symptoms, a differential clinical diagnosis may be very MEDICAL REVIEW. difficult, if not impossible. It is therefore a consoling L. T. RIESMEYER, M.D., Editor. Department Editors: Dr. F. J. LUTZ, General Surgery. Dr. E. C. RUNGE, General Medicine. Published Under the Auspices of the Yearly Subscription, $3.50. Single Copies, 10 Cents. To Contributors and Correspondents. All letters, whether intended for publication or not, must contain the writer's name and address, not necessarily for publication. No attention will be paid to anonymous communications. Secretaries of medical societies will confer a favor by keeping us informed of the dates of the meetings of their respective societies, and of officers elected. Members of the profession, who send us information on matters of general interest to our readers, will be considered as doing them and us a favor, and we shall take pleasure in inserting the substance of such communications. Communications, Medical Books (for review), and all letters containing business communications or referring to the publication, subscription or advertising department of the MEDICAL REVIEW, must be addressed to 0. H. DREYER, Publisher, 112 N. Fourth Street, St. Louis, Mo. Entered at the St. Louis Postoffice as Second-Class Matter. ST. LOUIS, MO.: MARCH 11, 1899. EDITORIALS fact that a bacteriological examination, made early in the disease, will in the vast majority, if not all instances, clear up any doubt with regard to its nature. In instances where there is any doubt regarding the diagnosis, as is often the case in sporadic cases, some cerebro. spinal fluid should be gathered by the insertion of an exploratory needle through the meningeal membranes. The punctures should be made between the second and third or the third and the fourth lumbar vertebræ. At a depth of about four centimeters in children and seven or eight centimeters in adults the fluid begins to escape drop by drop from the needle; aspiration being as a rule not necessary. If properly done the puncture is harmless and is claimed to be followed even by posi. tively beneficial effects. The fluid should be gathered in a sterile test-tube which should then be stoppered with sterile cotton. The fluid may thus be examined directly, by making cover glass preparations, as well as by the culture method. If the case be one of cerebro. spinal meningitis (cerebro-spinal fever, spotted fever), the presence of the meningococcus intracellularis-also called diplococcus intracellularis, and diplococcus meningitidis-the diagnosis will be no longer doubtful, even if there be an admixture of other organisms as, for instance, the pneumococcus. For the presence of the meningococcus intracellularis is pathognomonic of the dis Cerebro-Spinal Meningitis. According to the daily newspapers, sixty one deaths ease under consideration. Councilman recommends from cerebro-spinal meningitis have been reported in Loeffler's blood-serum mixture as best adopted for the this city to the Board of Health from February 1 to March 4. Reports have also been published of the growth of the organism, of which it is very difficult to existence of the disease in different parts of the country dance as shown by cover-slip examination of the meninobtain cultures even if they are present in great abun -Illinois and several Southern States. The disease manifests itself, with regard to symptomatology, in geal exudate and microscopic sections. The organisms various different forms, which Osler has divided into may be mistaken for gonococci, which also exhibit similar three main groups, viz.: the malignant form, the ordi- characteristics as to staining properties, both being decolorized by Gram's method. According to Councilman1 nary form, and anomalous forms; the latter being again dividable into three different types: the abortive, the the organism is in the tissues almost strictly confined intermittent, and the chronic type. The disease may be to the interior of polynuclear leucocytes. It has no confounded with certain manifestations of typhoid and definite position in the cell and is never found in the typhus fever, also some cases of pneumonia may closely simulate cerebro-spinal meningitis. Osler says: "I am quite certain, that many cases reported to the health boards as cerebro spinal meningitis belong to the cere bral form of typhoid fever or pneumonia." When it is further considered that influenza, gonorrheal and streptococcus infection may produce an inflammation of the meningeal covering of the brain and spinal cord it becomes evident that under some conditions, such as the sporadic appearance of the disease coupled with atypical nucleus. According to the same author, the number of organisms found by him in the cells varied from a single pair to such numbers that the nuclei of the cell were frequently obscured; the organism was only found in connection with the lesions of the disease and not in the blood, liver, spleen, and kidneys. According to Councilman's observations, the organism does not produce septicemia. The first description of an organism which might be regarded as the meningococcus intra 'Johns Hopkins Hospital Bulletin, February 1899, page 29. however, readily decide the question. The great value, then, of bacteriologic examination finds another illus. tration in the readiness with which a differential diag nosis can be made in cases of suspected cerebro-spinal meningitis, from which much benefit is derived, espe cially as regards