has little tendency to osseous regeneration. Effusion following fracture tends to keep the fragments apart. Contraction of the muscles. tends to keep them separated, and soft tissues interpose to fill the gap. The Roentgen ray shows that not in a single instance is reduction perfect even under anesthesia. The only rational remedy is to open the joint, remove the intervening structures, and accurately replace the suture with catgut or bronze wire, according to conditions.

A number of histories are given to illustrate the points taken. The views which he holds are summarized as follows:

(1) The Roentgen method, in combination with the usual methods of examination, determines the character of the suspected bone injury. (2) If there be no bone injury, the proper treatment consists in massage, followed by immobilization, a movable splint being preferable for the latter purpose.

(3) If there is a fissure or fracture, followed by no displacement, manipulations of the injured area must be avoided and immobilization in the most comfortable position applied. As a rule, plaster-of-Paris dressing answers the purpose best. After two or three weeks it must be removed and massage begun. In about two weeks a splint of plaster-of-Paris is applied, which the patient can take off and reapply.

(4) If there is any displacement, reduction must be applied at once. This can be done under the control of the fluoroscope on a translucent table, a plaster-of-Paris dressing being applied after reposition is perfect. This is a simple, short and cheap method. A more tedious, but a safer way is to reduce the displacement under the guidance of a skiagraph taken before. This will indicate in which direction the efforts at reduction must be made, and how far. After a plaster-oiParis dressing, padded with cotton layers at its ends only, is applied, the skiagraph is taken through it in order to ascertain whether reposition was complete. If it does not seem to be, the dressing must be removed and another attempt at reposition made. If the process of reduction meets with difficulties, an occurrence which can, as a rule, be anticipated from the nature of the skiagraph, anesthesia should be employed.

(5) In those cases, in which, on account of entanglement of the fragments, extensive splinter formation, or similar complications, reposition even under anesthesia cannot be accomplished, the fragments must be exposed by the scalpel and brought into apposition. If there be no tendency to displacement, a plaster-of-Paris dressing will insure immobilization. But if the fragments slip out easily, it is safer to unite them with catgut, provided there is enough periosteum to be utilized for that purpose. Otherwise it is best-especially if large bones come into consideration-to keep them together with a bronze wire suture. The sooner this is done the better it will be, because the smaller are the changes taking place in the soft tissues. C. G. D.

GYNECOLOGY.

BY REUBEN PETERSON, A. B., M. D., ANN ARBOR, MICHIGAN.

PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

AND

CHRISTOPHER GREGG PARNALL, A. B., M. D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN GYNECOLOGY AND OBSTETRICS IN THE UNIVERSITY OF MICHIGAN.

RECENT RESEARCHES INTO THE BACTERIOLOGY OF PERITONITIS IN RELATION TO PELVIC SURGERY.

SARGENT (Journal of Obstetrics and Gynecology of the British Empire, Volume XI, Number III) devotes an extended study to the bacteriology of peritonitis in relation to pelvic surgery. Peritonitis is to be regarded as a secondary or terminal process in the course of other diseases, many of which may, in themselves, be without dangerously serious import. The avenues through which infection may enter are: (1) Accidental or operation wounds; (2) Rupture or perforation of a hollow viscus, a cyst, or an abscess; (3) Passage of germs from an infected, but not perforated, hollow viscus, cyst or abscess; (4) Indirect infection of blood extravasated into the peritoneal cavity in such quantities as to be not readily absorbed; (5) Infection by way of the blood

stream.

The writer, after many observations in cases of peritonitis in general, comes to the conclusion that certain types of the disease may be recognized and differentiated according to the kind of infecting agent. The organisms found were, in order of frequency, the staphylococcus albus, the colon bacillus, the streptococcus, bacillus pyocyaneus, pneumococcus, gonococcus, and staphylococcus aureus. Although the staphylococcus albus was the organism most frequently found it is thought to exercise a beneficial influence when associated with other germs as it causes a marked phagocytosis. The colon bacillus is the most important causative factor in peritonitis, the type of the inflammation varying with the virulence of the infection. The streptococcus was rarely found, but when present gave rise to a rapidly fatal form of the disease. Of rare occurrence as causes of peritonitis are the bacillus pyocyaneus, the pneumococcus, and the gonococcus.

