author made it a rule to tell the parents beforehand that such a recrudescence might possibly occur, but that it would not last long, and in all probability would soon be followed by a decided improvement. It would be rash to claim for rhus aromatica the qualities of a specific in the treatment of enuresis in children as long as our knowledge of this drug and its action is based upon the results observed in barely one hundred cases on which reports have been published; but so much may be said in its favor that it appears to be as efficacious as belladonna, that it may be given for however so long without the slightest ill effect, and that good results may be obtained with it where belladonna proves ineffective. The astringent taste and disagreeable odor of the liquid extract of rhus aromatica are sufficiently disguised by syrupus aromaticus. The dose employed was: Five to ten minims for children 2 to 5 years old; fifteen to twenty minims for older children. A very convenient formula is the following: Syrup. aromatici. Al. m x. m xx. ...ad 3j. M. Sig. This amount to be given three times a day. Contribution to the Clinical Aspect of Scarlatinal Nephritis.-Bruno Sellner (Centralb. f. Kinderheilk.; Pedriatics). The form of nephritis most frequently met with in childhood is that of scarlatina. The toxin produced by scarlet fever in the body of the patient, is, in part, eliminated by the kidneys, and seems to exert a specific irritation on those organs. The time in which nephritis, during the course of scar. let fever, usually makes its appearance, in the period between the twelfth and twenty second day. Occasion ally it is only discovered during the fourth week, more rarely during the fifth week; in exceptional cases it even manifests itself shortly before the end of the sixth week. As regards the frequency with which this complica tion accompanies scarlet fever, the percentage is very variable, and depends greatly on the character of the epidemic. him, 60 per cent were attacked by nephritis. Ch. West mentions 4 per cent; C. Seitz records 185 cases, 23 per cent of nephritis. Among 800 cases of scarlet fever, with a mortality of 16.8 per cent Sellner himself found an average of 14 per cent of all cases of scarlatina attacked by nephritis. The mortality was between 1 and 2 per cent. Henoch is right when he maintains that even the gravest symptoms of uremia do not justify an unfavorable prognosis. Sellner has seen cases which lay in convulsions for days together, presenting total amaurosis and paralytic symptoms, recover in a short time. An unfavorable prognosis must be given in those cases in which extensive edema exists, which is not affected by the various diuretic measures employed. The situation becomes desparate when a pneumonia is added to a scarlatinal nephritis, for, under these circumstances, we may very soon expect a third factor, namely empyema. Nephritis, of scarlet fever nearly always ends in perfect recovery; it is rare to have it pass into a chronic form. Another sequel of this form of nephritis is occa sionally a polyuria, which may either continue uninter. ruptedly for months, or appear in a more clinical form. The septic variety of nephritis scarlatinosa deviates from the usual course. It may make its appearance be tween the first or fourth week, but it is characteristic of this form of the disease to come on very soon after the appearance of the exanthem, and to set in with very high flavor two factors which, as a rule, are not present in the usual form of scarlatinal nephritis. In accord. ance with its septic character, this form runs an extremely rapid course, and always ends in death. Death takes place usuall on the third to the tenth day. The latest period in which we may yet suspect the appearance of a nephritis is the sixth week of the dis. easë. These delayed nephritic forms make their ap pearance, as Sellner has frequently observed, in the wake of some very peculiar prodromal symptoms. The child is seized, for example, at the beginning of the sixth, or at the end of the fifth week, with an angina follicularis. Moderate fever makes its appearance, and after two or three days the punctate deposit in the throat disappears, but no blood and albumin is found in No reliance can be placed on the assertions usually the urine. In another patient the scene is ushered in made that the nephritis was caused by cold, unsuitable with a swelling of the submaxillary, or cervical lymphfood, insufficient rest in bed, and other external factors atic glands, accompanied by fever, which is then folfor we frequently meet with cases of the most severe lowed by a nephritis, after the lapse of two or three uremic forms, where a milk diet has been adhered to, days. In a case of this kind, the blood was examined and where the patient was kept in bed longer than one bacteriologically, but the result was negative. This month. The character of the epidemic only is answer- delayed form of nephritis is entitled to a favorable able for the more or less frequent appearance of this prognosis. complication. The condition of the urine in nephritis scarlatinosa, Th. Hase (Jahrbuch xxx.) who was able to study is, on the whole, the same that we meet with in all 2,453 cases of