prophylaxis and prognosis. cellularis was furnished by Leichtenstern in 1885. A broad and flat and directed towards each other by their more definite description of the organism was given in broad surfaces. In the lesions the organism is found 1887 by Weichselbaum, who found the meningococcus almost solely within the cells. In cultures the organ. in post-mortem examinations in the meningeal exudate isms grow singly, in pairs and in tetrads. By the of patients who had died from cerebro-spinal meningitis, microscopic examination of meningeal exudate its dif. and who also succeeded in demonstrating the patho- ferentiation is, except in the hands of experts, very genic properties of the organism by animal experiments. difficult from the gonococcus, according to Fürbringer, In 1895 Jaeger confirmed Weichselbaum's observations. who lays special stress upon the ready differentiation Jaeger's principal merit is to have directed attention to by the culture method. When only cover-slip prepara. the special association of this coccus with epidemic tions from the exudate have been made, the clinical cerebro-spinal meningitis; while to O. Heubner belongs history, the presence or absence of gonorrhea, would, the credit of having first demonstrated intra vitam the presence of the meningococcus in meningeal exudate. Other investigators have confirmed the investigations of Weichselbaum, Jaeger, and Heubner and their deductions, and among them Councilman in this country, whose conviction regarding the pathognomonic significance of the meningococcus intracellularis is expressed The outbreaks of cerebro-spinal meningitis are localby the following sentence: "A great deal of interest ized and rarely widespread. Country districts are attaches to sporadic cases of cerebro-spinal meningitis. usually more afflicted than cities. Winter and spring We can only be certain that these sporadic cases are are the favorable seasons for the occurence of epidemics. the same as the epidemic form when the organism Where persons live closely together, as in large barassociated with the epidemic form has been found in racks, and under physically and mentally depressing them." Osler has also accepted this intracellular surroundings, the disease seems most liable to make its diplococcus as the etiologic factor of cerebro-spinal appearance. European epidemics seem to demonstrate meningitis. As regards the errors in diagnosis and the that recruits and young soldiers are very liable to coninaccuracy of general mortality tables Councilman says: tract the disease. In civil life, children and young "A great deal of stress should be laid on the rarity not adults are most susceptible. only of epidemic meningitis but of all forms of menin. gitis in children under one year of age. Nothing more clearly shows the incccuracy of general mortality tables than the ages given in cases of meningitis. In nearly all of these tables a large percentage of cases are attributed to children under one year of age. In looking over these mortality tables one receives the impression that errors in the diagnosis of meningitis are not uncommon." To determine the diagnosis in sporadic cases of cerebro-spinal meningitis is also of importance as regards prognosis. Councilman points out that "it may be generally assumed that cases of sporadic meningitis which recover are of the epidemic variety." The same author has not been able to find a single case which, from its association with other conditions, could be regarded as due to a pneumococcus or streptococcus infec tion, and which has recovered. The meningococcus intracellularis is described by Weichselbaum as a diplococcus whose component parts are not lanceolate like those of the pneumococcus, but 'Loc. Citat. According to Osler the disease "seems not directly contagious and is probably not transmitted by clothing or the excretions." The various excellent text books on the practice of medicine furnish all the information required as to symptoms, pathologic anatomy, treatment, history of the different epidemics, etc. It has been our aim to consider, in this article, almost exclusively information which is based upon relatively recent investigations and accepted facts. New City Dispensary for East St. Louis. -Supervisor Wheeler of the St. Clair County Board of Supervisors introduced a resolution at the meeting held March 4, authorizing the County to purchase a stock of drugs and equip a drug store and dispensary in a room in the new City Hall, to be furnished by the city of East St. Louis. Mr. Wheeler stated that he had seen the Mayor and the members of the City Council, and all agreed that they would give a room in the new City Hall for the purpose of a City Dispensary. After con. siderable discussion, during which the action of the East St. Louis authorities was complimented, it was agreed that the matter be laid over to the next meeting force the limb could be rolled in but when released it SOCIETY PROCEEDINGS flew back to its old position. Every muscle reacted NEW YORK ACADEMY OF MEDICINE. Section of Orthopedic Surgery. MEETING OF DECEMBER 16, 1898. Shortened Pectoral Muscle. DR. R. WHITMAN presented a patient, a girl 11 years of age who could not raise her right arm more than 30 degrees above the horizontal. The cause appeared to be obstetrical paralysis. Round shoulders and curva ture of the spine were present. He had advised divi sion of the unyielding contraction of the lower border of the pectoralis major muscle, which