sary to be able to make a correct diagnosis for which a Any opera MEDICAL REVIEW. knowledge of pathology is a sine qua non. 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. general interest to our readers, will be considered as doing them and tive surgical procedure is not so harmless as some venturesome or impulsive persons seem to think. Discre. tion in operating increases with thorough knowledge and experience-attributes which must necessarily be supplemented, however, by a keen sense of moral responsibility. The Closure of Bone Defects by the That a regeneration of bone takes place when any kind Members of the profession, who send us information on matters of of sterilized osseous tissue, viz, periosteum, ivory chips, us a favor, and we shall take pleasure in inserting the substance of etc., is introduced into a bone defect, has for some time Communications, Medical Books (for review), and all letters con- been a well-known fact. It has only relatively recently such communications. taining business communications or referring to the publication, subscription or advertising department of the MEDICAL REVIEW, must be addressed to O. H. DREYER, Publisher, 112 N. Fourth Street, St. Louis, Mo. Entered at the St. Louis Postoffice as Second-Class Matter. ST. LOUIS, MO.: MARCH 25, 1899. EDITORIALS Conservative Surgery. been more generally recognized, however, that the implantation of dead bone tissue acts only as a stimulus to the regeneration of bone from living periosteum or bone-marrow existing in the bone whose defect is to be filled by a regeneration of bone. New bone can not be formed from a dead bone. The introduction of the salts of osseous tissue into bone defects produces the same effect as the implantation of pieces of bone or perios teum, i. e., by the stimulus produced by the presence of bone salts, new bone is formed from living periosteum and bone marrow. The implantation, in other words, Scientific conservatism in surgery is an exaction of dead bone tissue in any form does not regenerate which it is pre-eminently just to demand from every bone, it only excites regeneration. Dr. Grosse1 reports surgeon. The term, scientific conservatism, as far as from the clinic of Professor Landerer that after prelim. surgical operations are concerned, implies that explora. inary animal experiments he introduced into the bone tory operations should not be resorted to excepting, defects of trephined skulls of patients bone which had perhaps, under unusual conditions. Exploratory inci. been subjected to glowing heat. In the cases where the sions are to be discouraged if they are the result of a wounds healed by first intention, the pieces of bone lack of skill in diagnosis or inadequate knowledge of produced a perfect closure of the defect. Where there pathology. This is true of all operations, but especially were fistulous tracts, for instance, after sequestrotomies, so of those concerning vital organs. Truly scientific the pieces of bone were again thrown off. The same surgeons are usually also conservative. The pros and result was obtained when, instead of pieces of bone, the cons, based upon a careful diagnosis and the knowledge salts of osseous tissue were, after subjection to a glow. of pathology, must be carefully weighed before an oping heat, introduced into defects made with the trephine. eration is decided upon. The severing of the Gordian The author was able to demonstrate that the newlyknot by operating where the exact indications can not be based upon the necessary foundation of a thorough knowledge of pathology and a pretty certain diagnosis, should be discouraged. Excepting under unusual conditions, strictly scientific indications are the requisites in determining the propriety of operating. It is a fallacy to believe that a practical knowledge of anatomy and a formed bone was not reabsorbed, a phenomenon which has been claimed to take place when dead bone or bonesalts are introduced into defects of bone. In defects which had thus been closed for from two to three and a half years were equally filled by newly formed bone as they were a few weeks after the healing process was skillful handling of the knife are the only requisites in completed. The, at that time, only thin masses of the education of a surgeon. It is at least equally neces 1Centralblatt für Chirurgie, No. 9, 1899. The papers were read before the Society and elicited an interesting discussion which was participated in by a number of guests and visitors. The Society voted that steps should be taken to secure as wide and favorable publicity for these papers as possible, in order that the people of St. Louis may be brought to a sense of the practical importance of inspec bone, since then rather gained in compactness; and Dr. Charles Shattinger, as the author of the best essay, when they were of greater thickness and firmness from and the second prize by Dr. Norvelle Wallace Sharpe, the beginning they had not lost with regard to these both gentlemen being residents of this city. qualities. The same results were obtained at other parts of the skeleton. The bone-salts, which the author employed in these investigations, consisted of the fol. lowing proportions: Phosphate of lime 85.6, phosphate of magnesium 1.75, fluoride of calcium 3 5, carbonate of