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that on a second test being applied 76 per cent. of the clinically non-tuberculous show the ophthalmo-reaction. Dufour, however, found that two successive instillations into different eyes always yielded concordant results, though the second reaction might be more severe; with two successive instillations into the same eye, the first being negative, the second was sometimes positive; with three or more instillations, the first being negative, the later ones were sometimes positive in the same eye, but not in the opposite one. Anaphylaxis is, therefore, local.

Tuberculosis and the Inman (The PracOpsonic Index. titioner, May, 1908) gives the following points upon this subject:

1. Early or febrile cases of pulmonary tuberculosis may be treated with advantage by means of pure air and graduated exercises. When such treatment is undertaken it must be borne in mind that "tuberculin by auto-inoculation" is being used.

2. The opsonic index is a valuable guide to such treatment, and also gives useful information if inoculations of Koch's tuberculin are employed.

3. Rest is essential in febrile cases of consumption, and in these cases injection of tuberculin, using as a guide the opsonic index, is the treatment indicated.

The reader will gather from what has been written that the latest methods of treating consumption are those which aim at co-operating with the natural methods employed by the body itself for its own protection and defense. Where it is possible, as in the afebrile cases at Frimley, the body is made to carry on its own continuous inoculation, the efforts of the physician being directed to prevent excess or deficiency. Where, as in febrile cases,

this cannot be done without harm, the need is supplied artificially. And in both cases a watch is kept over the blood by means of the opsonic index, so that the conditions may be maintained under which "the policemen of the body" can best discharge their duties.

Anti-Typhoid Inoculation.

Sanborn (Boston Medical and Surgical Journal, June 4, 1908), gives the following conditions under which anti-typhoid inoculation may be considered in practical medicine:

(1) When an individual contemplates a sojourn in a typhoid-infested district; for instance, it is not uncommon in England for the families of civil and military officers going to certain of the colonies to be protectively inoculated.

(2) When a person starts on an extended journey into places where typhoid exists, where sanitary arrangements are questionable and drinking water of doubtful purity, and under conditions that would render an attack of typhoid a serious handicap in the carrying out of special purposes.

(3) In the event of an epidemic of typhoid, before the source of infection is discovered, when an attack of typhoid would be of serious consequence to a particular individual, not only in consideration of the question of ultimate recovery that always exists, but of the confinement for a number of weeks and the necessary absence from the conduct of affairs of perhaps the highest importance to the incividual.

(4) In the case of nurses in a general hospital, constantly caring for the typhoid patients, and too frequently succumbing to infection, protective inoculation may be considered and offered.

(5) In the case of an army in the field. A plain statement should be made to

each individual to be inoculated as to the symptoms that may follow. If the importance of freedom from typhoid ontweighs a few hours of malaise subsequent to the inoculation, the physician may advise such a course. If we are considering protective inoculation during an epidemic in individuals possibly already exposed we must further explain, first, the possibility of their being already infected and in the septicæmic stage before symptoms have developed, and the probability that if inoculated under these conditions a more serious attack may be brought on than would have naturally followed if the individual had not been inoculated; second, the possibility of their becoming infected immediately after inoculation during the period of depressed resistance or "negative phase," when they would, of course, be abnormally susceptible to the disease. It should be added that the disease, occurring under the latter circumstances, is usually mild in its course.

Senile Tuberculosis.

Ranzier (La Prov. Médicale, Vol 20, No. 44, 1907; Ctrlbltt. f. inn. Med., No. 19, 1908). Tuberculosis in the aged is probably more common than is usually assumed, but it is often not correctly recognized. It must also be taken into consideration that the number of positive anatomical findings is greater than the number of clinical findings. The aetiology is referable, as a rule, to the exacerbation, or persistence, of a latent tuberculosis.

Heredity is a minor factor altogether. The disease may, however, be first acquired in old age, certain favoring conditions being supplied by damage of the organism through diabetes, cancer, abuse of alcohol and close association with tuberculous individuals. Senile tuberculosis takes the same course as in other ages, but is distinguished by the more frequent tendency towards a cure. The course is retarded by emphysema, which may be general, or limited to the surroundings of the pathological foci. Tuberculous foci outside of the lungs are rare in aged patients, and are most apt to consist in tuberculous pleurisy and pericarditis. The complication of cancer and tuberculosis is very common, œsophageal and gastric cancer taking the first rank in this connection. Among the symptoms of the disease the most striking is the emaciation; night sweats are uncommon, but otherwise the course does not differ essentially from that observed in youthful individuals. The diagnosis is difficult; chronic bronchitis, bronchiactasis, emphysema and cancer of the lung must be kept in mind for the differential diagnosis. The most reliable guide to the diagnosis is the demonstration of bacilli. The prognosis is not very unfavorable in so far as the course is slow. The treatment is apt to meet with certain difficulties, on account of objections on the part of these old patients. It does not differ essentially from the treatment of the disease at other ages. F. R.

