PRACTICE OF MEDICINE.

IN CHARGE OF

S. WESTRY BATTLE, M.D., U. S. N., ASHEVILLE, N. C.

EMBOLISM OF THE ABDOMINAL ÁORTA.-Heiligenthal (Deutsche med. Wochenschr., 1898, No. 33) reports an interesting case that came under his observation. The patient was a woman, forty-eight years old, who had been under the author's care for loss of compensation in mitral stenosis. Ten days after leaving the hospital, while sitting down and cleaning clothes, the patient felt a most intense pain in both legs; the pain continued, varying in severity from moment to moment. Admitted at once to the hospital, the patient was excited and restless and cried out continually: "My legs, my legs!" The face was sunken, the nose and extremities cool and cyanotic, the face and hands covered with sweat. The respiration was superficial, the pulse small, irregular, and too frequent to count. The heart-dulness was as before the attack. auscultation being impossible on account of the noisy breathing. The legs were blue and livid to the hips, and the color extended up the abdomen to a curved line, with the convexity downward, three fingerbreadths below the umbilicus. Voluntary motion was impossible, but there was complete passive mobility of the legs. The patient had no knowledge of the position of his legs; reflexes and sensibility to touch and pain were abolished up to the line of Poupart's ligament. On opening a small vein little blood appeared; heat caused no reaction in the skin. The femoral and popliteal arteries did not plusate. Urine drawn per catheter contained blood, albumin, and granular and epithelial casts. After a few hours the lightning pains subsided, the livid color disappeared, but the paralysis persisted. The patient became drowsy, waking at intervals, and died about half a day after the onset. The diagnosis of embolism of the abdominal aorta was confirmed at the autopsy, when a firm, non-adherent thrombus was found at the bifurcation, extending into both iliac arteries. The mitral valve was contracted, the heart muscle not palpably fibroid. It was remarkable that there were no thrombi in the left heart, and the author thinks that a clot formed there was thrown in toto into the aorta. In seven other cases in the literature, six with mitral stenosis, the left heart was free from thrombi. The author has been able to find altogether twentynine cases reported, and adds to the report of his own case some remarks on symptoms, the formation of collateral circulation, and other pathological features. In two cases death did not follow the acciden until symptoms subsided considerably.-Am. Jour. Med. Sci.

PEDIATRICS.

IN CHARGE OF

J. W. P. SMITHWICK, M. D., LAGRANGE, N. C.

TWO CASES OF MANIA DURING MEASLES.-Finkelstein (Wratch, 1898, No. 20) reports two cases of this rare complication of measles in his service at the Saint Nicholas Hospital.

I.-A boy, aged thirteen years, was admitted on the twenty-eighth day after the onset of measles. The psychic 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 enfeeblement of nutrition. Intellection was slow, but questions were answered when repeated several times. There were hallucinations of a terrifying character (a black man); he made efforts to escape, fighting with his hands and uttering loud cries. Sleep was agitated. 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.

II. The second patient was a girl, aged fourteen years, who showed mental disturdance 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 hallucinatory 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. On admission to the hospital there was extreme exaltation and activity, preventing satisfactory examination; she cried out, striking with her fists; she did not answer questions, and repeated only the single word "injustice." She ran about the ward and threw everything away from her. She was very pale, and when examination of the chest could be made the vesicular murmer in both lungs was noted to be very harsh. Two days later the agitation was less violent and there was mental depression. Respiration was accelerated; and she seemed to have fever, but no thermometric record could be obtained. The next day the pharnyx 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. — Am. Med. Jour. Sci.

GENERAL SURGERY.

IN CHARGE OF

H. T. BAHNSON, M. D.,

R. L. GIBBON, M. D.,

J. HOWELL WAY, M. D.

ABDOMINAL SECTION AS A MEDICAL MEASURE.-In a paper read before the Medical Society of London, Treves (British Medical Journal, March 5, 1898) reviewed those cases in which surgical measures in abdominal diseases appear to act upon the patient through other than surgical lines. There are cases in which the mere opening of the abdominal cavity appears to effect, in spite of all surgical prejudices, either cure of a disease, or at least its temporary amelioration. Prominent among these conditions stands tuberculous peritonitis. The results of the treatment of this disease by simple incision have been little short of miraculous, and show a percentage of 69.8 of cures, of which number 32.4 per cent. may be regarded as complete. Another series of cases are those in which a mere incision into the peritoneal cavity has led to rapid shrinking of certain malignant growths and to temporary improvement of the patient. Another group of instances in which relief unexpectedly followed abdominal section, with or without some further operative procedure, is illustrated by the large class of cases somewhat hopelessly styled nervous. These may be divided into two catagories: those in which the symptoms of well-recognized diseases are imitated and those in which the clinical phenomena are simply bizarre and fantastic. Where the symptoms of some well-recognized diseases are simulated operation for the disease and the removal of, for instance, a normal appendix, brings about a cure. The other cases are numerous in which the patients suffer great distress, in which it is impossible to give any name to the disease or to offer any explanation of the symptoms. It has been demonstrated that a great many of these are relieved, and, indeed, cured by abdominal section after all medical measures have failed.

