all of the organs and the area of necrosis in the pericardial fat can be explained only in this way, while the fat-necrosis may be explained by the presence of the fat-splitting ferment of the pancreas. It does not seem to Warthin that all of the changes can be produced by the action of the pancreatic ferments. Steapsin would not cause the necrosis of the lymphadenoid and muscle tissue, nor would the presence of the tryptic ferment affect the connective tissues in such a degree as to produce a liquefaction necrosis. It seems highly probable that other substances besides the known pancreatic ferments play a part in this widespread necrosis of tissues.

4. That the hemorrhage is most probably entirely from diapedesis, due to the effects of the poison upon the vessel walls, and that injury is not the essential factor of its production. There is at least no rupture of vessel walls to be found, but the hemorrhages are local, and relatively of slight importance.

5. That the process is apparently primary in the pancreas or in the structures lying behind that organ, and because of certain striking changes found in the area of Langerhans it seems not improbable that they play an important part in the disease process. The chronic changes found about the nerve structures behind the pancreas may be the primary ones, but it is impossible to establish any definite relations between the processes found here and those in the pancreas. 6. That death takes place most probably from shock, due, as Osler has suggested, to the involvement of the important nerve elements near the pancreas. 7. That no evidence exists of an infective process.

SURGERY.

UNDER CHARGE OF W. B. ROGERS, M.D.

Professor of the Principles and Practice of Surgery and Clinical Surgery,
Memphis Hospital Medical College.

The Treatment of Septicemia by Blood Letting and Infusion of Salt
Solution.

Young (Maryland Med. Jour., vol. 40, no. 6) reports the case of a boy, 15 years of age, who, after operation for suppurative appendicitis, suffered from general septic infection. Repeated injections of normal salt solution were used with most excellent results. Young's report with observations is best summed up in his own conclusions, which we here present in detail:

This case, which has been recited at considerable length, is a striking example of the wonderful therapeutic possibilities of saline infusions.

Of late evidence has been rapidly accumulating, showing their great value in acute anemia, uremia, eclampsia, coma, post-operative shock, etc. In cases of toxemia the rational treatment is certainly to remove by venesection as much of the toxic blood as possible and replace it by a normal salt solution. One vein may be used for both purposes, or one may be bled while one on the opposite arm is infused.

This simultaneous depletion and infusion makes it possible to withdraw much more of the poisoned blood without fear of shock.

As exemplified by this case, very large amounts of fluid may be necessary before the toxic agent is neutralized or washed out. The first 700 c.c. which

was injected beneath the breast reduced the pulse from 170 to 156; but it had no effect on the temperature, which even continued to rise, and the pulse soon became weak again. The next infusion (intravenous) of 1300 c.c. reduced the pulse from 156 to 130, and the temperature from 105° to 104°, but here, again, both soon began to rise, and it was only after the last intravenous infusion of 2500 c.c. both fell never to rise again.

An interesting question is, "How much dilution can the blood stand?"

Taking the common estimate, the adult man has between 4000 and 4500 c.c. of blood in his body. Our patient, a delicate boy of 15 years, probably had very much less, yet he received 4500 c.c. additional fluid into his vascular system without any bad effect.

It would, therefore, seem proper and justifiable in a case of septicemia in the adult to infuse 7000 c.c. or more of salt solution. Author feels sure no harm would be caused if it were injected slowly and at two or more sittings.

It is certain that small amounts-a quart or so-will be utterly useless in many cases. The curative effect is probably due both to the dilution of the poison and its rapid elimination by the excretory organs, brought about by the high artificial vascular tension. (The diuretic effect of infusions is very marked.)

Method of infusion: The subcutaneous and submammary methods are probably adequate for cases that are not urgent, but for others the direct infusion into a blood vessel is certainly much more certain and immediate in its results. The intravenous method, which was most successful in this case, is not without danger, on account of the possibility of air and foreign body emboli, and a few cases of death from such causes have been reported. This led Dr. Halsted, in 1884, to advocate centripetal arterial transfusion as being devoid of all danger. The radial artery, Dr. Halsted thinks, can be more easily exposed than a superficial vein in many cases, this being especially true with fat subjects.

All toxic conditions would seem to come within the province of the depletory venesection and saline infusion, not alone the surgical septicemias, but the toxic states of typhoid, pneumonia, diphtheria and malaria, and there is no reason why the procedure should not be repeated as many times as is necessary to combat the blood infection.

In a case of severe malarial coma last summer Dr. Schenck, at author's instance, removed thirty ounces of blood, and followed it by an infusion of nearly two quarts of salt solution, with very good effect. The loss of healthy corpuscles is more than compensated for by removal of parasites, toxins and dead corpuscles. Local Anesthesia.