scarlet fever, met with 253 caees of neph-other inflammations of the kidneys. It should, how. ritis among these, 14 7 per cent. Thirteen per cent of ever, be noted, that in the scarlatinal form of nephritis these presented uremic symptoms. The mortality was there are more frequently absent casts in the urine, at 1.9 per cent. Another author, Thomas, on the other the same time much blood and albumin is also present. hand, states that out of 180 cases of scarlatina seen by It is strange that we are often unable to obtain the re action for albumin, although the urine is distinctly the emphasized. Where inveteracy is once established, if color of beef tea. On the following day the reverse is the deformity is considerable, arthrotomy is indicated. often true. The percentage of albumin is very vari. The results of operative iutervention have frequently in able. It oscillates between five-tenths per cent and the past, however, been extremely unsatisfactory, and 12 per cent. for two reasons: either too little of the abnormal strucThe occurrence of a nephritis in scarlatina indicates tures that caused persistence of the dislocation were rea strict milk diet. Soda water and mineral waters may moved, in which case inevitably it recurred (often under be allowed for thirst. Wine, tea and cognac should be the operation bandage); or too much of the bony struconly ordered when the heart begins to weaken. Should tures was removed, an incision of the elbow being prac the disease continue for a longer time, eggs and roasted cally done, when a flail joint resulted-an eminently meats are recommended to strengthen the patient. The undesirable result. medicinal treatment consists in administering tannate of quinine three times a day, in doses of 0.25 grains, when only a slight edema, or none at all, is present. Where edema is prominent, the child should have a warm bath, 32°R., from one to three times daily, according to the condition. In extensive edema, an in. jection of pilocarpine, 0 01 grain, is to be administered previous to the warm bath. Internally an infusion of digitalis, 0.15 to 0 25: 70 0: 1000 grains, or tincture of strophantus, xx-xxx gtt: 700 of distilled water may be ordered as a diuretic. Should the urine be strongly tinted with blood, the hot bath must be discarded, and plumb. acet. pulv. 0 05 grains may be given three times daily. The internal administration of liq. ferri sesqui chlorat, extr. secal. cornut and tannigen did not yield any special results, according to Sellner. SURGERY. Old Dislocations of the Elbow.-Dislocations nowhere become inveterete and irreducible sooner than at the elbow. This is especially true in the young, where the developmental osteogenetic power of the periosteum is in full play, and where, consequently, the slightest injury or chronic irritation of the periosteum causes new bone-formation, the presence of which precludes the possibility of the joint surfaces reassuming their old relations. The soft parts, too, in growing in dividuals are much more easily modified in their devel. opment by irritative factors than later in life, so that hindrance to the reduction of a dislocation soon supervenes in the course of a case from faulty evolution of the involved soft tissues. Finally, the ultimate bone relations in joints and the nice correspondence of ap posing surfaces are the result of pressure and counter pressure of the parts upon each other during growth, and this being absent, deformity of the bony parts of the joints necessarily follows. The importance of the movements of the elbow-joint is very great, and, besides, from an anesthetic stand point, freedom of motion here is very desirable, since limitation of it always causes a striking peculiarity in the holding of the limb and awkwardness in the move. ment of it that are noticeable. As stated before, reduc. tion even by force soon becomes impossible. The neces sity for early diagnosis and prompt reduction is greatly Professor Stimson, is his new book on "Fractures and Dislocations," treats the subject with his well-known practical conservatism. He gives a sketch of new form. ation of bone on an old, unreduced dislocation of the elbow, as he has seen it in a number of cases. He ad. vises operation for the condition by a long incision on the outer side, exposing the radius and the mass of new bone. This should be freely chiselled away and the capitellum exposed by free division of the soft parts, keeping the knife at a little distance from the bone, so as not to damage the periosteum. The sigmoid fossa is then cleared of fibrous tissues. A second incision is now made on the inner side, curving close behind the epitrochlea or its site, the ulnar nerve is drawn forward, and the olecranon freed. If the epitrochlea has been 1"A Treatise on Fractures and Dislocations," by Lewis A. Stimson, B.A., M.D., Professor of Surgery in Cornell University Medical College, New York, (Lea Brothers & Co.). broken off and displaced upward and backward it must or rotated, omentum and even bowel wall was caught in be detached from the humerus, preserving its relations the small openings at the lower end of the tube, not with the lateral ligament. The clearing of the sigmoid only plugging them and so