GENERAL AND ORTHOPEDIC SURGERY.

UNDER THE CHARGE OF

EDGAR A. VANDER VEER, PH.B., M.D.,

Lecturer in Clinical Surgery, Albany Medical College; Attending Surgeon, Albany Hospital.

When to Operate In the International in Peritonitis. Journal of Surgery for May, 1908, in an article entitled "When to Operate in Peritonitis," in re

ply to a letter by the author, Dr. Charles Graefe, Dr. J. B. Murphy of Chicago replies as follows:

"In reply to your communication of

October 9, I would say, in answer to the question, 'When shall we operate?' for appendicitis, the answer should be: Immediately after making the diagnosis; and the diagnosis should be and can best be made within the first six or eight hours after the onset. There is no time, however, in the course of the disease when one is justified in waiting, whether it be the first, third, fifth, seventh, ninth or eleventh day, with emphasis on the odd day for luck.

"From the symptoms we are unable to tell of many of the pathologic conditions and their progress in the abdomen from day to day. From the symptoms and signs we are always able to make the diagnosis in the first 24 hours.

"Now, with reference to the peritonitis, my article on suppurative peritonitis includes the perforative variety; that is:

"(a) Perforations of the stomach. "(b) Perforations of the duodenum. "(c) Perforations of the intestinesprincipally typhoid-and

"(d) Direct perforations of the appendix into the free peritoneal cavity.

"It does not include the cases of circumscribed abscess with large quantities of purulent fluid in the peritoneum. These are not perforative cases, and practically all get well on the old treatment.

"I have had up to date 43 consecutive cases of perforative peritonitis in four and one-half years, and in all there was a direct communication from the peritoneum into the opening in the intestine, and in none were there circumscribed or encapsulating adhesions. Of these, 42 of the patients are living.

"The technique consists in:

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"I. Opening the peritoneal cavity. "2. Locating the point of leakage. "3. Closing the point of leakage. "4. Inserting a large drain into the pelvis, and if the infection be in the upper

abdomen, also one directly from the wound to the point of primary infection. "5. Placing the patient in extreme Fowler position.

"6. Instituting continuous proctoclysis, so that not less than 18 pints of salt solution are administered and absorbed in 24 hours. If it is not absorbed, it is not properly administered.

"7. Giving 20 c.c. of streptolytic serum each 12 hours until the temperature, pulse and other symptoms subside. Usually not over four or five doses are required.

"In doing the operation remember one thing: Get in quickly, and get out equally quickly. Do not manipulate, handle, sponge, wash or otherwise maltreat the intestines.

"Have the anæsthetic given by a competent anæsthetist, that can put the patient to sleep with æther in from three to five minutes.

"I consider it useless to operate on moribund cases. However, I must say that I have operated on every case that has come under my observation, regardless of the patient's condition, with the results above given. The diagnosis of perforative peritonitis should be made early, and when made it is cowardly, indeed, if not criminal, not to operate-hypocritically called conservative.”

The Treatment of Eichler Eichler (Beitr. . Malleolar Fractures. Klin. Chir., Vol. 55, 1907). The author reports the results from treatment of malleolar fractures in the Eppendorf Hospital, service of Dr. Kümmell. The former treatment consisted almost exclusively in fixation dressings. Since 1899 Bardenheuer's extension method was employed. The leg was placed in a Schultz gutter, meaning an open box, which has at its lower end an opening for lateral counter-extension, and

I. Attack.

an arch connected by a broad rubber band, for the purpose of preventing an abnormal plantar flexion of the foot. Moreover, the knee-joint is slightly flexed. As a rule, extension treatment with ten pounds during about three weeks is sufficient. The patients are given plaster dressings later on for walking, and receive the customary after treatment in shape of massage, etc.

The time of healing was approximately the same in either method. The functional results, however, differed in so far as the treatment with plaster dressings was followed by good results, meaning the complete restitution of the mobility. of the ankle-joint, with a walking capacity the same as before the accident, in 54 per cent. among 126 cases, whereas these results were obtained in 72 per cent. among 117 cases under combined treat

TABLE OF DIFFERENTIAL DIAGNOSIS BETWEEN BENIGN ISCHOCHYMIA AND GALLSTONE DISEASE.

Gallstone Disease.

Attack comes suddenly and ends
abruptly.

Pain in upper abdomen usually
more to right side over liver and
radiating to right shoulder, very
intense, frequently necessitating
relief by morphin.
Vomiting not usually present; if
present, contains last meal, but
no food from day before.
Vomiting usually is without much
influence on the attack.