presented a thick fibrous cord beneath the skin. Dr. A. B. JUDSON said that the contraction might have resulted from a paralyzed deltoid which had failed to give normal extension to the pectoral. DR. WHITMAN said that there was a very fair development of the shoulder muscles and that the curvature of the spine could not be relieved until the contraction that prevented the child from lifting her arm over the head was removed. Tuberculous Knee and Athetosis. DR. WHITMAN presented a girl 10 years of age who had been under observation for nine years. When 1 year old and under treatment for disease of the right knee she had a convulsive attack which was followed by right hemiphlegia. The return of voluntary power was accompanied by constant convulsive movements of the face, arm and leg which had continued to the pres ent time and had made treatment of the knee a matter of great difficulty. In spite of splints, traction and plaster-of Paris bandages the convulsive movements of the leg had caused severe pain and prevented repair, so that the local disease was still uncured. But for the youth of the patient, amputation would have been done. The case illustrated the advantage and necessity of rest in the conservative treatment of joint diseases. Cases of Doubtful Diagnosis. DR. W. R. TOWNSEND presented a boy 11 years of age who fell from a car three months ago and had com plained of pain in the left hip ever since. Six weeks ago, when he was first seen, there was symmetry in all the measurements of the lower extremities but the affected hip showed considerable resistance to motion in any direction, which could sometimes be partly overcome by persuation and considerable force. Manipulation was painless. He stood and walked with the left foot, leg and thigh everted or rotated outward 90 degrees and this persisted. By the use of considerable perfectly to galvanism and faradism. Tincture of iodine had been used locally and his locomotion had improved a little. A probable diagnosis of hysteria had been made by occlusion and because he could with effort stand and walk voluntarily in a normal manner and because the bad position could be overcome by a steady pressure and without causing pain. DR. WHITMAN said that a faulty position of a limb in an impressionable patient might be considered as a vol. condition following strain or other injury of a joint. untary or unconsciously selected adaptation to some DR. TOWNSEND said that the statement had been made that injury of the obturator nerve had in some instances caused a similar eversion, but he had not found any recorded cases. DR. G. R. ELLIOTT presented a man 32 years of age. The family history was negative regarding nervous and bony diseases. Five years ago inability to move the left thigh appeared. When motion returned to the left thigh the right was similarly affected. Other symptoms which still persisted were burning sensations in the feet, especially in the heels, great difficulty in standing erect, and walking and rigidity of the spine preventing him from bending backward. Torus palatinus was noted and there were other degenerative stigmata. The legs were bowed, but otherwise there were no signs of early rhachitic changes. The hamstrings were con. tracted. There was double hallux valgus and pes equinus. The upper extremities were normal. There were no sensory disturbances beyond the paresthesias mentioned. Neurologists had failed to locate any or ganic nerve lesions. Dr. Elliott was in doubt in regard to the diagnosis. He did not agree with an opinion expressed by some members of the Section that it was probably a case of rheumatoid arthritis, a disease which could not present so much disability with practically no involvement of the small joints, almost painless from the beginning and with no deposits about the joints. The pain that was present and the disability were due to the various contractions and consequent disuses of the parts implicated. Cicatricial Contraction of the Hand. DR. S. LLOYD presented a little boy with cicatricial deformity of the right hand, the result of burns receiv. ed a year ago. About six weeks ago the little finger, being very much twisted and distorted, was amputated and superficial tissue was removed from the remaining digits. To replace the cicatricial tissue with normal skin a flap including a little of the fatty tissue was partially dissected from the abdomen, being attached at the top and bottom. Under this the boy's hand was slipped and a plaster of Paris bandage was applied. This being removed the attachment of the fingers to the abdomen was very well shown. At a later stage the flap would be entirely detached from the abdomen. There had been no suppuration. MEETING OF JANUARY 20, 1899. The affection of the bones in this disease appeared to be a form of malacia in which the organic material is Secondary Pulmonary Osteo-Arthropathy somewhat increased and the mineral substance corre in a Child. DR. R. WHITMAN presented a girl 8 years of age, rather undersized but in fair physical condition. There was moderate kyphosis and rigidity of the spine, the result of Pott's disease of the tenth dorsal vertebra, ac companied by an abscess in the left iliac fossa, for which she had been treated by the application of a plaster-of-Paris jacket in 1893, when she was 2 years old. The abscess disappeared and the patient was recovering favorably till 1896, when persistent cough and expectoration followed an attack of whooping.cough. In 