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(grains x to grains xx) to the quart, or even the pint, to be followed by normal saline solution to prevent over-action, are of service.

Solutions such as Listerine, Glycothymoline, borolyptol, borax, sodium bicarbonate, 1 drachm of each to the quart of water, are of value as injections in catarrhal conditions. Gomenol-ms. xv. to ms. xx to the quart is also useful.

TUBERCULOUS MOTHERS AND NURSING INFANTS.

A. Deutch, in Münchener Med. Wochenschrift, 1910, vol. lvii, p. 1335, emphasizes the importance of investigating the relation between the tuberculous mother and the safety of the child she nurses, and also the effect of nursing on the course of the disease in the mother. In practically all text books relating to the care of infants the advice is given not to allow a tuberculous mother to nurse her child. Biedert counsels against nursing by mothers with incipient tuberculosis, and even when an hereditary tendency to tuberculosis can be shown in the family. Schlossman objects to nursing by mothers with well-developed or progressive tuberculosis, and counsels weaning as soon as possible; but when the disease is not welldeveloped or progressive he allows the mother to nurse, so that the child, besides the danger of tuberculous infection which it runs anyhow, will not be laid open to the additional danger of an unnatural and unaccustomed food.

If we grant the rarity of congenital tuberculosis; that an inherited disposition plays no rôle in very early childhood; that infection is conveyed by both ingestion and inhalation; and that nourishment, including cow's milk, plays a minor part as an infective agent as compared with close contact with a bacillus-shedding individual, then the decisive point is whether or not the breast milk of a

tuberculous woman contains tubercle bacilli. The bacilli occur in cow's milk, but experiments show that

tuberculosis of the udder in cows causes most of the bacilli-containing milk, and that the milk from clinically tuberculous cows is free from bacilli. Tuberculosis of the mammary glands is rare in women. and to the author's knowledge tubercle bacilli have never been demonstrated in breast milk.

Again, tuberculosis begins primarily in the mesentery of calves and household animals fed on milk, while in children the bronchial lymph glands are the first affected. Deutch examined seventy-four nursing mothers; 40% were free from tuberculosis; 25% had active processes of the disease, and the rest incipient or inactive. The effect of nursing on the tuberculous mothers showed that only rarely were they benefited, that most of them lost weight and were unbenefited, and that occasionally the effect was quite deleterious. On the other hand, birth and the puerperium in the widest sense did not seem to affect either the improvement or the stationary condition of the disease. The effect on the children was as follows: Out of sixteen children nursed by mothers with active tuberculous processes, five were infected with, and two died of, tuberculosis. Out of eight children nursed by mothers with inactive tuberculous processes, two were infected and one died of the disease. Four children born of mothers with active tuberculosis, but not nursed by them, were not infected. None of the children of tuberculous mothers, active or inactive, developed the disease if not nursed by the mother. The infected children all nursed from the tuberculous mothers, while the children not so nursed but also hereditarily tainted have so far remained well. Deutch concludes that breast milk does not carry the infection, but possibly contains substances which break down the child's resistance, infection then occurring through contact with the usually infected secretions.

Appendicitis, With Rupture Into the Cecum.

BY B. MERRILL RICKETTS, M. D., Cincinnati, Ohio.

Special Professor of Surgery of the Abdomen and Thorax, American Medical College, St. Louis, Mo.

R

UPTURE of an inflamed appendix into the cecum is an exceedingly rare event; yet it is one of those rare occurrences in surgery which have a general and practical interest, because none can tell where or when he may encounter it. The case reported by Dr. Ricketts was one of ordinary chronic appendicitis, and up to the time of operation there was nothing to indicate that there was anything out of the ordinary to deal with, except that the facies and the pulse denoted great shock. Characteristic features of the post-operative condition were intense thirst, discharge of dark blood from the bowel and mouth, and distension of the abdomen. A second incision was made seven days after the original operation, allowing about three quarts of normal fluid feces to escape and relieving the embarrassed respiration. The hemorrhage into the alimentary tract was due to the escape of blood into a mass of adhesions from which there was no exit except through Gerlach's valve into the cecum. Death was due to exhaustion from infection, which no doubt existed before operation.

Hemorrhage of any degree resulting from rupture of the appendix is a rare occurrence, but that of considerable magnitude resulting from rupture of a pathologic appendix into the cecum is exceedingly so. However, such was the experience in a male of fifty-six years of age, during August, 1910, under the care of Dr. Crow, of Helena, Ky. The patient had, during early childhood, been the victim of swallowing lye, with stricture. of the esophagus resulting. In consequence thereof deglutition was thereafter more or less difficult. He complained for several years of gastric and intestinal disturbances and pain in the right lower abdomen. During Saturday night he complained of severe pain and tenderness in the appendicular region, with nausea and distention of the bowel. About 7 a. m. Sunday castor oil was given at the suggestion of his wife. At 2 p.m. there was a considerable amount of dark, watery feces evacuated.

