., Chicago (American Gynecology, October, 1903). Dysmenorrhea is often caused by factors not explained by local findings in the sexual organs. The etiology of this condition is very unsatisfactory, as is the therapeutics. Cases of dysmenorrhea amenable to successful operative treatment are comparatively few and belong to well-defined classes with distinct pathologic changes; as, cases caused by congenital or acquired malformations; by submucous fibroids; or by inflammatory disease of the appendages. In other cases, the disease persists, even after various operations upon the genital organs.

This new treatment was suggested by Fleiss, a rhinologist, to the Berlin Obstetrical Society in 1897. A series of experiments convinced him that certain forms of dysmenorrhea, not relieved by the onset of the menses, were dependent upon changes in the nose and that they could be cured by the correction of these nasal conditions.

There are certain spots in the nose, which he calls genital spots, situated at the anterior end of the inferior turbinated bones and spots on the septum opposite these. At menstruation these areas increase in size and sensitiveness, bleed easily and are more or less cyanotic.

In certain forms of dysmenorrhea, which he calls nasal dysmenorrheas, the pain disappears immediately upon the application of two or three drops of a twenty per cent cocain solution to these spots. Both the inferior turbinated and the spots on the septum should be cocainized. Cauterization of these spots yields the same results. Experiments have been carefully performed, using sterile water and different inactive solutions, to exclude the possibility of suggestion causing a cure. Several men have reported excellent results from this treatment. Doctor Ries, himself, has tried this in four cases with good results. He advises further experimentation along this line. All cases of dysmenorrhea are not of the nasal class and therefore all cases will not react to the treatment.

C. L. P.

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