1897 enlargement of the fingers was noted, the gait was feeble and shuffling and there was pain in the knees and ankles with exaggerated patellar reflex and ankle clonus, and marked effusion into the knee and ankle joints. The terminal phalanges and the nails were enlarged, and there was cough with abundant expectoration, and râles at the apex of the left lung. spondingly diminished so that the structure of the bone is weakened. The characteristic change in a deposit of new bone beneath the periosteum of the shafts of the phalanges, the metacarpal and metatarsal bones and the lower part of the bones of the lower arm and leg with local sensitiveness, sympathetic arthritis and clubbing of the ends of the digits and hypertrophy of the nails. The affection had been first described in 1888 by Bamburger and independently by Marie who differentiated it from acromegalia with which it had been confounded. In practically all of the cases reported, upward of 80 in number, it was secondary to chronic disease of other parts; in 75 per cent to tubercular or suppurative dis ease of the lung or its coverings. The cause of the periosteal and other changes was supposed to be the absorption of irritating substances from the focus of suppuration in or about the lung, combined with im. paired circulation. Thus the first evidences appeared in the ends of the fingers. It was a rare disease and this was believed to be the first typical case reported in a child. In 1898 the pain was relieved by the antirheumatic administration of salicylate of soda, and although there was a marked general improvement, the swelling of the knees and ankles persisted, and the increased clubbing DR. H. E. PEARSE, referring to the great increase in of the nails had attracked much attention and was the size of the bones, called attention to the fact that thought to be an instance of the so called Hippocratic the radiographs showed that the enlargement was lon. fingers, due to obstruction of the circulation caused by gitudinal as well as transverse. disease of the lungs. Expectoration was moderate in amount, and bacilli were not found. In October, how ever, an examination showed thickening and enlargement of the bones of the lower arms and sensitiveness to pressure, and swelling of the wrist joints. DR. A. M. PHELPS said that he had been impressed with the remarkable bony enlargement. A post-mor. tem examination of the brain and cord would be of great interest. Acromegaly was due to a tumor or growth in one of the ventricles of the brain and he This made the diagnosis clear, and at once connected questioned whether or not in the case presented there the clubbing of the fingers, the arthritis and the en was a central lesion due to poisoning from the diseased larged bones as symptomatic of the affection known as area. The lungs had not been sufficiently involved to secondary pulmonary hypertrophic osteo-arthropathy. cause obstructed pulmonary circulation. The child was found to have no psoas contraction or joints there was destruction of bone from a central other trace of abscess and there was apparent recovery from the disease of the spine. There was slight dull ness at the apex of the left lung and increased respiratory sounds at the base of the right. In tabetic lesion, and cases of rheumatoid arthritis might perhaps have a similar origin and not have been rheumatism at all. He doubted whether such a thing as a simple rheumati joint existed. They were always multiple. The moet marked peculiarity was the great size of DR. R. H. SAYRE said that the pathological views the hands as compared with the size of the child and of presented were not entirely convincing. It was not the lower arms and legs as compared with the upper clear why proliferation of the periosteum should visit segments of the extremities, giving the impression of the phalanges rather than other parts of the skeleton. atrophy of the thighs and upper arms. The bones of In a patient affected with a tubercular knee joint the the legs and forearms were sensitive to pressure. The radiograph had shown a very marked proliferatiod of knees, ankles and wrists were enlarged by an effusion the periosteum of the lower end of the femur and there into the joints and by thickening of the surrounding were marked clubbed fingers. The patient had the parts without redness, heat or muscular spasm. Motion appearance of a consumptive in whom the destruction was very slightly limited. The digits were thickened of the lung was far advanced, but her lungs showed no and their terminal phalanges remarkably enlarged with nails rose red in color but not especially thickened or curved. The circumference of the ends of the fingers and the breadth of the nails were about twice as great as normal. This condition was somewhat less marked in the feet than in the hands. change. In another patient there was the same condition of the fingers which were more tender sometimes than at others. Movement greatly aggrevated the inflammation and nothing gave relief but absolute rest. DR. H. S. STOKES said that the etiology was far from being established, as might well be in a disease that had been recognized for only eight or ten years. It evidence of femur rhachitis and the usual signs of had not yet been positively determined even that the double coxa vara. For several years he had complained condition was dependent on disease of the lungs. If it were, why did it not occur more frequently? In the absence of the characteristic