Before a recent meeting of the Berlin Society für Innere Medicine, Wohlgemuth (Med. Press & Cir., vol. 66, no. 3093) said local anesthesia could be reduced to three principal forms-1, by compression; 2, by cold; 3, by the use of local medicinal anesthetics. As regarded the first it was methodically employed in the 17th century. According to reports amputation of the leg had been painlessly performed under its use 100 years ago. James Moore is reported to have performed amputation of the thigh painlessly in this way. The use of cold had long been known, and Hunter and O'Larry had performed operations under its use. He then mentioned Richardson's methodical use of ether spray. Ether was contraindicated when the skin lay in folds as in the scrotum, in inflammatory conditions from the pain it set up, and in the neighborhood of the eyes, nose and

mouth. As regarded local anesthetics, cocaine stood in the first rank. Schleich's infiltration method gave a new field for its use, as in it the dangers of intoxication disappeared. But even Schleich's process was wanting in some respects. Whitlow could not be operated on with it, as the infiltration in these cases was very painful, and when the injection was made into the pus cavity the pain was enormously increased by the increase of tension. For the same reason it was useless in the opening of boils. It failed also in brawny swelling of the palm of the hand and sole of the foot. It was best suited for the extirpation of tumors, and for laparotomy and herniotomy. For the opening of whitlows, Obst's method was the best; the application of rubber tubing round the base of the finger, and the subcutaneous injection of a 1 per cent. solution of cocaine near the nerve trunks. In recent times Manz of Freiburg had performed amputation of the hand and foot in this way. Substitutes for cocaine had been tried, eucain, for instance, which acted well on mucous surfaces, but was not so serviceable for subcutaneous injection. Orthoform acted well on raw surfaces, but not elsewhere. It was unsuitable for subcutaneous injection, as it was not readily soluble, and as a bydrochloric acid salt lost a good part of its power. He had not had much experience with aneson. From his observation in some cases, its effect was good, and in any case it was absolutely non-poisonous..

OPHTHALMOLOGY.

UNDER CHARGE OF A. G. SINCLAIR, M.D.

Professor of Diseases of the Eye, Ear and Throat, Memphis Hospital Medical College; Ophthalmic, Aural and Laryngeal Surgeon to St. Joseph's Hospital, Memphis, Tenn.

Cerebral Sounds and Pulsating Exophthalmos.

Weiss (Vienna Cor. Med. Press & Cir., vol. 66, no. 3107) related the history of a peculiar case of traumatic exophthalmia with strange phenomena. The patient when injured was 22 years of age, strong and robust. He was thrown from the top of a van on the ground on the left side of the head, and crushed against a wall, from which he was taken up insensible. Two days after bleeding at the nose, mouth and ears commenced, with protrusion of both eyes and a roaring noise in the head. Ophthalmoplegia, imperfect vision, and, after a month's time, blindness of the left eye was complete with slight ptosis. At the present time the large veins of the lids were full and greatly elevated, the left abducent was paralyzed, the left pupil fixed, while the veins of the fundus were pale. The sound in the head was synchronous with pulsation in left eye and arteries, which was abolished by pressure on the carotid. It is evident that there was an aneurism of the left internal carotid about the sinus cavernosus occurring after the fracture. The right carotid must also have been wounded. The treatment in these cases is digital compression and ligature of the carotid; the former being unsuccessful in bilateral exophthalmos, while tying has been performed in 106 recorded cases with varying results.

Protargol a Specific for Blenorrheal Conjunctivitis.

Darier, A., of Paris (Die Ophthal. Klinik) considers from a very large experience with protargol that this is an antiseptic agent which produces quick and prompt healing of inflammations of the conjunctiva. On account of protargol causing

absolutely no irritation, it can be used in a 50 per cent. solution without causing any disagreeable symptoms. As a rule the author permits patients to drop a 5 per cent. solution in the eye from two to four times daily; for local applications by the brush he uses 20 per cent. to 50 per cent. solutions once a day or every other day, according to the grade of inflammation. For treatment of blenorrhea he cauterizes the conjunctiva twice a day with the 20 per cent. solution. If this does not suffice, he uses a 50 per cent. solution as long as the secretion remains purulent. He makes applications twice a day, and as it gets better increases the intervals. Protargol is of special benefit in those cases in which deep, widespreading ulcers occur. In inflammation of the lachrymal sac protargol is the best application we have, as it speedily reduces the purulent secretion, and does this without causing pain; injections may be allowed to pass into the nose without causing unpleasant symptoms. Protargol is not only a remedy for the cure of blenorrhea, but may be used as a prophylactic in a 10 to 15 per cent. solution, as is commonly done with the 2 per cent. solution of nitrate of silver. Modern Views of Trachoma.

