cancer of the sigmoid, and internal hemorrhoids. A case of internal hemorrhoids where the attending physician had entirely neglected to examine the rectum, had been treated by lavage seven months, for so-called dyspepsia and dilatation of the stomach without benefit, and was told that a gastroenterostomy was the only hope of cure. After an operation for radical removal of the internal hemorrhoids he was cured of his dyspepsia. A care, ful diagnosis would have saved this patient years of suffering. The patient's life in one instance (possibly) and certainly the general reputation of the medical profession in all of the cases would have been better had the patient been carefully examined. This neglect was found to be true not only of the physicians in this country, but of physicians in Europe, who had treated some of the cases in the list reported. The author made a plea not only for local but bacteriologic examination, claiming that every case of diarrhea, continuing for a longer time than is sufficient for nature to elimivate the irritating material that may be causing it, is due to a more serious disease. There are many local conditions that cause a chronic diarrhea which would be eliminated by a simple operation or local treatment. When allowed to become chronic while depending upon oral medication, frequently the time when a cure could be affected, had passed, and chronic invalidism or death may result.

SIR CHARLES BALL'S OPERATION FOR INTERNAL HEMORRHOIDS.

GEORGE W. COMBS, M. D., of Indianapolis, read a paper bearing this title. He briefly described the operation advised by Mr. Ball for the removal of internal hemorrhoids which consists: (1) of making a curved incision opposite the pile being treated, terminating in the mucous membrane on either side of the pile, the greatest convexity not including more than one-third of the revoluted anal ring; (2) of bluntly dissecting the pile from the external sphincter, the dissection being carried upward until healthy mucous membrane is reached; (3) of crushing the pedicle in a powerful clamp; (4) of passing a heavy silk ligature subcutaneously in the remaining two-thirds of the revoluted anal ring and through the crushed mucous membrane pedicle, one part of which is constricted in a first tying and the whole of it in a second; (5) of tying the ligature very tightly, thus bringing the remaining two-thirds of the revoluted anal ring up into position, maintaining it there until union takes place and constricting the pedicle so that sloughing will occur. The results obtained by the writer have not been so favorable as those that should follow the procedure as indicated by the author. The following are the writer's conclusions: (1) The postopeartive pain is greater than after the usual ligature or clamp and cautery method. (2) The duration of the healing period is not shortened because of the sloughing of the ligature from either the skin or pedicle before union takes place, leaving the wounds to heal by granulation. (3) There is a necessity for unusual watchfulness that all ligatures may be removed as hey slough. (4) Failing to secure primary union, skin-tabs frequently remain for subsequent removal. (5) No time is saved by this modifica

tion of the ligature operation. (6) There is danger of secondary hemorrhage from an early tearing off of the pedicle by traction.

THE TECHNic of the INJECTION TREATMENT FOR HEMORRHOIDS. EDWIN A. HAMILTON, M. D., of Columbus, Ohio, stated that the injection treatment does not have a wide application, as its indiscriminate use is followed by embolus, abscess and other complications; and relapses are prone to occur except in cases especially adapted to this method. The instruments needed are a cone-shaped anal speculum with one broad fenestrum and a special copper-tipped long needle of large caliber with an outside barrel which may be screwed to the needle proper to regulate the depth to which it may be inserted. The solution is ten per cent carbolic acid and ninety per cent oil of sweet almonds. Neither water nor glycerine is used in the solution as they cause pain. When the sphincter is normal or hypertrophied, the hemorrhoids are never strained outside of the rectum and treated there, but are allowed to protrude through the fenestrum of the speculum and attended to in their normal location. In cases where the sphincter is dilated and the hemorrhoids are easily replaced, they may be treated outside, but under no other conditions. From four to eight drops. are injected in a hemorrhoid, only one injection being made at one treatment. The patient rests in the recumbent posture for several minutes. No application or dressing is applied. The bowels are moved after the second. day. Subsequent treatments may be administered at intervals of five days.

[TO BE CONTINUED.]

ORIGINAL ABSTRACTS.

MEDICINE.

