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tinctly remittent type of the temperature At the autopsy it was found, as has alcurve suggested the possibility of the ready been noted, that the liver was only presence of the malarial organism, but slightly enlarged, while before death upon a microscopical examination of the there was great increase in its size. It blood, no malarial parasites were found, is well known that where obstruction to but another very significant fact was circulation exists, the liver may become noted, i. e., the presence of a marked enormously distended, yet after death leucocytosis ; and upon a blood count it but little or no enlargement exist. was found that there were present about Again, a rotation of the liver forward and 25,000 leucocytes per c.m. of blood. It downward, a condition frequently met was found upon examination of the urine with in women who have borne many that no albumen was present, but that a children, will simulate an enlarged conlarge increase in the amount of uric acid dition of the organ. Out of forty-two existed, an observation entirely in accord cases of cholelithiasis tabulated by Riewith that of many investigators, which del, in eighteen the liver was entirely is to the effect that a permanent or even normal ; in twelve cases it was enlarged a temporary increase in the number of as a whole, or at least in the right half, the white corpuscles is always attended and in the same number of cases a by an increase in the amount of uric tongue-like process projected downward acid. A trial of Ehrlich's test proved and forward from the right lobe benegative. In typhoid fever, as is well neath the costal margin. He says that known, there is little, if any, increase in as could have been forseen, the enlargethe number of white corpuscles in the ment of the liver only occurred in those blood, so that notwithstanding the pres cases in which gall stones had migrated ence of the time-honored clinical signs into the deeper ducts, or when they of intestinal gurgling, the step-ladder were located in the gall bladder had elevation of temperature, and the charac caused swelling of the biliary passages teristeric tongue, which were present from that point. While in cholelithiain this case, the diagnosis of enteric sis, evidences of inflammatory processes fever was by the blood examination ex were not infrequently seen in the serous cluded.

covering of the liver, as indicated by the Appendicitis was excluded by the ab- deposition of fibrin, the presence of cirsence of McBurney's tender point, by cumscribed adhesions with the parietal the disappearance of the pain from the peritoneum, the omentum, the stomach, ileo-cecal region, and by the absence the transverse colon and the duodenum, of physical signs of a tumor. That it yet in a series of sixty-four cases rewas a distended gall bladder was ren corded by him, i, e., Riedel, no case of dered improbable by the fact that a tumor hepatic abscess was noted. the shape of the gall bladder could not be In this connection, it may be interestmade out, although the liver at that time ing to relate the history of a case kindly projected about 5 cm. below the costal furnished me by Dr. Charles E. Simon margin. The presence of a sub-dia of this city, which very well shows the phragmatic abscess was thought un value of a blood examination in obscure likely, because no increase in hepatic cases of abdominal disease. dullness was apparent upward.

J. F., married, 30 years of age, preHence in view of the fact that the vious history negative, except for ocliver was enlarged with swelling below casional attacks of “indigestion,” which the right costal border, the peculiar tem were always accompanied with very perature and marked sweating, as well as severe pain. On June 9, 1893, he started the degree of leucocytosis, the diagno- with an attack of typhoid fever, which sis of hepatic abscess of course suggested was of extreme severity, the temperaitself, which, from the previous history ture rising on one occasion to 106.5°, at of the patient, i. e., recurrent attacks of 7 A. M., and reaching normal for the colic, was thought to be referable in all first time on the thirty-fifth day. Durprobability to the presence of gall stones. ing the following three days the temper

ature ranged between 98.6° and 100.6°, course suggested. A blood examinawhile the pulse during the same time tion made at this time, however, showed ranged between 88 and 104 per minute. the existence of a slight leucocytosis