This gave considerable relief, but the pain continued, gradually increasing until midnight, when the physician was called

to relieve his pain with morphine. The diagnosis of appendicitis was then made and Dr. Garr called in consultation at 4 a. m. on Monday. The diagnosis was then confirmed, and morphine here given to relieve pain. His condition remained pretty much the same until 2:30 the following day, Tuesday, when I arrived to have the diagnosis verified for the second time. The temperature on the previous night had arisen to 103°, but at this time was only 1011⁄2°, and pulse 96. The pain continued severe, with great rigidity of the abdominal muscles, without distention. There was great tenderness over the appendix, but the presence of tumefaction could not be determined. The facial expression and character of pulse indicated severe shock. There was nothing to indicate that the appendix had ruptured, or that there was anything to contend with other than chronic appendicitis, pure and simple.

Immediate operation was advised and preparations at once instituted. Under chloroform narcosis a middle Hancock incision through the abdominal wall.

The peritoneum was free from adhesions, but there was a mass, involving the head of the cecum and appendix, about four inches in diameter. The ileum was not in any way involved in this mass. The finger was thrust into it, after it had been brought well into the incision, about five ounces of exceedingly offensive decomposed blood and pus, about the consistency of fluid tar, escaped externally.

A pea-sized concretion had escaped through a rent in the appendix, which was rotten to a high degree. After ligating the appendix proximally, it was hastily removed, the cavity wiped out, cecum left to view in the wound and gauze inserted into the cavity for drainage.

He rallied from the effects of the anesthetic and operation with considerable shock. His thirst for water was intense, but it was given only in small amount for two or three hours, after which he was permitted to have large quantities at frequent intervals. One-half gallon of warm water was given per rectum three hours after the operation, resulting in the discharge of about three quarts of black, tarry fluid, similar in character, but thinner, than that which was discharged at 2 p. m. on Sunday, forty-five

hours before.

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was some anxiety about the pathologic esophagus causing trouble.

His temperature varied from 99° to 101° for several days, and pulse uniform and of a good character, but his mental condition was very much disturbed, being very boisterous at times, with hallucinations. This condition continued very much the same, with an occasional failure to swallow food or water. Bowels moved freely, kidneys remained active and the abdomen not at all distended.

On Saturday afternoon, seven days from the first attack, the abdomen became greatly distended, it being impossible to evacuate the bowel by means of the

enema.

The wall of the cecum present

ing in the opening in the abdominal wall was incised without difficulty. This permitted about three quarts of normal fluid feces to escape through the original abdominal incision.

This caused the abdominal wall to relax completely, and permitted respiration to be deep and normal, where before they had been shallow and abnormal. His condition at this time was exceedingly critical, and became thereafter more so, until the following Tuesday morning, nine days after the onset, or seven days after the operation, when dissolution occurred.

Remarks.

Hemorrhage in this case into the alimentary tract was due to the blood escaping into a mass of adhesions from which there was no exit except through Gerlach's valve into the cecum.

Had this not been its exit the pathologic sac would have ruptured, causing the blood to flow into the peritoneal cavity, or the wall of the cecum would have ruptured there by permitting the blood to flow into the cecum.

Death was due to exhaustion from infection, which no doubt existed before the operation."

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Some Surgical Sequelæ of Tonsillitis.

BY DAVID C. HILTON, A. M., M. D.

Professor of Surgical Anatomy in the Nebraska College of Medicine. Lincoln, Neb.

HE author thinks that not sufficient attention is paid to the danger of sequelæ in tonsillar disease. He points out that these sequelæ may be immediate, extending to the mucosa and submucosa of the naso-pharyngeal and laryngeal tracts; or remote, spreading by way of the lymphatics into the deeper structures of the body. In this article he considers some of the sequelæ of tuberculous disease of the faucial tonsils. Metastasis by way of the cervical lymphatics, he says, is frequent, the physician often being called upon to deal with tuberculous lymphadenitis of the neck. By retrograde metastasis the infection may reach the axillary glands. In treating these conditions the author complains that too often the original seat of the infection is overlooked, and states that it is his practice in all such cases to completely enucleate the diseased tonsils in addition to whatever other treatment may be called for. He cites several clinical cases to illustrate his contentions.