In considering peritonitis arising from diseases of the female pelvic organs, the author states that the relative frequency is changed. The less virulent infecting agents are more common in inflammation confined to the pelvic peritoneum. Peritonitis of pelvic origin is considered under five divisions: (1) Extrauterine gestation; (2) Salpingitis ; (3) Inflamed ovarian cysts; (4) Infections connected with pregnancy; (5) Accidental infections.

(1) Extrauterine Gestation.-In seventeen cases examined, a staphylococcus albus of low virulence was isolated in each case. The

infection starts in blood clots resulting from rupture of the sac. The same organism was present in cases of intraabdominal hemorrhage following rupture of the liver and spleen.

(2) Salpingitis.—Tubal inflammation is the most common cause of peritonitis met with in gynecological surgery. The process is usually of a comparatively mild type, occurring either by direct extension or through rupture. The pus sac, in case of salpingitis, generally speaking, contains the gonococcus or is sterile. Cultivation of the gonococcus is so difficult that this fact may account for the repeated failure of many observers to recognize the organism as a cause of peritonitis. Since the inflammatory process in cases of gonorrheal peritonitis is of such a mild character, it is rarely necessary to employ drainage.

(3) Inflamed Ovarian Cysts.—Only three cases were investigated bacteriologically. Two of the cases showed a colon bacillus infection of the cyst contents, and the third a streptococcus infection of the cyst with staphylococcus albús present in the peritoneal exudate.

(4) Infections connected with Pregnancy.-No examples of these infections occurred. From a study of the literature, the peritonitis following puerperal sepsis is often of streptococcus origin and is generally fatal.

(5) Accidental Infections.-Any of the organisms mentioned may be the cause of postoperative peritonitis, the kind of infection depending on the location of the field of operation. One case of fatal postoperative peritonitis due to the bacillus pyocyaneus is mentioned. There was also one instance of pneumococcus peritonitis.

From the bacteriological investigations, the author draws his conclusions, regarding treatment, under the following divisions:

(1) Operative Treatment.-Since the recovery of a patient suffering from peritonitis depends largely on the leucocytes of the exudate acting as phagocytes, the surgeon should limit his operative intervention to thorough drainage and local cleansing. No unwarranted attempts should be made to remove diseased structures, and the leucocyte barrier must not be washed away by copious irrigation. In cases of intraabdominal or intrapelvic hemorrhage, the blood may be removed by irrigations of salt solution as the infection at first is mild, and there is always danger of after-infection of blood clots by virulent. organisms.

(2) Drug Treatment.-The writer merely considers the inadvisability of using opium. This drug masks the symptoms, may be a contributory agent in causing intestinal paralysis, and, according to Dudgeon and Ross, inhibits leucocytosis.

(3) Specific Serum Treatment. In all cases of peritonitis the writer urges an attempt to early recognize the infecting agent and then to employ a corresponding multivalent serum. Results, so far, in Sargent's experience with serum therapy, have been "sufficiently suggestive to warrant an extensive trial" of the method. C. G. P.

PEDIATRICS.

BY ARTHUR DAVID HOLMES, M. D., C. M., Detroit, MICHIGAN.

THE FREQUENCY, PROGNOSIS AND TREATMENT OF LOBAR PNEUMONIA IN INFANTS AND CHILDREN.

KOPLIK (Boston Medical and Surgical Journal, Number I, 1905) says double pneumonia in children is less frequent, but involement of the upper lobes is more frequent as compared with adults. The prognosis depends upon the age, severity, kind of infection and complications, but as a rule cases below the tenth year offer the best prognosis. The author's greatest mortality occurred below the age of two and a half years, and was greater in the winter months. A marked absence of leucocytosis foreshadows an unfavorable termination. He says a complicating otitis, pleurisy or empyema do not materially influence the prognosis, if they are recognized early, and treated properly. Hydrotherapy is our sheet-anchor-sponging and cold compresses-in controlling the temperature if it is doing harm. If the child does not react well with cold, substitute tepid sponging. The author has not seen much benefit from the use of oxygen, but advises thorough ventilation, the room being kept at a temperature of 68° Fahrenheit. Support the heart and administer strychnin. For the cough and pain give codeia to the older, and paregoric to the younger children. For collapse, place heat to the heart and extremities and administer camphor and nitroglycerine.

