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affection is 50 per cent. Immediate and thorough surgical interference is the only treatment. Some systematic writers accept, and cases are recorded of a primary suppurative perimeningitis or idiopathic suppuration of the loose peridural areolar tissue. Twenty-four cases of the so-called primary suppurative perimeningitis were collected, eleven of which present sufficient data for purposes of analysis.

An attempt is made to establish the relationship of these cases of primary suppurative perimeningitis to the acute osteomyelitis of the spine, based on the similarity of the clinical and pathological manifestations and the a priori improbability of such idiopathic peridural suppuration. For the reasons detailed at length in the paper, it seems advisable to abolish entirely from our present nomenclature the term idiopathic or primary suppurative perimeningitis, and to regard all such cases as identical with the acute osteomyelitis of the spine.

The Channels of Tuberculous Infection in Childhood.

Westenhöfer (Berlin Cor. Med. Press & Cir., vol 77, no. 3388) reported the results of his investigations.

For the purpose of experiment he had made use of guineapigs, rabbits and calves, and had injected into them in the region or the loins or back tuberculous material, mostly taken from the human subject. After some time had elapsed there was always caseation at the point of injection, as also of the regionary lymph glands. There was also caseation in all cases of the glands in front of the sacral promontory, at the point of division of the aorta and of the retro-peritoneal and subdiaphragmatic glands. The liver and spleen were also generally diseased, and less frequently the lungs, and still less so the kidneys. This showed that tubercle first spread along the lymph tracts. In a certain number of the cases the bronchial glands were also affected, but without disease in the lungs themselves. In one case the submaxillary glands even were affected. Daily experience at the Berlin Central Abbatoir confirmed these observations. The experiences of both physicians and pathologists had shown that tuberculosis did not show itself in the infant before the third month of life,

and that from this date it gradually increased in frequency. The speaker explained this by the statement that the first dentition began at this period, that the mucous membrane of the mouth was in an irritable condition, and that it frequently sustained slight damage. This was why small children lay more quietly and were less exposed to infection than after they had passed the third month of life. Our domestic animals were either born with teeth, or they got them a few days after birth. The pig was an exception to this, and it was the only one of the domestic animals that became tuberculous during the first year of its existence. It must be borne in mind that the pig was the only animal fed on offal, the others being fed with care. Virchow and Schultz found that in young pigs

the disease began in the submaxillary glands.

The course of infection was this:-In a portion of the cases the disease of the cervical glands, and perhaps of the bronchial also, healed up; in another portion the disease burst through into the lungs; in others the disease remains latent.

It is remarkable that the so-called ulcerous phthisis scarcely ever occurred in children.

If the patches that were healed in the apices of the lungs in adults were examined, it would be seen that they were mostly bronchial patches. As regarded the question of inhalation, it might be looked upon as certain that tubercle bacilli could penetrate as far as dust could, if not into the alveoli, into the small bronchi.

The tonsils and glands of the fauces might occasionally be ports of entry for tuberculous infection. Careful investigation, however, had but very rarely revealed tuberculous disease of this form. If disease from this source were more frequent, we must often find these organs, with their lymphatic structure, diseased, for tuberculosis was typically a disease of the lymph glands.

The practical teaching of these investigations was to show how very important the careful cleansing of the gums and the mouths of young children was, especially in families in which a member suffered from tuberculosis; how much care must be taken to prevent any object being put into the child's mouth that had directly or indirectly come into contact with the sputum of a tuberculous individual.

Tuberculous infection with cow's milk, on the other hand, did not come into consideration. The flesh of tuberculous cattle was generally harmless, as tubercle bacilli had not yet been found in it.

Speaking of v. Behring's views, he remarked that they presupposed an increased permeability of the walls of the intestines. It had been shown, however, that the mucous membrane of the intestines of the infant did not differ from that of the adult, and that of its stomach only in the first two days of life, during which it, as a rule, did not get any milk. It was true, as Orth had shown, that tubercle bacilli could pass direct through the walls of the intestines of adults. v. Behring's trial animals were all tuberculous; in children, however, he assumed that the disease remained latent, and yet tuberculosis in children ran a very rapid course. He agreed with v. Behring in this, that the contest against tuberculosis should begin with the children, but by other means than his.