On the 37th day of the disease, only and out of 500 leucocytes counted, 11.4 475 cc. of urine were voided, while pre per cent. were of the small mononuclear vious to that time the amount secreted variety, 1.4 per cent. transition forms, was about normal. During the after 83.4 per cent. multi-nuclear neutrophiles noon of the same day, he began to vomit and 0.2 per cent. eosinophiles. and to complain of pain in the lower ab. In view of the fact that the degree of dominal zone, particularly in the right leucocytosis generally stands in direct iliac region, which was not relieved by relation to the degree of local reaction, turpentine stupes, nor sinall doses (one the diagnosis of peritonitis was of course sixth of a grain) of morphia. A abandoned and that of cholelithiasis refew hours later, a few teaspoonfuls of garded as the more probable, a view paregoric were given and at 10 P. M., the correctness of which was later one-fourth of a grain of morphia, the demonstrated by the fact that the urine pains at that time being agonizing. became bile-tinged, that a distinct icWhile the temperature at 8 P. M.

terus was developed, and by the passage was 100°, it steadily rose during the of a soft clay-colored stool in which, it next few hours until at midnight it was is true, no calculi were found, but which 105.5° The pulse made a correspond- contained a piece of inspissated bile, ing rise from 104 to 176. At this time very much resembling a piece of indiathe patient was deeply comatose and ap rubber. In this connection it is expeared to be moribund. During the tremely interesting to note that the ocsucceeding two hours three pints of currence of a piece of inspissated bile, whiskey and numerous injections of which was regarded as the cause of the camphor were given. The temperature obstruction, is a condition of extremely gradually decreased, reaching normal rare occurrence. the next day about noon, from which In personal conversation with Dr. point off, the temperature continued Simon, I was told that only one other about normal, notwithstanding the fact case, after a careful survey of the literathat the patient was in deep stupor. ture, had fallen under his notice ; that The pulse varied between 120 to 140 was a case which he had occasion to exper minute. The amount of urine voided amine for Dr. Simon Flexner of the during the 38th day was slightly in ex. Johns Hopkins Hospital, and which was cess of 500 cc. Physical examination discovered at an autopsy. In Dr. Flexmade on the 38th day revealed, in addi ner's case the obstruction was about 5 tion to the conditions already noted, centimeters long and i centimeter thick, three beginning bed sores, one upon the while in Dr. Simon's case the obstrucsacrum, and one on each trochanter. tion was only about one-half that size. Moist rales were also to be heard at In reference to the differential diagnosis both bases. The liver was found some between septic infection and cholelithiwhat enlarged; the abdomen tender asis, it seems to me that it would have throughout, most marked, however, in been impossible at that stage of the disthe right half. Right rectus muscle ex ease to have positively decided which of tremely tense. Although the liver was these conditions was present, without enlarged and was easily palpable, it was an examination of the blood, as by the impossible to make out any enlargement presence or absence of a leucocytosis, of the gall bladder. The spleen was the presence or absence of septic infecenlarged and had been in such condi tion is determined. When we remember tion during the course of the disease. the almost unvarying fatality of perfora

From the general symptoms 'escribed, tive peritonitis in connection with tynotwithstanding the absence of the char phoid fever, it will not be thought acteristic facies noted in cases of perfora strange that the hopes of the family for tion, the diagnosis of peritonitis was of the recovery of the patient were resting

entirely upon the result of the blood ex

scess, Frerichs states that inflammation amination.

and ulceration of the biliary passages, One lesson to be drawn from the study which may succeed upon the presence of these two cases is the importance of of concretions, etc., are, many times, an examination of the blood. By it the cause of hepatic abscess. the presence of septic infection may be Dr. Osler speaks of the difficulty of definitely excluded, and in many cases a making the diagnosis from intermittent positive diagnosis made.

fever, and states that the diagnosis must A second is the importance to be at many times be made by the administratached to a sudden decrease in the tion of quiuine, or a blood examinaamount of urine secreted by the kidneys. tion. He states that where suppuraGreat stress is laid upon this condition tion has its primary start in the bile by certain French writers, A. Robin, ducts, the temperature may present an Gubler, Hayem, G. Sée and others, who intermittent curve, there is great enrecognized by this means the onset of largement of the liver, and death invamany complications, before the physical riably takes place early. signs of such changes were sufficiently Bright speaks of biliary calculi assoadvanced to be detected.