preventing any flow toward cavity is then completed. The only obstacle to reduc the tube, but themselves becoming injured. tion, then, if there be one, will be the shortening of the Taking one hundred cases each of similar pelvic in. flexor muscles of the hand, induced by their action in flammation, untoward results, including fatal and comthe abnormal position caused by the dislocation. If plicated cases, followed in 20 per cent undrained, but necessary they must be partly divided close to the in 54 per cent of drained operations; suppuration of the humerus. Professor Stimson gives a picture of his re- abdominal wound existed in 14 per cent of undrained, sults, which we produce. Altogether he has operated in 24 per cent of drained cases. Deaths were 6 per cent upon some ten cases by this method, and the results in undrained, 13 per cent in drained. These statistica have all been flexion within a right angle and extension are taken from a résumé of 563 abdominal cases. varying from 120 to 170 degrees, with preservation of rotation. Nor should all these troubles be avoided, had the pa tient or surgeon heard the last of the drainage tube. There was yet another, and apparently an unavoidable, On the Sealing of Operative Wounds result, and that was subsequent ventral hernia. The About the Abdomen.-In the Medical Press and muscles of the abdominal wall are so disposed that, Circular; Therateutic Gazette, Bishop presents a paper when firmly united, their combined action compresses under this title. He says it has always been noticed the abdominal contents toward the spine, but when that after division of any tissues, especially after the once the central union is divided, each half tends to separation of those previously adherent through inflam- drag itself farther from its fellow of the opposite side. matory changes, although all spouting or even evident If reunited at once, and kept together by sutures which vessels were closed by ligature, twisting, sponge press- will not yield until the plastic stage is over, and a firm ure, or in any other way, fluid still continued to exude fibrous union established, hernia does not appear to be from the raw surfaces; such fluid was usually colored probable, but if allowed to remain open at any one spot to some extent by blood, and when bacteriology was until granulation tissue is formed, the union is for a even faintly understood, was recognized as excellent long time so soft and pliable that the action of the mus. culture material for the growth of micrococci. Any cles slowly but surely thins it out, until a very little infailure to avoid septic processes in the wound, or in the crease in the internal pressure of the abdominal cavity cavity where these raw surfaces existed, attributed to demonstrates the weak spot by a hernial protrusion. the presence of this fluid, which, gradually accumulating and becoming stagnant in the closed wound or cavity, was supposed to decompose, and it was assumed that the accompanying poisonous material thereby And no one can doubt but that this was resulted. true. The practice adopted was, however, one sided. Every attempt was made to remove this fluid. Chassaignac introduced his rubber drainage tube; Koeberle, one made of glass; and Macewen, tubes made of decalcified chicken bone. Counter openings were made in the most dependent parts so that the influence of gravity might be enlisted in the attempt to drain it away quickly. In the case of the abdomen all such fluids were believed to gravitate into the pelvis; in women, into Douglas' pouch. Presently it was found that so long as the tube remained, so long was there always some fluid to remove, and that if left too long even pus was found in it, even if none were previously present. So a rule arose that when the fluid is colorless and sweet the tube may be taken away. The writer then inserts a case illustrating the point above stated. He says we may consider pus found in chronic pus sac as practically free from active organ. isms, and as merely representing the débris left behind after the authors of it have perished. With regard to other fluids, Waterhouse's observations show the necessity for careful hemostasis, before the closure of the peritoneum, so as to avoid the possibility of including blood clots of any size. The only other fluids likely to be present in the majority of cases will be the serous oozing from any large adhesion which has necessarily been separated during the operation. As far as possi ble such raw surfaces should be covered by adjacent peritoneum, which is attached so loosely that in most instances it can be drawn over them, and this fluid may safely be left to be dealt with by the peritoneum. It is of course evident that progress in this direction is absolutely dependent on the exclusion of germs, the maintenance of absolute asepsis. There remain a very few exceptional cases in which great damage has been done to intestine, and in which it is impossible to feel certain that the bowel wall may not give way. As to these opinions are still greatly di vided, and it seems at present impossible to lay down any definite rule-but these cases are rare. Some surgeons preferred to leave a rubber tube when the glass was