lime 9 0. As early as 1892, the author closed defects in different parts of the skeleton with pieces of bone which had either been sterilized by iodoform-ether or sub- tion work in schools looking to the prevention of the jected to a glowing heat. In order to obtain a complete spread of dangerous diseases among the pupils. result in closing bone defects by a new generation of bone two postulates must be fullfilled: (1) Perfect asepsis is required, antisepsis being less appropriate, and (2) there must be present a bone producing mother tissue, i. e, periosteum, or bone marrow. If, as the author's investigations affirm, the sterilized salts of bone-tissue excite to increased bone formation the periosteum and marrow of whatever bone-tissue is left in the individual concerned as effectually as steril. ized periosteum, ivory-chips, or bone freshly removed from an animal, the use of such osseous salts would seem to be the most rational of all materials which have heretofore been employed for the repair of bone defects; for all other bone ingredients of which bone. tissue consists would only be superfluous material. how great a degree this is true, or to what extent the superfluous material might retard even the progress of bone regeneration can, of course, only be determined by practical experience in a considerable number of clinical cases, or animal experiments. To Medical Society of City Hospital Alumni; The MEDICAL REVIEW for October 29, 1898, announced that a prize or prizes would be offered in the name of the Medical Society of City Hospital Alumni for the best paper or report by one or more of its members, based on the practical and scientific medical aspects and results of the inspection of public school children, the conditions of the competition and of the award be ing duly made known in this journal in the issue of December 24, last. Five essays were entered in the contest, and the decision of the Committee on Award was made known at the meeting of the Society held on the 16th inst., when it was announced that the first prize had been won by It is understood that the Board of Education fully favors the proposed work and only delays moving in the matter through a lack of available funds. The Society has been invited by the Board to submit. a plan for the medical inspection of all the public school children in St. Louis, and a committee was provided for at the last meeting to consider this matter in all its bearings and report its conclusions to the Society for further definite action in this direction. ABSTRACTS MEDICINE AND THERAPEUTICS. Advances in Our Knowledge of Typhoid Fever.-Since the sad experience of our troops at home and abroad last year with typhoid fever, medical interest in the disease has been if possible, even more keen with regard to everything pertaining to it than be. fore. The springtime nearly always witnesses a recru descence of the disease in various parts of the country, owing to the fact that the melting snows and the spring freshets carry down with them into the water-supplies of towns a certain amount of infective typhoid material Typhoid is one of those diseases of which the practi that has been accumulating during the winter months. tioner is apt to think that "there is nothing new under the sun," at least, nothing new that has a practical ap. plication, or is of value in the prophylaxis or treatment of the disease. A glance, we think, at Dr. Taylor's the new quarterly review of medical progress, edited article on "Typhoid Fever" in "Progressive Medicine," by Professor Hare,' is apt to disabuse one of any such unprogressive notion. With regard to prophylaxis of others during the 'Progressive Medicine,-A Quarterly Digest of New Methods, Discoveries and Improvements in the Medical and Surgical Sciences. Edited by H. A. Hare, M.D., No. 1, March, 1899. (Lea Brothers & Co., Philadelphia). treatment of a case of typhoid, these noteworthy recom the brain fail to disclose any adequate lesion to explain mendations from a French source are given: the symptoms, that it gives pleasure to be able to report positive results. CASE I.-March 11, 1896. A girl aged 2 years; in with characteristic symptoms, and in the afternoon of the same day a typical rash appeared. For four days the temperature ranged from 103 to 105°. 1. Isolate patients suffering from typhoid fever, or at least do not permit them to be treated in a room or ward containing young people who have not previously the midst of an epidemic of measles, she was taken sick had typhoid. The warning contains some wholesome advice too often neglected, and sometimes with sad results, because we are persuaded that typhoid is not an air borne disease, and forget that contiguity favors in fection because precautions will inevitably sometimes be neglected. Nurses for typhoid cases should, if possible, be only such as have had typhoid themselves. In a family the young people should be removed. 