Diseases such as typhoid fever, diphtheria, etc., are looked upon by the profession and laity as affections of a grave nature. The physician is expected to give these cases his continuous and most skillful attention to avert fatal issues. There is another group, to which most tonsillar infections belong, that are considered by the laity, and too often by the general practitioner, as trivial ailments. They are not supposed to require the watchfulness and skill which serious sicknesses demand. Ordinarily, tonsillitis is passed over as a "sore throat," for which some household remedy, or a prescription from the family physician, is all-sufficient, if, indeed, any remedy at all is necessary.

To him alone who follows the subsequent course of these patients is the gravity of tonsillar infections apparent and the true extent of their ravages upon health and life appreciated. It is in the light of their sequelæ that tonsillar infections exhibit their malignant potencies. Any disease condition in which we may have acute articular rheumatism, pericarditis, pleuritis and nephritis as a part

of the clinical picture establishes that condition as grave.

Near and Remote Results.

The complications and sequelae of tonsillar infections not only flame up in parts somewhat remote from the primary lesion but also in structures contiguous to the tonsils themselves. By way of the mucous membranes and submucosa they may give rise to serious inflammatory lesions in the communicating nasal, aural and pharyngeal tracts. By way of the parenchyma of the gland and the periglandular stroma they may give rise to tonsillar and peritonsillar abscesses, which by perforating important blood vessels may result in spontaneous hemorrhages or in septic thrombosis, or in embolism.

By way of the cellular tissues of the neck they may give rise to cellulitis, as, for instance, Ludwig's angina. By way of the lymphatics, cervical lymphangitis and lymphadenitis may ensue and spread to other regions. The reflex congestions and neuralgias set up in places apart from the inflammatory zone may also become severe.

The course of any tonsillar infection depends upon the type and virulence of the infecting microorganisms, whether they are diphtheritic or pus-producing, or germs of the various granulomatous diseases; upon the anatomic distribution of the infection in its primary and secondary manifestations; and upon those physiologic properties of the tissues and sera known commonly as "resistance power."

Tuberculous Tonsillitis.

It is the purpose of this paper to consider some of the sequela of tuberculous disease of the faucal tonsils. Tuberculosis of the tonsils is usually primary in the light of present knowledge. It is often observed in tonsils that have been hypertrophied, or secondarily atrophied as a result of recurrent acute inflammatory outbreaks, or by chroni lesions of a purul nature.

Tuberculosis of the tonsils is undoubtedly common and its distribution coinciIdent with human tuberculosis of other types. Robertson, in a series of tonsils examined following tonsillectomies on 232 patients, found 8% of these patients to have had tonsillar tuberculosis. In seven of 45 consecutive cases in children from three months to 15 years, A. Latham demonstrated tuberculosis of the tonsils removed by operation or post

mortem.

Metastasis by way of the cervical lymphatics is frequent. Schlenker claims that the majority of tubercular cervical glands become infected from the tonsils. By direct metastasis the process confines itself to the neck, and if not halted the infection may reach the general circulation at the terminus of the thoracic duct on the left side, or of the right lymphatic duct on the right side. By retrograde metastasis the process may extend to the glands of the infra-clavicular group, or into the axillary glands, and possibly by other routes into groups within the chest. In fact, it seems quite certain that apical pulmonary tuberculosis, pleuritis, and pericarditis often originate in this way.

Adenitis.

The general practitioner and the surgeon are repeatedly called upon to advise and treat cases of tuberculous lymphadenitis in the neck. Too often these patients are treated or operated on with a view to subduing the lymphadenopathy and restoring the general health with utter disregard to investigation and eradication of the primary focus of infection. The frequent recurrence of the infection after radical operations has part of its explanation in this oversight.

It is my practice in any case of tubercular lymphadenitis in the neck or axilla to investigate the head and neck and especially the tonsils for the primary focus, and having found a suspicious place, to eradicate the infection therein, as by complete ablation of a diseased tonsil prior to operating on the locality complained of by the patient.

Case Reports.

The following case reports are of interest in this connection. Miss A., aged 22, white, American by birth, vocalist by occupation. Family history: Well marked history of tuberculosis on the mother's side. Clinical history: Had passed through childhood and adolescence with good health, barring atacks of measles, mumps and influenza, from which she seemed to have made complete recovery. Since childhood she has been affected by nasal catarrh, frequent "cs" and "sore throat." She had suffered from an attack, of acute follicular tonsillits every winter for a few years past. About two years ago small lumps appeared on t left side of the neck and graduan tinued to enlarge and become thonumerous. During the past three rising she has noticed a progressive declineal physical vigor that has finally incapad tated her for her usual employment.

Physical examination: A slight, poorlynourished blonde; pulse, 96; afternoon temperature, 100; teeth and gums, healthy; chronic hypertrophic rhinitis; chronic follicular pharyngitis; chronic

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