ALBION WALTER HEWLETT, B. S., M. D.

PROFESSOR OF MEDICINE IN THE UNIVERSITY OF MICHIGAN.

DAVID MURRAY COWIE, M. D.

CLINICAL PROFESSOR OF PEDIATRICS IN THE UNIVERSITY OF MICHIGAN.

DO TUBERCLE BACILLI CIRCULATE IN THE BLOOD

STREAM?

UNTIL Rosenberger's somewhat disquieting report in the American Journal of Medical Sciences, February last, it seemed that the question of tuberculosis being a bacteriemia had long since been settled in the negative by the conscientious work of master workmen. Proofs had accumulated by experimentation on man and the lower animals. We were aware that in a number of advanced and pronounced cases of tuberculosis, tubercle bacilli gained entrance into the blood stream, and that acute general tuberculosis

was dependent upon bacilli in the blood stream; that not only in the tissue juices but also in the blood stream of the fetus of mother having miliary tuberculosis, tubercle bacilli could easily be demonstrated.*

The demonstration of these facts, however, does not lead the profession to regard it as evidence of a bacteriemia, for in a true bacteriemia the organisms are present in the blood in all cases of the disease, as for instance typhoid.

Rosenberger seems to have conducted illy planned experiments upon which he based what appears to be far-reaching conclusions. He reports blood examinations of one hundred twenty-five tuberculosis subjects representing all stages of the disease. He claims to have found tubercle bacilli by direct microscopic examination in every case. He reports two guinea pig inoculation experiments, both positive. One of these an advanced case, the other acute miliary tuberculosis. This report served the purpose at least of reviving the old question.

Because of a special method of direct examination, which, however, differs very slightly from ones previously employed, Schroeder and Cotton (Archives of Internal Medicine, August 1900) took up the work of confirmation. They made use of the technique described by Rosenberger and in addition to this conducted inoculation experiments with the blood of cattle which had previously responded to tuberculosis tests and which showed tuberculosis at autopsy.

In all forty-two cattle in various stages of the disease, except miliary, were used. Eighty-eighty pigs were inoculated. In not a single instance were bacilli found in the blood by Rosenberger's method, nor did tuberculosis develop in any of the guinea pigs. The two reports accordingly cannot be harmonized. In favor of the conclusion of Schroeder and Cotton, that tuberculosis is not a bacteriemia, we have history and well controlled experiments, while in reality there seems to be naught in the report of Rosenberger, to uphold his contention.

Until otherwise proved, tuberculosis still remains among those infections which do not produce a bacteriemia as one of their chief characteristics.

D. M. C.

THE CLINICAL VALUE OF THE ELECTROCARDIOGRAM. HERING (Münchener medicinische Wochenschrift, 1909, VII) states that the electrocardiogram obtained by the use of the thread galvanometer has passed the physiologic stage and will ultimately be used for clinical purposes in large hospitals and medical schools. Its cost and the experience required for its successful operation preclude its use by the practitioner. It has not only confirmed many old facts but has also led to the discovery of new ones. In the absolutely irregular heart rhythm it shows no evidence of auricular contractions. While most of the heart beats in this condition originate from the auriculoventricular bundle, there are also frequently *WARTHIN and CowIE: Journal of Infectious Diseases, Volume I, Number I.

extrasystoles. It shows that ventricular extrasystoles often originate from the ventricular muscle itself rather than from the conducting system of fibers. It is not improbable that the electrocardiogram will ultimately permit of an early diagnosis of disease of the heart muscle.

A. W. H.

SURGERY.

FRANK BANGHART WALKER, PH. B., M. D.

PROFESSOR OF OPERATIVE SURGERY AND CLINICAL SURGERY IN THE DETROIT COLLEGE OF MEDICINE.

CYRENUS GARRITT DARLING, M. D.

CLINICAL PROFESSOR OF SURGERY IN THE UNIVERSITY OF MICHIGAN.

SURGERY OF THE INTESTINES.