ciated with multiple abscess. Louis A third lesson is the necessity for reports a case of the same kind, there greater care in the examination of the being in this case some thirty to forty patient with reference to the diagnosis abscesses. Abercrombie has reported of the disease. In my case I at first two cases. Budd reports several cases. believed I was dealing with a beginning Lebert reports a case in which the bilityphoid fever, and not until the micro ary passages, even down to the smallest scopical examination of the blood made canals, were filled with gall stones a few days before the sudden fall of associated with suppuration. Frerichs temperature revealed the presence of a reports a case in which the biliary pasmarked leucocytosis, was the true con sages were obstructed by calculi, causing dition recognized.

inflammation of the same, associated In reference to the relation existing with an abscess in the liver substance, between cholelithiasis and hepatic ab the size of a child's head.

PUS IN THE PELVIS.—The inflamed 6. We may hesitate to perform lapFallopian tube too often escapes detec arotomy when there are clearly defined tion. Dr. Grace Harrison relates a se broad adhesions between the tumor and ries of cases in the Alabama Medical ana bowel or vagina. Surgical Age, from which he draws the 7. When rupture has occurred into following conclusions :

the bowel or vagina, we should care1. The symptoms of pyosalpinx vary fully but thoroughly cleanse the cavity greatly according to previous condition with antiseptic solutions. Preferably of patient, size and mobility of the tube. warm boracic acid sol. or peroxide hy

2. Complete anesthesia is essential to drogen. thorough examination of the pelvic and 8. By proper care an artificial anus abdominal organs.

may be relieved without operation, if 3. The sickening nausea and vomit seen in time. ing is probably due to pressure on the 9. In debating an operation we should ovary.

banish all hope of establishing or fear of 4. Pyosalpinx seldom ruptures into injuring a good reputation and consider the peritoneum, but nature seems to the patient's good, and his alone. If guide the tear toward the vagina or an operation offers one chance in a more often the rectum.

thousand it should be given. Not our 5. It is probably unsafe to aspirate interests, but the patient's, first, last and save through a broad adhesion and at a all the time. point of great tenderness.

WHY BALTIMORE IS A HEALTHY CITY.
READ At The Forty-sixTH ANNUAL, Session OF THE AMERICAN MEDICAL ASSOCIATION,

HELD AT BALTIMORE, MD., MAY 7-10, 1895.
By D. W. Cathell, M. D.,

Baltimore. BEFORE presenting a few statistics is 300,000,000. This is one of our chief which aid in proving that Baltimore is sources of health. a very healthy city, a brief synopsis of The rich and diversified soil, the its location, climate, etc., seems proper.

swarming waters, and the teeming forBaltimore lies in latitude 39° 18', longi ests about Baltimore furnish an unsurtude 76° 36'. It is situated on the Pa passed abundance and variety of food. tapsco river, one of the tributaries of the Added to these, we have an unequalled great Chesapeake Bay, which divides climate for permanent residence, for the State of Maryland into two portions neither the cold of our winters nor the -eastern and western, the city of Bal heat of our summers continues long timore being on the western portion, enough to entail deleterious effects on about fourteen miles from the junction the general health. Our snows end of the Patapsco river with the bay. We with March and our autumn frosts begin have an excellent and large harbor for with November. our shipping.

Baltimore is chiefly surface-drained, Baltimore covers an area of 31/2 and although it has about 35 miles of square miles and, like Rome, may be underground sewers, the function of said to lie on seven hills. Its soil is most of these sewers is to carry off stormboth healthy and favorable for building. water from certain localities. The city The city has 99,987 houses, with an ap has no slums, and comparatively few praised value, including the ground, of tenement houses, although, like all large $274,000,000. Its population, as ascer cities, there are many thickly populated tained by the police census of 1894, is neighborhoods where many poor people 496,315, of whom 422,568 are white and live too closely huddled. The mean 73,747 are colored. It has 780 miles of temperature for 1894 was 55.9°; the paved streets, with 234 miles of rapid- highest temperature of summer was 98°; transit street railways, running 785 cars, the lowest in winter was 7° above zero. some cable, some electric, each car being Our average annual rainfall is 44 inches. provided with a fender in front for the The number of days on which rain and protection of life and limb, and all stop snow fell in 1894 was 134, and strange to take on or let off passengers at the to say, the greatest monthly precipitanear side of streets, instead of crossing tion was in May, 7 inches, and the the street before doing so, and each least was in March, 1/4 inches. The must come to a full stop before crossing total mortality in the city of Baltimore any intersecting railway. By these rules for the year 1894 was 9486, of which our street railway accidents are reduced