3. The floor of the sick-room should be oiled, so as to be impermeable. Carpets and rugs should be re moved, and the raising of dust should be avoided by frequent use of a cloth dampened with antiseptic solu tion. 4. The nurses should wear linen clothes, which they should remove when they leave the sick room, and in general they should be warned to be circumspect in their relations with others, and especially careful of the utmost details of antisepsis in the matter of the preparations of food and drink for themselves and others. The review of the question of typhoid infection from oysters is full and conclusive. The possibility of typhoid infection through salads is made clearly apparent, manure being used in bleaching the plants and gardeners being careless in handling it and washing the plants in any sort of water, or sprinkling them with infected cis tern-water. The strikingly practical features of this excellent review of the recent literature of typhoid are the discussion of the question of typhoid without intestinal lesions, and of its corollary that intestinal lesions, even when existent, often play a very minor role in the disease. How important these questions are for the matter of treatment is clear at once. All the so called abortive methods of treatment, all the much-lauded systems for securing intestinal antisepsis, all the many drug formulæ and combinations that have been enthusiastically recommended for the treatment of typhoid, assume that the essence of the disease is the intestinal lesions. This is a notion that must disappear before scientific advance of our knowledge of the true nature of the disease. Acute Cerebral Paralysis in the Course of Infectious Diseases.-Dr. David Bovaird, of New York (Archives of Pediatrics, March, '99): The occurrence of acute cerebral paralysis in the course, or as a sequel, of an infectious disease is sufficiently rare to render the notes of such cases of interest. The obscurity that surrounds the nature of the process leading to such paralysis lends peculiar interest to the results obtained from post mortem examinations. So often in cases in which the clinical symptoms have been most pronounced, and even when the paralysis has persisted for days, does the most careful examination of On the 12th she was same what delirious, otherwise there was nothing remarkable in the course of the affec. tion. On the 15th the rational and physical signs of bron. cho pneumonia were developed. On the morning of the 17th, the pneumonia being still present, the patient had a convulsive seizure, marked by a sudden turning of the head to the left and rigidity of the right arm and leg. The convulsion was followed by loss of power in these parts. Half an hour later there was a slight return of power, but in the afternoon the paralysis of the right arm and leg was complete. There was a slight rigidity of the parts; the patellar and plantar reflexes were absent. The face was not involved. The child failed rapidly, and died at eleven o'clock. At the autopsy made the following afternoon there was found in the outer half of the left optic thalamus, just external to the internal capsule, an area triangular in section, each side measuring about three eighths of an inch, much redder and softer than the surrounding tissue. Microscopical examination of sections from this area showed a marked engorgement of all of the smaller vessels within the area, together with numerous minute hemorrhages from them. Apart from the dam. age done by these microscopic hemorrhages, the brain substance appeared normal. CASE II. December 11, 1898. A boy, 10 months of age, was taken sick, with temperature of 102° and a diarrhea. December 13.-The eruption of measles appeared; temperature, 102°. December 17.-Fever continues, and he has devel. oped signs of pneumonia of the left lower lobe; the temperature ranges from 102° to 105°. December 28.-Temperature ranges from 101° to 102°; he develops a nasal discharge, and an exudate is found upon the right tonsil; Klebs-Loeffler bacilli found in cultures; given antitoxin. December 31.-Signs of pneumonia continue; sibilant and sonorous râles all over both chests; temperature, 103° to 105°. January 3.-Temperature continues high-101.8° to 104°; pulmonary signs much less marked; few subcrepitant râles over left chest, both anteriorly and pos. teriorly; white, sloughing tissue on both tonsils. January 4.-After a restless night had a general convulsion; temperature, 105°. He became comatose; the head was retracted; the left arm and leg were rigid, with twitching of the fingers and toes; later a twitching of the left side of face. January 6.-Paralysis of left arm and leg; semi-mental depression. Respiration was accelerated, and comatose; temperature much lower, ranging from 98° she seemed to have fever, but no thermometric record to 102°. January 12. The paralysis of left arm and leg has continued; he has remained semi comatose all the time; the temperature has gradually fallen, but the child has failed steadily, and died at 7:45 A.M Previous to death a twitching of the right arm and leg was noted, but there was no general convulsion. The autopsy showed careous bronchial glands, with a simple broncho pneumonia of both lobes, the left be. ing more involved. The brain showed an intense congestion of all the superficial vessels, especially over the vertex, with a transudation of blood into the meshes of the pia mater over the anterior half of the right hemis phere and the posterior half of the left. There were no hemorrhages or other gross lesion of the brain sub stance. Two Cases of Mania During Measles.Finkelstein (Wratch.; Amer. Jour. Med. Sciences). The