THE second number of the ninth volume of Surgery, Gynecology and Obstetrics contains three articles relating to surgery of the intestines. The first, on "Obstruction of the Bowels," is by Thomas C. Witherspoon, M. D. of Butte, Montana. The subject is treated from a practical point. of view, based upon experience in thirty-seven cases. The important question is how to treat the obstruction so that the patient may recover. Success depends upon correct knowledge associated with prompt and welldirected action.

His cases are grouped according to the cause of obstruction. He takes exception to the term "Fecal Obstruction" so frequently used in the textbooks, and says that in all his list of cases he has not found one that could be considered a genuine case of fecal impaction of the cecum or small bowel. This belief in fecal obstruction and that it may be relieved by cathartics is frequently the cause of dangerous if not fatal delay before. resorting to operation.

Some cases are purely toxic and may be relieved by drainage. A loop of inflated bowel may be drawn through a short abdominal incision and opened, or appendicostomy may be performed for the purpose of drainage.

The cause of obstruction can always be found by exposing the entire bowel, but this procedure adds greatly to the danger. A simple enema may become a source of danger when a large amount of fluid is retained to excite reverse peristalsis and fecal vomiting.

When the obstruction is due to strangulated hernia, the dead bowel may be resected, or, in very bad cases the dead portion may be brought out through the abdominal incision and drained.

Obstruction due to invagination should be treated by complete removal of the segment of gut involved. Drainage is of great importance and the strength of the patient should never be taxed by long procedures. In desperate cases the operation should be performed under a local anesthetic.

The second paper, by F. Gregory Connell, M. D., of Oshkosh, Wisconsin, reiterates "Some of the Principles of Intestinal Suturing." The

anatomy of the parts must be understood, particularly the blood supply, which should always be followed to its origin so that none of the repaired surfaces may be deprived of nutrition.

In gangrene, the mucosa may be diseased beyond the line of the other layers; care must be taken to remove all diseased parts. Repair sometimes fails because the sutures are not placed in normal tissues. When the mesentery is damaged or there is thrombus of the mesenteric vessels or when there is malignancy, the mesentery should be removed. End-to-end approximation should be the method of repair employed when the operator is familiar with the technique. Mechanical aids are of historical interest only. The basic principle of seroserous apposition, introduced by Lembert in 1824, still remains, and a suture merely for the approximation of serous surfaces should not include the mucosa. The opinion prevails that for security the stitch should be through all tissues, and some prefer a second row which does not penetrate the mucosa. The tendency of all stitches is to migrate toward the lumen of the bowel. Linen or silk are the best materials for sutures. There is little danger of capillary drainage from the intestine to the peritoneal cavity.

The third paper, "Submucous Lipoma of the Gastrointestinal Tract," is written by Dewitt Stetten, M. D., of New York City.

Scarcely any attention has been called to the benign neoplasms of the alimentary tract, but the writer has collected records of seventy-six cases of lipoma of the stomach and intestines from 1757 to date, which he has carefully tabulated. The youngest patient was sixteen, the oldest eighty-seven. The development of these tumors in the intestines corresponds to their growth in other parts of the body. The largest number (fifteen) was found in the ilium, the next largest (nine) in the colon. They usually appear singly, but in three cases a number was found in the same individual. They may vary in size from a pea to a child's head, the average size being about that of a walnut. The attachment to the gut may be a narrow or a broad pedicle.

The tumor arises from fat in the connective tissue of the submucosa, and probably has a long period of development but in some instances the symptoms appear suddenly. The symptoms are very irregular and in some cases very indefinite, the condition being accidentally found postmortem. Such tumors are usually small while tumors with definite symptoms are larger.

The patient may suffer for an indefinite time from cramp-like pains which may have some relation to meals. Constipation with the usual signs of partial obstruction is the rule. The stools may contain blood, mucous, or pus. Rarely the tumor can be felt. It may be expelled spontaneously. and recovery take place or acute intestinal obstruction or intussusception may develop and an operation become necessary.

When invagination takes place, the tumor will be found at the apex of the invaginated portion and is the probable cause of the condition, either by pulling upon the intestine or exciting irregular peristalsis. Such a tumor