discarded, gradually, and day by day, shortening this, regardless of the fact that if their previous theories were true the shortened tube could not reach the remaining pool of stagnant fluid, and so at The question of drainage of the abdominal cavity in. last it was abandoned to the same risks as those exist cidentally involves the question of general drainage of ing at first. But the glass drainage tube had several wounds, and it is easy to show that most of the argu. dangers of its own. Unless it were constantly moved, ments used in reference to the one apply with similar force to the other. In this relation, however, the treat-loidin plate, as it sets, contracts and drags upon the ment of the incision in the abdominal wall is of im- skin in all directions toward the line of union. Its portance. If no drainage is required for the cavity, edge frills, and just there small blisters will rise during then no drainage is needed for the abdominal wound. the first two days. But if these are opened, the fluid We have, by its elimination, all the conditions favora dried off, and the surface dusted with boracic acid, so ble for primary union of the tissues composing that far he has seen no ill effect. If the blisters are not too wall; and when once the whole line of incision is clos- large, they may indeed very safely be left. They grad ed, and the edges of the skin approximated in a right ually dry up, and when the whole covering becomes line, it is evident that the second question arises to loose, as it tends to do between the tenth and the which we have referred as in process of change, and fifteenth day, being then only held by the sutures, the that it is the one of dressings. new epidermis has formed under the now dry scurfy material which represents the blister. If we could at the moment when the operation is finished apply some air-tight material which would seal Even if the asepticity of one's work is not perfect, it the wound from the entrance of anything from without, is an advantage to be able to see at once through the and which would remain air-tight until healing was transparent dressing where it is faulty. Increased redcomplete, all nutrient fluids would be preserved for ness and heat are easily recognized, whilst the tension their legitimate purpose, bacteria would be absolutely of increased swelling is quickly appreciated by the excluded, and primary union might be reckoned patient in its earliest stage, the celloidin being very resistant. upon. The first attempt under this line of reasoning was made with collodion and a wisp of cotton wool, which A Rare Combination of Fracture and was so arranged as to cover the wound and its sur- Dislocation of the Shoulder. In Lieferung rounding skin for some distance. Good results were obtained by this, but perpaps a later material has on the whole shown itself more fitted for the work. The collodionized wool shuts off the line of incision from immediate observation. With the new dressing-cel loidin-a transparent, closely adherent film could be applied, which in addition to this advantage of transparency added another of strong contraction. This latter quality acted for good in two ways: it decreasd the area of the scar, an immense addition for good in some instances, as in scars about the face, and it tended to contract the skin vessels immediately around the line of union, thus limiting the tendency to overfulness of those vessels after any traumatism. Dr. Mackenzie has reported three cases treated in this way with success: An amputation of the breast, removal of a large lipoma from the gluteal region, and a strangulated hernia. To these the writer adds three out of a large number as illustrating its use in abdominal practice, typical of its advantage of the principle of non drainage. In all these cases, as in most in which this method has been used, the temperature rose during the first twenty-four hours; it did not go beyond 100°F, and then steadily fell, not rising again. Perhaps the last case emphasizes most thoroughly some of the advantages of the practice of sealing as opposed to the use of dressings. Children bear confinement badly, and its evil effects would have been greatly intensified had the use of drainage in this case necessitated the constant employment of dressings and bandages. Of course, in order to avail oneself of these advantages, sterility during the precedent operation is doubly necessary. If, however, this is secured, the only other drawback that he has found to its use has been its tendency to produce small blisters at its edge. The cel XXVI of the Deutsche Chirurgie, Professor Kronlein describes a dislocation of the humerus downward and inward, due to direct violence. The blow was received from above upon the acromion, and only dislocated the humerus after it had broken that process. Professor Stimson quotes the case as a unique one, in his new book on "Fractures and Dislocations." Before the book had found its way through the press, Professor Stimson himself had, toward the end of last December, the opportunity to observe a case with the same condition, in his service at the New York Hospital. The injury was caused by a brick falling from a height upon the outer curve of the left