author reports two cases of this rare complication of measles occurring in his service at the St. Nicholas Hospital. could be obtained. The next day the pharynx was observed to be reddened, and on the following day the eruption appeared. From this time on she became quieter, and two days later remained quietly in bed, occasionally mumbling to herself and not replying to questions. The heart was weak. Pneumonia developed and, with increasing feebleness of circulation, terminated in death six days after the appearance of the rash. The mind never cleared. No autopsy was permitted. SURGERY. The Manner in Which the Mastoid Becomes Involved in Middle Ear Inflammations. In order to understand the development of mastoid inflammation one must have clearly in mind certain anatomical features of the middle ear. the cilia on the tubal epithelium favoring such a result. The act of swallowing normally opens the tube suffi ciently to permit a small quantity of air to enter and properly ventilate the tympanic cavity. The normal condition of affairs is such that any se cretion forming in the mastoid antrum should pass from there, through the aditus, into the attic, thence to A boy, aged 13 years, was admitted on the twenty- the tympanic cavity proper, and from there through the eighth day after the onset of measles. The psychic Eustachian tube into the nasopharynx, the motion of disturbance had existed since the twenty-first day; it was characterized by furious delirium, with periods of extreme terror. At admission there were acceleration of cardiac activity, exaggeration of knee-jerks and en feeblement of nutrition. Intellection was slow, but questions were answered when repeated several times. There were hallucinations of sight of a terrifying character (a black man); he made efforts to escape, fighting with his hands and uttering loud cries; sleep was agi. tated. This condition lasted for a week, and then gave place to gradual and complete recovery. The history showed that the father was an alcoholic, and that the child had been abandoned, and, finally, had been apprenticed in a shop where his life was very unhappy. The second patient was a girl, aged 14 years, who showed mental disturbance from the time of the invasion of the disease, six days before admission to the hospital. The parents denied any heredity. During the first two days, while at home, the girl was sad, and responded slowly to questions; the third day she showed signs of incoherence and hallucinary confusion, manifested by dread of everything surrounding her. She cried out, threw away from her everything that came within her reach, and tried to run away. Under abnormal conditions the tube may be forcibly opened and delecterious products, carrying with them disease germs, may be landed in the tympanic cavity or even in the mastoid antrum itself. Such conditions may, and do, result from too violent blowing of the nose, the use of the nasal douche, sea-bathing, vomit. ing, etc. The Again, in the abnormal conditions present in grip, head colds, pneumonia, and the exanthemata, sepsis is also prone to extend from the nasopharynx to the tympanum. Another important factor is the normally very narrow passageway between the tympanic cavity proper and the pathologically important attic above. narrowness is due to the numerous folds and reduplications of mucous membrance covering the various structures, ossicles, ligaments, chorda tympani, etc., located in this portion of the cavity. With this arrangement it can be readily understood how a slight inflammatory swelling of the mucous membrane will suffice to completely shut off the mastoid antrum and attic above from the tympanic cavity and Eustachian tube below. On admission to the hospital there was extreme exaltation and activity, preventing satisfactory examina Again, the aditus ad antrum, the passageway from tion; she cried out, striking with her fists; she did not the antrum to the tympanic attic, is so narrow that any answer questions, and repeated only the single word considerable swelling of the mucous membrane, partic"injustice." She ran about the ward and threw every- ularly if enforced by the formation of any unhealthy thing away from her. She was very pale, and when granulation tissue, may separate these cavities, thus examination of the chest could be made the vesicular leaving the mastoid antrum and cells entirely cut off murmur in both lungs was noted to be very harsh. Two from any channel whereby the products of inflamma days later the agitation was less violent, and there was tion may escape. The absoluteness of the closure seems surprising when we find it has been easier for the pus as a corollary, it is important in this class of cases to to find its way through solid bone than through the act, and act promptly, even in the presence of seem. swollen soft tissues. The tension of the confined pus ingly slight symptoms. is often enormous, sufficient at times, upon opening through the outer mastoid cortex, to cause the pent-up pus to spurt upward as much as two or three feet. This paper would perhaps seem incomple without a word relative to the part which microbes play in these conditions. While reported observations vary to a con The formation of the mastoid cells is another factor siderable extent, still the following would seem to be in the difficulty of escape for the pus. There are two pretty well-established facts. The germs most fre sets of cells, the horizontal, including the antrum, which quently present in acute middle ear inflammations are can much more readily empty their products into the the streptococcus and the pneumo diplococcus; in aditus than the vertical, which extend downward toward chronic suppurations we are more likely to find the the mastoid apex. staphylococcus. It seems further to be true that as a The infection having extended into the vertical cells, rule the most virulent infectious are caused by the they may be easily cut off from communication even streptococcus.