The Deficient Urea-Excretion in Gout and Lithemia.

R. K. Macalester (Med. Rec., vol. 65, no. 16) says:

1. Persistent deficient urea-excretion is always present in, and characteristic of, chronic gouty conditions.

2. The total urea output in gout is considerably lower than that found in chronic Bright's disease, about two-thirds of the amount in other miscellaneous chronic disorders, and only about three-fifths of the quantity, excreted in health.

3. Deficient urea-excretion is an important factor in the differential diagnosis between gouty and chronic rheumatic troubles, and between lithemia and certain nervous conditions dependent on other causes.

4. It is not present in chronic rheumatic conditions.

5. It points to perverted hepatic metabolism, and lends color to the Murchison theory of gout, there being in the cases discussed no clinical evidence of kidney trouble in support of the renal theory.

6. A diminished uric-acid excretion is to a certain degree commensurate with that of urea.

7. Gout, goutiness and lithemia are of the same origin, and but modifications of the same disorder.

8. Chronic gouty conditions are in general more amenable to treatment, especially to balneotherapy, than chronic rheumatic affections.



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

Origin of Hernia.

Waldryer (Ger. Cor. Med. Press & Cir., vol. 77, no. 3387) before the Berlin Medical Society, discussed the origin of hernia.

During the course of years, he said, he had collected a large amount of material, and from it he had arrived at the conviction that when a hernia formed there had always been a congenital disposition to it. This disposition consisted in a dilatation of all the exit passages in people who had hernias, even if they remained empty. He would not say that the herniæ were congenital, but the disposition to them was so.

If in inguinal hernia bowel and testicle lay in the same sac the hernia must have been congenital. If the tunica vaginalis propria closed close above the testicle and the processus vaginalis remained open, so that rupture could take place, and the covering was attached to the tunica vaginalis propria of the testicle, then it was not a congenital hernia, but the tendency to hernia was congenital.

The anterior abdominal wall showed three depressions on the peritoneal side which were bounded by the projections of three folds. The fold in the middle line was formed by the obliterated urachus; between this and the plica vesicalis lateralis lay the fovea supravesicalis; to the side of this, and separated from it by the last-named fold, lay the fovea inguinalis media; this extended laterally to the plica epigastrica formed by the epigastric artery; then followed the fovea inguinalis lateralis. Rupture might take place through all three depressions, most rarely through the fovea supra-vesicalis. All three kinds took place at the external or subcutaneous inguinal

ring. Cooper's fascia, which covered the inguinal ring, was the external muscle fascia of the external oblique muscle; it mixed with the aponeurosis of the muscle. This Cooper's fascia formed the external layer of the hernial sac, and it might be very thick. The reason why the region above Poupart's ligament was so often the point of exit for hernia was that the abdominal wall was thinnest here. The transverse muscle ceased a little above the symphysis. The external oblique had a division here forming the pillars of the inguinal opening, and the internal oblique muscle was also very thin at this spot.

According to Braune, a bundle passed from the fascia of the transverse muscle to the inguinal ligament, a second to the sheath of the rectus; both these bundles surrounded the fascia inguinalis media. As regarded obturator herniæ, they passed through a canal 2 to 2.5 in length. The bone here was not so thick, but the hernia passed it obliquely. The obturatic foramen was filled by lumps of very soft fat, which was always present even in thin people. The hernia could follow three courses, according as it pushed the fat, the obturator muscle, or the pectineus muscle before it.

In regard to ischiadic hernia there were three kinds a hernia supra-pyriformis, infra-pyriformis, and tuberoso spinosa.

He would call the peritoneal fascia the subperitoneal fascia. In internal hernia the intestine pushed through a previously formed fossa without appearing under the skin.

Diaphragmatic herniæ also passed out through a congenital split or divergence of fibers.

The Behavior of the Costal Arch in Diseases of the Abdominal Organs and its Importance as a Diagnostic Symptom.

E. Eliot, Jr. (Med. News, vol. 84, nos. 17 and 18) summarizes his observations made in a varied series of surgical cases thusly:

1. That the symptom of costal resistance may always be elicited in the acute and subacute inflammatory processes of the contiguous underlying organs. In chronic inflammation of these same organs it is present irregularly, either genVol. 24-19

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