There is a somewhat more definite form of abdominal trouble that the author imagines may lay claim to the term "intestinal hypochondriasis." Many of the patients who are the victims of this condition are men, mostly of middle age. Nearly if not all have been the subjects of chronic colitis. They are apt to complain of fixed pain and tenderness at a spot a little below and to the left of the umbilicus. The spot indi

cated would not be far removed from the inferior mesenteric vessels and plexus. The patients suffer from troublesome constipation, from dyspeptic troubles, from sickening pain in the abdomen, and from indefinite depression. The whole mind is engrossed by the consideration of their bowels and the contemplation of the concerns of their abdomen. There is no doubt, from the study of these and similar cases, that the sigmoid flexure is a very irritable part of the alimentary canal. It is impossible that, in these cases, long-continued catarrh has led to a permanent state of irritability of the muscle forming the bowel wall, to a condition of abiding spasm, which may well cause pain and the sensations of obstruction. Various distortions of the colon and sigmoid have been observed by the author, and give rise to chronic constipation. Cases of idiopathic dilatation of the hollow viscera have been shown frequently to depend upon a stricture of their normal outlet, though they are often met with where no such condition is present. The term is too freely employed where a certain diagnosis has not been established.Am. Jour. Med. Sci.

THE OPERATIVE SURGERY OF THE JOINTS.-In regard to operation on the joints, Marsh (British Medical Journal, March 5, 1898) says there is an obvious parallel to be drawn between the joints and the abdomen in rgard to the results that have followed the introduction of asepsis into surgical practice. It is certain that it is just as safe to open the knee, or any other joint, as it is to open the abdomen, and that, as in the case of the peritoneum, so in that of the synovial membranes, the old view that these structures are in some way inherently unsuitable for operative treatment is erroneous.

As an illustration of the truth of this statement, he relates the results which he has obtained in the open treatment of different joints for the various injuries. In operations for loose cartilages in the kuee-joint he prefers their removal to suture, and in all of the twelve cases operated upon the functional result has been perfect and the recovery afebrile

Loose bodies in the knee are also favorably operated upon, and two recent cases which he reports extensive manipulation was extremely well borne, with a perfect recovery and complete restoration of function.

Suture of the patella represents a test-operation by the open method in recent or old fractures. The results obtained appear to show conclusively that this operation has taken its place on the list of recent advances in practical surgery, and the evidence it affords as to the tolerance by the joints of active interference is sfficiently conclusive.

The general safety with which excision of the joints can now be performed is best illustrated by the results obtained in the case of the knee-the largest of the joints-and that in which an operation involves the most extensive wound of the soft parts, and the largest exposure of cancellous bone. Yet when care is taken to select appropriate cases,

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primary union after excision of the knee is as certain to take place as it is after ovariotomy or removal of the appendix.

Operation in sacro-iliac disease the author believes to be as free from danger under aseptic conditions as is operating on the other joints, and he holds that excellent results can be obtained even where the disease. in this particular region, has advanced to a considerable extent. He illustrates the results obtainable by the histories of five cases where operation produced gratifying results. Am. Jour Med. Sci.

MISCELLANEOUS.

A FEW POINTS IN THE TREATMENT OF IRITIS. (Int. Med. Mag. Nov. '98.) Dr. Walter L. Pyle says when one was called to a recent case of acute iritis, the all-important procedure is to obtain full dilatation of the pupil. This puts the eye at rest, breaks up recent synechiæ and relieves and prevents pain and congestion. As long as the iris is attached at any point, all treatment is handicaped, and protraction of the case may be expected. First drop one drop of a four-grain-to-the-ounce solution of atropine in both eyes every ten minutes for half hour, after which, if the pupil in the affected eye remains undilated, cocaine in four per cent. solution should be instilled in that eye. only to render the cornea more porous, by separation of its epithelium. Then follow with three applications of one drop of the atropine solution heated, at five-minute intervals. Should the pupil still remain bound down, hot compresses should be laid on the eye for one or two hours with ten-minute intervals of rest, and if there be much congestion, three leeches should be applied to the temple of the affected side, and preparations made for diaphoresis. Atropine is again tried every ten minutes for half hour. In many cases the first application of atropine will dilate the pupil, but if the case is refractory, the additional measures will usually break up recent synechiæ. When the pupil is fully dilated, remnants of the posterior synechiæ may be seen as black pigment-spots on the anterior capsule of the lens. Full mydriasis should be continued as long as there are any signs of congestion, pain or cloudiness of the aqueous humor. This can usually be effected by one drop of the four per cent. solution of atropine, three times a day for the first week, or as long as pain and congestions are severe; after the violent symptoms subside, one drop daily is sufficient. If atropine becomes irritating to the patient and causes conjunctivitis, a boric-acid wash should be given, and hydrobromate of scopalomin, gr. 1-12 to one ounce, substituted.

One of the most troublesome symptoms is pain. Leeching, either by the natural leech or the Heurteloup apparatus, and hot, moist compresses for twenty minutes every hour, are the best routine measures to combat it. For two or three nights in succession the patient should be given a Dover's powder, a hot drink, a hot foot-bath, and be kept in perspiration under blankets for two hours. If the pain still continues severe, hypodermic injections of morphia, even in the temple if necessary, should be used; and sleeping po