LARYNGOLOGY.

BY WILLIS SIDNEY ANDERSON, M. D., DETROIT, MICHIGAN.

ASSISTANT TO THE CHAIR OF LARYNGOLOGY IN THE DETROIT COLLEGE OF MEDICINE.

THE CLINICAL VALUE OF THE DIRECT EXAMINATION OF THE RESPIRATORY AND SUPERIOR DIGESTIVE PASSAGES.

CARL VON EICKEN (Archiv. für Laryngology, XV, Number III) gives a general résumé of the value of autoscopic examinations as developed by Kirstein. He speaks first of its value in the examination. of children, where it is so difficult to use a laryngoscope. It enables the examiner to inspect the larynx by direct vision. Foreign bodies in the larynx, or trachea, can be located and removed with great precision. In stenosis and displacements of the larynx, retropharyngeal tumors, projections of the posterior wall of the pharynx, the direct method offers many advantages. The author speaks of this method in goitre, especially in diagnosing the endotracheal variety, or in malignant disease of the gland where the trachea is involved. Certain aneurysms of the ascending arch of the aorta, which are to be differentiated from intrathoracic goitre, carcinoma of the esophagus and

other mediastinal affections can be accurately diagnosed by direct tracheoscopic examinations. The bronchi and the esophagus, as well as the trachea, can be examined by this method, and the surgery of these passages can be made more exact.

GANGRENE OF THE TONSIL.

CHARLES W. RICHARDSON (American Journal of the Medical Sciences, October, 1905) reports two fatal cases in his own practice and abstracts of three cases found reported in literature. The condition is rare, the laboratory findings are of little help to diagnosis, and a fatal termination seems to be the rule. One of the reported cases showed upon examination a grayish, brownish, putty-like slough on the right tonsil, anterior and posterior pillars and as far down the pharynx as one could see. The odor of the breath is always offensive, the temperature is indicative of sepsis, and the prostration is marked. The source. of infection in the cases reported could not be traced. One of the author's cases was of the moist, the other of the dry, type of gangrene.

PROCTOLOGY.

BY LOUIS JACOB HIRSCHMAN, M. D., DETROIT, MICHIGAN.

CLINICAL PROFESSOr of proCTOLOGY IN THE DETROIT COLLEGE OF MEDICINE.

THE TREATMENT OF HEMORRHOIDS.

CHARLES B. KELSEY, in The Therapeutic Gazette, Volume XXII, Number III, states that years ago he abandoned the use of the ligature for the clamp and cautery. The clamp and cautery in his hands has always been satisfactory, where the patients were willing to submit to operation under general anesthesia. His reasons for preferring the clamp to the ligature were at first that it caused less pain and gave quicker convalescence; now he is convinced that the pain caused by either operation depends far more upon the individual technique and skill of the operator than upon the method of closing the operation. He wishes to emphasize that the clamp and cautery is the last step of the operation for piles and not the operation itself. The operation consists of dissecting the pile from its attachments as far up toward its base. as is consistent with safety, and the dissected mass in the grasp of the forceps is either cut off and tied, or clamped and cauterized. Kelsey usually does the latter, but on some occasions still uses the ligature as taught by Allingham.

Kelsey states that either operation may be done in suitable cases under local anesthesia. Where the sphincters cannot be fully stretched, general anesthesia is demanded. He absolutely opposes the Whitehead and the "American" operation, on account of the many cases of stricture and ulceration following them, and states that he abandoned the injection treatment years ago, on account of its many septic sequences, and inherent dangers. After a systematic search for some method which would accomplish a cure without general anesthesia or