bacilli it was not certain that the child presented had tuberculosis. In view of her history it would not have been strange if her gen eral condition had been worse. It was almost impossible to make a diagnosis of lung affections in children with deformed chests. He had seen a specimen of kyphosis from a case in which the diagnosis of tuberculosis of both lungs had been made, and yet, at the autopsy, the lungs had been found to be normal. Similar cases were not uncommon. of discomfort and pain in the left hip and thigh, the pain at times being severe especially after exertion. When about 5 years of age he was treated by a physi cian for eighteen months for supposed hip disease, and a year later by the application of a plaster jacket for spinal deformity. On September 8, 1898, an operation was begun for the correction of the deformity of the femora by removing wedges of bone from the trochan. ters. On removing the periosteum from the upper end of the left femur a peculiar dark color and a somewhat reticulated appearance of the bone were noticed and at the first touch the chisel broke through the brittle ccrDR. &. R. ELLIOTT said that if speculation were in tex and entered a cavity from which spurted a quantity order he would agree with Dr. Phelps that the cause of of serum of the color of prune juice. The cavity was this rare condition was to be sought for through the of the size of a hen's egg, its base being shut off from central nervous system. There was reason to believe the medullary cavity of the diaphysis by a cone shaped that the cause of various distal bony changes and pecu projection covered apparently with cartilage. Its upliar vascular phenomena presented by the distal ex. per extremity reached about half way to the apex of tremities, including great sensitiveness, together with the trochanter. Its walls were lined by a smooth certain well-marked types of so-called osteo-arthro fibrous covering which bled freely on manipulation. pathy were traceable to central lesions. In the patient As it was feared that the inner part of the femur was presented there were clinical and x ray evidences of a weakened by the cyst, aud as it was evident that union disturbance of the normal equilibrium between the bone in case of fracture would be doubtful, to restrain hemproducing and organic producing cells leading to the orrhage the cavity was simply packed with gauze which enlargement. The signs were bilateral and symmet was removed at the end of four weeks and the boy berical evidences of central irritation. To say that such gan to walk about. The sinus closed one month later. a condition was associated with a chronic disease It was evident that spontaneous fracture, as in other meant very little; to say that it was circulatory was cases of coxa vara, could not have been long delayed. untenable. He believed that the explanation would be If the symptoms should recur, a second operation for found in this—that the trophic and vasomotor cells had the removal of the walls of the cyst would be indicated. been thrown off the track by some poison, be it tuber- Cysts of the femur were usually found at the extremity calar or other, circulating through the central nervous of the diaphysis, most often at its upper extremity. A system, selective in its nature and degenerative in its diagnosis before operation had not been recorded. final expression. They were said to be the result of softening or trans. formation of an originally more solid growth of a car. tilaginous or fibro-cartilaginous nature, probably a displaced fragment of epiphyseal cartilage. DR. STOKES said that the five or six autopsies which had been made no nerve lesions had been found in spite of careful and thorough examination. DR. ELLIOTT said that that was true of other diseases which were considered to be due to central nervous lesion. DR. SAYBE had examined the boy 2 or 3 months ago. As he had not offered to operate, the patient passed out of his care. At that time he had taken a radiograph of the hips and had observed a spot on the femur which might have been the cyst. Value of Radiographs. DR. WHITMAN said that many cases of osteo arthropathy were probably not true examples of the disease in question. In many the only change observed was clubbing of the fingers which was sometimes seen in cases of simple obstruction of the circulation, described by Hippocrates as a symptom of advanced phthisis and DR. T. H. MYERS said that he had tried, but usually not very uncommon in cases of empyema of long stand in vain, to detect abscesses, tubercular foci and other ing. One fact had been established, viz.: that hyper- lesions in the bones by means of skiagraphy. In a case trophic osteo-arthropathy was practically always sec-of abscess of the head of the tibia an area of diminondary to some chronic disease, in the case presented, for example, to Pott's disease and chronic bronchitis. Speculation as to its cause would seem to be less im portant than further and more careful descriptions and classifications of cases. Cyst of Femur-Double Coxa Vara. ished density at the site of the abscess had been clearly revealed, with increased density about it, similar to the contrast seen between the center and the periphery of a long bone in any skiagraph. DR. PHELPS said that a radiograph would usually show a shadow where there was a lesion, but it could not tell what it was. He had been deceived by pictures taken by good machines and had cut down upon lesions |