-J. E. SHEPPARD, M.D., of Brooklyn, in with the antrum, thus becoming a distinctly localized the Brooklyn Medical Journal. mastoid abscess. When the pus does not extend be. yond the antrum, and the infection is not too virulent, Treatment of Uremia by Injections of there is a possibility that the case may get well without Serum in the Renal Vein.-The Paris correopening the mastoid, through a lessening of the swell-spondent of the Medical Press, under date of February ing, with a subsidence of the inflammation, especially 19, 1899, reports that at the last meeting of the Lyons if aided by an early free opening in the appropriate Medical Society, M. de Lignerolles gave an interesting portion of the tympanic membrane for the escape of pus. account of his treatment of uremia by injections of serum into the renal veins. The kidney, he said, pos. sesses an internal secretion which it pours into the organism by means of its efferent vessel. The importance of the antitoxic rôle of that secretion against hurt- / ful substances that the kidney could not eliminate had been demonstrated by numerous experiments and by clinical facts. To remedy that renal insufficiency Brown-Séquard, Meyer, Ajello, and Parascandalo, injected in animals deprived of their renal organs the diluted juice of kidney extract; they obained in uremic troubles very favorable results, which confirmed the clinical observations of Dieulafoy, Teissier, Donovan, and others. But "would it not be better," asked BrownSéquard, "to employ the venous blood of different parts of the organisms than the extracted juice of these parts. The venous blood coming from an organ containe, in fact, the principles of the internal secretion special to that organ." If in a given case, time be allowed for the spontane ous cpening of the mastoid, this may take place through either the outer or the inner cortex, if through the outer cortex, there follows a secondary periostitis, with the external evidences of mastoid trouble; if through the inner cortex, we may have meningitis, abscess, either epidural, subdural, or in the substance of the cerebrum or cerebellum, or phlebitis, and thrombosis of the lateral sinus. There is no special reason why, if left alone, the pus will perforate the outer rather taan the inner cortex, hence it becomes plain why the external symptoms of mastoiditis should never be waited for, and why conservatism compels an early operation. In mastoid troubles, arising from chronic middle ear suppuration with long standing discharge, the course of events is somewhat different. In a majority of such cases the attic is involved in the suppurative process, and in many of them the antrum as well. The ossicles, This conception, which had already guided Meyer in one or more, become carious, as do the surrounding his experiments on the periodic respiration of Cheyne bony walls of the attic and antrum-granulations and Stokes, had been realized by Prof. Vitzon, of Buchapolypi spring up-in some cases the superficial epithe rest. The remarkable cases of prolonging life which lium of the attic and antrum takes on a desquamative he obtained in animals, from which the kidneys had process with the resultant formation of cholesteatoma been removed by injections of defibrinated renal venous -in many cases the outer mastoid cortex becomes the seat of a condensing ostitis. Any, or all, of these processes may go on indefinitely without any other symp tom than the otorrhea; but at some time or other the escape of pus from the antrum is interfered with by The blood of the renal vein of a young and healthy granulations, epithelial débris, or cholesteatoma, or the goat was drawn under perfectly aseptic conditions, and carious process reaches dangerously near the cranial its serum decanted into small six-drachm bottles. The cavity and obscure threatening symptoms develop toxic properties of the serum were insignificant, especwhich must be looked upon as grave danger signals. ially when the liquid was injected into the subcutane Permit me to emphasize this point, since in the chronic ous cellular tissue. suppurations with thickened ivory-like mastoid cortex, it would not be reasonable to expect, nor do we find, the symptoms so prominent as in the acute cases, and blood, encouraged Dr. Turbure to treat in the same way patient suffering from uremia. Under the inspiration of Prof. Teissier, the speaker made a special experimental study of the treatment at the hospital. The cases he presented to the Society were not nu merous on account of want of time, but such as they were they merited attention, not only on account of the |