shoulder. The point of impact was clearly demonstrated by the presence of an abrasion just beyond the outer edge of the acromion. The head of the humerus lay close beneath the coracoid process. The acromion was broken at its base and displaced downward and inward, with dislocation of the acromio. clavicular joint, and could be moved with slight crepitus. The joint surface of the clavicle could be distinctly felt through the skin. Reduction was easy by traction and direct pressure upon the head of the humerus. The acromion returned to its place, and there was no tendency to recurrence of the acromio-clavicular dislocation. As this form of direct violence-a blow on the point of the shoulder-is not at all rare from falling objects, the stroke of a stick or club or even a fall, it seems more than possible that this special combination of fracture and dislocation at the shoulder is not so rare as might seem to be the case from consultation of the lit erature of the subject. It is very probable that now, since the exact character of the lesion is clear, cases of it will be reported oftener. "A Treatise on Fractures and Dislocations," by Lewis A. Stimson, B.A., M.D., Professor of Surgery in Cornell University Medical College, New York. (Lea Brothers & Co.). The exact knowledge of all the conditions present in a lesion of this kind is so important, because of the in valuable indications it gives for proper treatment, that this study of the details of certain forms of trauma is eminently desirable. It is too often the custom to diag nosticate the principel lesion in a fracture and disloca tion, missing its complications unless they are very serious or striking, and risking defective results of treatment. Therefore, this spirit of thorough inquiry into the details of such lesions that characterizes Professor stimson's acute observation in this case should prove contagious, and the treatment of these conditions will be lifted from the plane of more or less unsatisfac tory empiricism on which it now rests to one of thor oughly scientific principles and practice. Points in the Arsenical Caustic Treat ment of Cutaneous Cancers.-1. The arsenious acid caustic treatment of skin cancers does not contemplate or depend upon the actual destruction of the new growth by the caustic. 2. The method is based upon the fact that newlyformed tissue of all kinds has less resisting power than the normal structure when exposed to an irritation and its consequent inflammation. Hence, the former breaks down under an "insult" which the latter successfully resists. 3. If, therefore, the whole affected area can be sub jected to the influence of an irritant of just sufficient strength to cause a reactive inflammation intense enough to destroy the vitality of the new cells, the older normal cells will survive. 4. Arsenious acid of properly mitigated strength is such an agent, and its application causes an inflamma tion of the required intensity. 5. It, therefore, exercises a selective inflnence upon. the tissues to which it is applied, and causes the death of the cancer cells in localities outside the apparent limits of these new growths, where there is as yet no evidence of disease. the ripe clinical experience usually considered so neces. Recent We note among them a bimalleola Pott's fracture by inversion in a boy aged 14 years. The external malleolus is separated at the epiphyseal line, and the fracture shows very clearly. The fracture of the internal malleolus does not show in the skiagram, though recognized 6. It is superior, in suitable cases, to any method-clinically by indubitable signs. knife or cautery, which requires the exercise of the surgeon's judgment as to the extent to which it is to be carried. That that judgment is often wrong, and nec essarily so, is shown by the frequency of recurrence under these methods even in the best hands. 7. It is applicable to all cutaneous carcinomata in which the deeper structures are not involved, and which do not extend far onto the mucous membranes. 8. It is easy of application, it is safe, it is only moderately painful, and its results compare favorably with those obtained with other methods.-WILLIAM S. GOTT HEIL, M.D. Limits of Usefulness of the X-Rays for the Diagnosis of Fractures.-On their first introduction it was thought that the xrays would give absolute and immediate assurance of the presence of fractures in bones and make it possible to dispense with 1"A Treatise on Fractures and Dislocations," by Lewis S. Stimson, B A., M.D., Professor of Surgery in Cornell University Medical College, New York. (Lea Brothers & Co.). Tuberculin. At the last British Association meeting, Dr. McCall Anderson made a plea for the more general use of tuberculin by the profession as a diagnostic test, as a means of discovering additional foci of disease of which there is no evidence at the bedside, and as a curative agent. Instances were cited in illustration of the value of tuberculin in these different ways. A very important point, it seems to the writer, is that at the same time that tuberculin is being used means be taken to change the soil by mrans of hy giene, food, pure air, and the use of antistrumous rem edies, including cod liver oil.-Medical Record. |