2. Pain.

3. Vomiting.

4. Influence of Vomiting on Condition of Patient.

5. Condition of Stomach.

6. Results of Stomach Examination.

7. Condition of Liver.

8. Icterus. 9. Fever.

10. Sex.

ment with extension and plaster dressings. The chief advantage of the later method consists in the avoidance of traumatic flat foot, which could be demonstrated with a frequency of 15 per cent. in the former treatment, as compared to a frequency of 4.2 per cent. in the present method of treatment. A further advantage of the extension method consists in the avoidance of obstinate chronic œdema, the proportion of the cases treated by the old and new plan, respectively being as 10.3, 1.7 per cent.

F. R.

Ischochymia Simulat- Max Einhorn
ing Gallstone Disease.
(American Journal
of Surgery for June), in an article with
the above title, gives the following diag-
nostic table:

Benign Ischochymia.

Attack does not come abruptly, it
usually lasts a week or more.
Pain in upper abdomen, diffuse, in-
tense, but frequently endurable
without the use of morphin.

Vomiting of large quantities of
food, containing usually food
from day previous.
Vomiting brings relief; pain some-
times ceases after it.

Stomach usually much dilated;
peristaltic restlessness at times
visible.

Examination of stomach contents
in the fasting condition shows
presence of food remnants from
day previous.

Liver not enlarged.

Icterus not found.

Usually absent.

More frequent in en.

Stomach usually not especially dilated. Gastric peristalsis not visible.

Examination of stomach in fasting condition shows that the organ is empty or contains only a small amount of gastric juice with or without bile.

Liver usually enlarged, both upward and downward.

Icterus present at times.
Usually present.

More frequent in women.

mon Carotid.

Ligation of the Com- Yordan (Archiv. f. Klin. Chir., Vol. 83, H. 1, 1907). The danger of ligation of the common carotid lies in the failure of a sufficient collateral circulation, with the appearance of nutritional disturbances and softening process in the brain. Cerebral disturbances develop in 25 per cent. of the cases, and about 10 per cent. terminate in death. In order to gain an estimate of the possible sequelae of carotid ligation the author recommends the ap plication of a loose temporary ligature during 24 hours as preliminary treatment.

This operation must be performed under local anesthesia, since the cerebral disturbances sometimes follow immediately upon the awakening from general austhesia, so that their origin cannot be demonstrated. The tightening of the constricting band must be performed very cautiously and gradually. Should the slightest cerebral disturbances manifest themselves during the constriction, or subsequently, the ligature is to be removed at once. In these cases the contemplated permanent ligation will necessarily have to be omitted. F. R.

CLINICAL PATHOLOGY AND DIAGNOSIS.
UNDER THE CHARGE OF

The Laboratory of Clinical Observation, 616 Madison Avenue.

Index.

The Clinical Signifi- Jürgens (Berliner cance of the Opsonic Klinische Woch., No. 13, 1908). This article describes and criticises Wright's method of determining the opsonic index. Phagocytosis, the author states, is not entirely dependent upon the action of opsonin-containing serum or bacteria, but may also take place when opsonin is completely absent. This latter action is termed by Wright "spontaneous phagocytosis;" it is relatively slow, not of high intensity, and can, according to Wright, be abolished by using as the liquid medium a 15 per cent. saline solution.

In the actual work of determining the opsonic index it is impossible to exclude the influence of spontaneous phagocytosis. If, for example, we find that in one investigation 100 leucocytes contain 200 bacteria, in another 220 bacteria, and in the control 210, the opsonic index would be put down as 0.95 in the first case and 1.05 in the second. We attribute here the entire phagocytosis to the action of opsonin, whereas, as a matter of fact, the 200 or 220 or 210 bacteria have only partly made their way into the leucocytes by

opsonin action; a portion of them has entered spontaneously. But this spontaneous phagocytosis does not necessarily occur in precisely equal degrees, and hence there is involved a source of error which cannot be estimated.

Moreover, the bacteria, as well as the leucocytes, give rise to difficulties in the practical work of opsonin determinations. In the first place, we must take account of the fact that even the best emulsion of tubercle bacilli or cocci has a tendency to the formation of clumps; but the count varies if (1) the bacteria which come into contact with the leucocytes are all single, or if (2) the bacteria also occur in groups. As a typical case in point Jürgens réproduces a photomicrograph showing three leucocytes; one of them contains five bacilli, another two, and the third none. The five bacilli lie close together; they were probably close together in the original emulsion, and presumably they all entered the leucocyte in a group. Ought this leucocyte to be excluded from the count? If so, and if we lay down the rule that every leucocyte containing a group of bacilli must be disregarded as

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