number 7242

were white persons and to a minimum. Besides business, car 2244 colored, being a marked decrease riding for pleasure is a source of both rec in comparison with the five preceding reation and health to our people.

years, notwithstanding a decided inOur city has an inexhaustible supply crease in population. Our death rate of excellent water, chiefly from the Gun for 1894 was 20.84 per thousand, but if powder river, kept in 8 separate storage the death rate per thousand were comreservoirs, which have a total capacity puted as in other cities, upon an estiof 2,274,000,000 gallons, the daily con mated population, instead of the U. S. sumption of water being 45,000,000 gal census of 1890, it would show a rate of lons, while the daily capacity of supply only 19.04 per thousand for the whole

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476

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21.77 20.99

90 100

9,486

100

population, which would make Balti Childbed,

82 more rank high among the very healthi Dysentery,

72 est cities in the world. Among the The number of deaths in public insti9486 deaths there were 1085 deaths of tutions was : persons above 70 years of age.

Baltimore City Jail, Taking the different periods of life

Penitentiary,

15 separately, there were :

Hospitals and asylums Under 1 year,

2616

Deaths reported by coroners,
Between 1 and 2 years,

669
including inquests,

770 5

During the year there were 777 inter5

255

ments in the two public cemeteries, 15

143

Eastern and Western, at the public ex15

pense. A comparison of the mortality 30

in Baltimore for the past five years 30 40

780

shows the following decreasing ratio : 40 50

735

Total number of deaths. Ratio per 1000
50
“ 60

801
1890
10,198

22.41 60 70

832
1891
10,073

22.13 70

701
1892

10,582
80

322
1893

9,554
1894

20.84 59 110

The vital statistics of our race tell us

3 The ratio of deaths of children under that the average duration of human life

is about 37 years. five years of age to the total mortality

Up to 1875 there was 3972. In addition, there were 721

were no reliable vital statistics kept in still-births during the year.

Baltimore ; and I am ashamed to tell you The death rate among our colored

that even now, almost at the dawn of population is always greater than that

the twentieth century, we have no comof the whites. This I attribute chiefly plete record of the births ; but of the to their meager comforts and lack of 174,923 deaths that occurred in Balti

more during the twenty years ending opportunities for advancement, compared with those of the whites, coupled

December 31, 1894, we find the followwith their relative lack of knowledge of ing large number of aged decedents : sanitary laws. Thus, in 1894 :

12,651 were between 40 and 50 years of age. The annual death rate per 1000 white pop

12,752

50 60 ulation was 18.85.

12,800

бо

70 The annual death rate per 1000 colored pop

10,779

70

80 ulation was 31.60.

4,972

80

90 759

90 Among the chief causes of death in 1894 we find :

95

13 were above 110 years of age. Consumption,

1106 Pneumonia,

790

Nature has done a bountiful share for Cholera Infantum,

440

Baltimore, and man has done much to Disease of heart,

aid her, and of this her physicians have Cancer,

264 done their full share. We have about Bright's disease,

226 450 regular practitioners in the city, beTyphoid fever,

sides quite a sprinkling of irregulars of Diphtheria,

198

all shades and colors. We now have Diarrhea,

144

laws regulating medical practice, which Influenza,

132 bid fair to be of great benefit to the comWhooping cough,

munity.

Besides the great Johns HopAccidents,

kins Hospital, we have scattered through Bronchitis,

90

the city numerous other and well manScarlet fever,

85 aged hospitals and homes, some for the

100

100

IIO

438

222

I2

109

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