Schudhoff (Wien. Med. Press) gives a very complete summary of recent work on the etiology, pathology and treatment of trachoma. He quotes some striking figures as to its prevalence: In thirty Austrian counties there were, in 1895, nearly 30,000 sufferers, while in the Russian army, in 1896, the number of victims reached the almost incredible proportion of 62 per cent. The author summarizes the results of his investigations in the following conclusions:

Trachoma is an infectious disease which can be spread by contagion. Its appearance is favored to a certain extent by special conditions, such as race, locality, general nutrition and occupation. The actual natural history of the affection is not yet established; experiments and inoculations into animals have so far failed. The hypertrophy of the conjunctiva (granulation) is pathologically and histologically the principal characteristic of the morbid process. Hitherto the following have been generally accepted as the best means of treatment: Solution of silver and its substitute argentamine, touching with copper sulphate, washing out with sublimate, the galvano-cautery, and in very obstinate cases more extreme measures, such as the use of jequirity, peritomy, and the removal of the hypertrophic folds. Among the newer remedies the following deserve a trial: Guaiacol-glycerin, ichthyol, sozo-iodol preparations and electrolysis. But the most important measure by far is prophylaxis, by means of regulation of the sanitary conditions, and prevention of the spread from patient to patient.

NOSE, THROAT AND EAR.

UNDER CHARGE OF RICHMOND MCKINNEY, M.D., MEMPHIS.

Emphysema of the Antrum of Highmore.

Kyle (Int. Med. Mag., vol. 7, no. 12) says:

Emphysema of the antrum of Highmore is a condition in which there is accumulation of gas in the antral cavity. Although it is not commonly met with, it is of great importance and is often overlooked. The prime factor in its etiology is the generation of gases from a decayed tooth which communicates with the antrum. The gases so originating may be confined in the cavity, either from VOL. XIX-3

some occlusive condition of the orifice by morbid processes, or through failure to find vent through the ostium maxillare. If the antral opening is not affected the escape of the offensive gas into the nose will lead to the mistaken diagnosis of a nasal lesion with ozena, and the treatment will be directed to the unoffending nasal mucous membrane.

This condition Kyle has observed in five cases. In one case there was no intranasal lesion, and the main symptoms that caused the patient to seek relief was the disagreeable and offensive odor. The other cases, however, had some irregularities within the nasal cavity whose only significance is the possibility of their being so located as to occlude the antral opening. Age does not seem to be an important etiologic factor, as the cases coming under his observation varied from childhood to past middle life.

The symptoms vary, depending largely upon whether the antral opening is partially or entirely occluded. There is usually a sense of intranasal pressure which may gradually increase. Pressure pain is dull; heavy, sickening headache is usually present, and is markedly increased by stooping forward. Disturbance of the eye, nose and buccal functions may ensue. If the antral opening is closed, the accumulated gas will give rise to pressure symptoms the same as in confused suppuration of the antrum. Percussion over the antrum may give a variation in resonance, although this is of little value, owing to the great variation in the size of the antral cavity. Unless the condition is associated with an inflammatory lesion of the antrum, transillumination is of little value, as the confined gas will offer no obstruction to the rays.

The diagnosis is not always easy, and may often be made only by exclusion. Lesions of the teeth may call attention to their genetic influence. The symptoms of dental irritation in this region, with subsequent cessation of pain, and later development of pressure symptoms in the cheek, with ozena that is continued or interrupted, are always regarded as suspicious. There is usually an absence of the systemic phenomena of the presence of pus.

The prognosis is excellent. The majority of cases recover spontaneously and rapidly after vent is given to the confined gas and proper treatment of the offending tooth or teeth, or the removal of necrosed bone.

The treatment of course consists in the evacuation of the confined gas, and this is usually better performed by the removal of the suspected tooth. Tapping of the antrum through the nose may be performed, which will relieve the pressure symptoms, but as the cause of the accumulation of gas is a diseased tooth, treatment should be directed toward the removal of the diseased tissue, and necessitates the skillful aid of the dentist or a thorough knowledge of dentistry by the rhinologist; otherwise teeth may be unnecessarily sacrificed.

The Local Use of the Aqueous Extract of the Suprarenal Glands of the Sheep in the Nose and Throat.

Swain (N. Y. Med. Jour., vol. 68, no. 26) reports results of several months investigation of the use of suprarenal extract in various inflammatory conditions of the nose and throat. He takes of the extract of the suprarenal gland of the sheep 20 to 30 grains, and adds to half a drachm of cold water. After stirring, this is filtered. After a number of clinical experiments with the solution, Swain thinks he may safely sum up his experience as follows: