after such operations as osteoclasis, where infection by pyogenic germs is out of the question. Further study of this subject, with a large series of cases, is very desirable.

As an illustration of a pyogenic temperature take Fig. 1, a case of ventral fixation for complete prolapse of the uterus in a very fleshy woman, forty-seven years of age, operated upon at St. Luke's Hospital last December, in which the abdominal wound became accidentally infected. rise of temperature began about twenty hours after the operation and progressed to 103° F. on the third day, being temporarily held in check by catharsis on the second day. The pulse kept pace with the temperature, running up to 120 and 130 beats to the minute. The symptoms gradually subsided after the wound had been freely opened. On the fifth day there was a leucocytosis of 21,800.

Figs. 2, 3, and 4 are illustrations of aseptic fever, of which I could show many more. Fig. 2 is from an abdominal hysterectomy for supposed malignant degeneration of the placenta, with a dead, poorly developed, three-months' fetus. The abdominal wound healed absolutely by primary union without a sign of peritonitis. The patient had had a temperature of 99° to 99.4° F. before operation. Sixteen hours after operation it had risen to 101° F., then gradually fell, but did not fully reach normal for eighteen days. The pulse at no time rose above 80 and was only 70 when the temperature was at its highest, 101.6° F.

Case III. was an amputation of the forearm for recurrent epithelioma of the hand in a farmer, eighty-one years of age, but in vigorous condition. The wound, with very thin flaps, compressed firmly by the dressing, healed by first intention absolutely, and it would seem as if there could not have been a cavity large enough to cause any absorption. The operation produced no shock whatever. But the temperature rose at once and in twenty-four hours reached 103° F., the pulse then marking 70 beats to the minute, but subsequently reaching 78. A careful examination of the chest on the second day revealed some scattered subcrepitant râles, but there was no cough, and not change enough to explain the temperature (Fig. 3).

Case IV. was a rather poorly nourished but apparently healthy youth of nineteen, with bilateral floating kidney which occasioned him annoyance and positive pain. November, 1898, nephrorrhaphy was performed on the right side by the split-muscle incision of Abbe, similar to McBurney's incision for removal of the vermiform appendix. Chromicized catgut sutures were passed directly through the kidney substance.

Within twelve hours the tempera

Temperature curve after amputation of the upper extremity.

as his, from a woman thirty-nine years of age, from whom we removed a small pedunculated myoma from the fundus uteri by a laparotomy, and then secured the uterus to the abdominal wound (ventral fixation). This patient had a temperature of 101° F. in eight hours, gradually subsiding, with a pulse of only 96, no sign of peritonitis, and primary union of the wound.

Fig. 5 shows another sort of absorption fever, a very common type. The patient was a colored woman, twenty-eight years old, with large and very

Temperature curve after abdominal hysterectomy.

wiping and washing out the pus. The stump of the cervix had been previously covered with peritoneum. The operation was difficult and tedious, and was followed by severe shock, but there was no sign of peritonitis, and the patient made a good recovery with absolute primary union of the abdominal wound. The temperature rose to 100.6° F. within six hours, but meanwhile the pulse had been reduced from 120 to 104 by an intravenous saline infusion and stimulants of various kinds; 101° F. was recorded about twenty-four hours after the operation with a pulse of 118. The fall of tempera

sorption of the bile after operations on the biliary passages when the wound is left open and packed, absorption of thyroid juice after thyroidectomy, all cause a rise of temperature. We have seen two cases of a fatal result after partial thyroidectomy for exophthalmic goiter, caused by acute thyroid poisoning from absorption of the juice of the gland, accompanied by very high temperature, in one case reaching 109° F. before death, with absolute asepsis of the wounds. Fever is often seen after operations for tubercular peritonitis and arthritis, caused by the absorption of the tuberculin toxin.

The peculiarity of all these absorption fevers, including aseptic fever with them, is their prompt beginning immediately after operation, whereas inflammatory fever requires twenty-four hours or more before it begins, as shown in Case I. A virulent infection, such as occurs in a poisoned wound (such as a surgeon might obtain in operating upon a septic subject) might cause an almost immediate rise of temperature, but we are discussing operation wounds in which great pains are taken to avoid infection, and in them the infection will be slight and slow in development. But it is not altogether safe to assume that the slight infection seen in operating wounds may not cause some of the pyrexia generally known as aseptic fever merely because the latter begins so promptly. The chill and sharp rise of temperature seen after urethral instrumentation is so sudden that it seems impossible to explain how it can be caused by infection, and yet it can be almost entirely prevented by proper cleansing of the urethra and sterilization of the instruments and surgeon's hands. There may be a nervous element in it, but the main cause must be infection, otherwise aseptic precautions would not so greatly influence its occur

rence.

All the cases in which a sudden rise of temperature follows operation, however, cannot be charged to absorption, and a certain proportion of them seem to us to be caused by shock. The classical picture of shock with a subnormal temperature followed by a reactionary stage with a febrile movement after some hours, may be correct for accidental injuries, but it does not portray the symptoms observed in shock after modern surgical operations. This may be due to the great difference in the conditions of ancient and modern surgery. In old days an operation resembled an accidental injury in many points the patient was conscious and endured great pain. In the case of accidents, the patient often receives a severe mechanical shaking and concussion, and generally lies somewhat exposed or has to be transported after the accident. These conditions

would tend to lower temperature. In the modern operating-room the patient is anesthetized after preliminary starvation and evacuation of the bowels and bladder, he is generally kept warm, and stimulation by strychnin, alcohol, and other means is supplied at once if the pulse weakens. There is little to cause a subnormal temperature (except prolonged etherization), and it is rather the exception to have it go below 98°. On the other hand, the anesthetic acts in a complicated manner on the bronchi, heart, kidneys, and stomach, and may easily produce effects which result in a febrile movement. The older surgeons warned against the danger of too free stimulation in shock for fear of a dangerous reaction, but although the heart may be exhausted by over-stimulation, we know that excessive dosage of alcohol, strychnin, and digitalis cannot elevate the temperature, and that the fever which they called reactionary fever is to be considered one of the nervous phenomena of shock. It is to be associated with the great ante mortem rise of temperature seen in many diseases, for instance in tetanus, and is a sign of nervous exhaustion.

Fig. 6 is an example of a high temperature apparently purely the result of shock. The right upper extremity was entirely removed (except the sternal half of the clavicle) in a married woman twenty-two years of age for sarcoma of the scapula. The patient was in profound mental depression from anticipating the loss of her arm and had a rather sluggish circulation. She lost only eight or ten ounces of blood during the operation, and the pulse remained slow, but became very compressible and feeble. A venous salt infusion was given about two hours after the operation. When she left the operating-room her temperature was 98.6° F., in four hours it was 99.2°, in eight hours 101°, and in twelve hours 102.6° F. The pulse-rate had risen continually from 90, 120 to 130. The temperature fell a little, but the pulse-rate rose to 140. In twenty-four hours the temperature was 103.6° F., and the pulse over 150. Another intravenous infusion was given, and both temperature and pulserate then slowly fell. On the third day the picture was complicated by complete hemiplegia of the left side, without change in pulse or temperature, probably caused by thrombosis slowly developing in the cerebral arteries, or possibly an embolism from a clot extending back into the carotid from the point of ligation of the third part of the subclavian. The wound was healing by first intention, but on the tenth day some infection was observed at the upper angle, probably a late infection, for the wound had been somewhat exposed at that point by slipping of the dressing, and the temperature had

meanwhile become quite normal. It is seldom that one sees a patient with such a severe case of shock recover, and the house-surgeon of St. Luke's Hospital, Dr. Wadsworth, deserves great credit for the result. The usual picture of severe shock with high temperature after operation is that shown in Figs. 7 and 8, ending fatally.

Fig. 7 is the chart of an abdominal hysterectomy patient, a very tedious and severe operation with great shock, terminating fatally with a rapid rise of temperature to 106.4° F. Fig. 8 is the chart of a man thirty-one years of age who fell forty feet and sustained a fracture of the upper dorsal vertebræ. One week after the accident a laminectomy was done, removing the broken spines and arches of the fourth and fifth dorsal vertebræ, and the broken spines of the three bones above. There was an extradural clot which was removed, but the membranes were not opened. The autopsy showed that the cord was crushed at this level. Severe shock developed during the operation. Previously the temperature had been normal, but four hours afterward the temperature was 102.8° F., with a pulse of 150, and respirations of 24 per minute. In twelve hours the temperature reached 105.6° F., the respiration 32, and the pulse the same. Just before death the thermometer marked 107.4° F.

In Case VIII. the high seat of the injury renders it possible to imagine an irritation of some spinal or medullary heat center, but the fact that the dura was not opened and the only change made in the conditions produced by the accident itself was the removal of some depressed bone and blood-clot, made this highly improbable, especially as the man's temperature before operation had been normal. It is more reasonable to ascribe it to the shock, which was increased by the patient lying on his face during the operation. We have come to look upon a sudden and great rise of temperature as a frequent and very dangerous sign of severe shock after operation, for it is seldom that such patients can be revived.

In making the diagnosis of aseptic fever, then, we can distinguish it from shock by the good quality of the pulse, and we can readily exclude the other varieties of absorption fever (toxins, bile, thyroid juice), by the history of the case. We can distinguish it from inflammatory fever by its very early appearance, by the fact that the pulse remains relatively low, and the patient has few subjective sensations. He may be a little flushed and thirsty, but does not show so much depression or nervous excitement as is seen in inflammation. The character of the pulse is important as well as its rate, for in

aseptic cases it remains quite soft, and has not the quick beat and wiry tension so common in inflammation. The pulse will probably be the best guide in doubtful cases. The fall of aseptic fever is not so characteristic as its rise, for it may come down in two or three days, or it may continue for as many weeks a little above normal.

We must bear in mind, however, that there are many mixed cases. In a case of laparotomy for pyosalpinx, for instance, there may be severe shock, absorption of toxins from the sterile pus in the tubes, absorption of non-infected blood-clot in the abdomen, and finally accidental infection of the abdominal wound by a suture-the result being an immediate abrupt rise of temperature from shock, continued by the toxins, and maintained afterward by the inflammation of the external wound.

As a member of the committee appointed to report on the use of fibroid extracts in fibromata uteri I can only give a brief note of my observations in the use of this remedy in eight cases.

Cases of myoma or fibromyoma were generally selected, which gave emphatic symptoms, such as pain, hemorrhage, or general nervous disturbance, all of these symptoms being present in greater or less degree. In two cases there was some pain but little hemorrhage and an unusual amount of mental irritation. In three cases pressure symptoms and other manifestations of pain were conspicuous. In four cases hemorrhage was present to a severe degree, and in five of the cases menorrhagia was very marked. Five of the women were married, of whom two had borne children. Three were unmarried and between the ages of twenty-five and forty. In those cases in which pain and pressure symptoms were prominent the tumors, with one exception, were from the size of a fetal head to a diameter of eight inches; and in the cases accompanied by excessive hemorrhages the size was rather less.

In the two cases where marked nervous disturbances were conspicuous the growths were small and the ovaries evidently implicated in the diseased conditions about the

uterus.

Thyroid extract was administered in one case only three times a day, in amounts of 21⁄2 grains. But in this case it was found that the cardiac disturbance was such as to demand a suspension of the remedy for a while. In all of the other cases one morning dose was administered of 21⁄2 grains and continued regularly during a period cover.

Read at the twenty-fourth annual meeting of the American Gynecological Society, held at Philadelphia, May 23, 24, and 25, 1899.

In two cases diminu

ing from six weeks to five months. tion in the size of the tumors was demonstrable and the symptoms of hemorrhage became so much ameliorated as to be quite remarkable.

Pain was diminished in two cases and the intervals of respite from pain in another were quite extended.

In the "nervous" cases the effect seemed to be decidedly beneficial, the patients becoming more calm and rational, hysterical symptoms abating markedly.

In several instances the tumor continued to grow and called for surgical intervention to give necessary relief.

Incidentally it was observed that the remedy had a salutary effect upon cases of post-operative nervous disturbance such as is found so uncomfortable after ablation

of the uterine adnexa. In one case involving distinct melancholia, following removal of the appendages in an operation for dermoid cyst, the continual use of the remedy in the dose above mentioned for two months accomplished a complete cure or, at least, the patient became perfectly normal under most unpromising circumstances.

It is my opinion that much more extended observation, covering a large number of cases during a period of at least two years, is necessary to give a fair estimate of the real value of thyroid extracts in these diseases. The physical and pathological conditions of these fibromata vary so much, their history and progress, without any treatment whatever, differ so markedly that we should be careful not to jump too quickly at conclusions as to cause and effect. We all know how disappointing has proved the operation of oophorectomy for the arrest of fibroids, and yet, a few years ago it was advanced as a most valuable conservative measure.

To-day the administration of thyroid extract seems to be followed by distinctly beneficent changes in a sufficient number of cases to make it advisable, if not obligatory, for us to give our patients the benefit of its fair trial. But we must not make the mistake of erecting a hypothesis and then strive to force our observations to coincide thereto.

Certain it is that in the majority of cases requiring interference (and there are some which may be practically ignored) we should hold ourselves ready to give that positive relief which can only come from a well-directed, well-executed modern operation.

MEDICAL PROGRESS.

Three Cases of Aortic Tubercle.-BLUMER (Albany Med. Ann., May, 1899) reports a third case of tubercle on the intima of the aorta, two similar cases having been previously reported by him in the American Journal of the Medical Sciences for January, 1899. In all three cases the source of the tubercle was evidently in the blood, as there was no direct extension of the process from an adjacent focus. In the third case in particular, the tubercle was still a small one, and nearly its whole center was composed of fibrin, so that the microscopical appearances seemed to support the theory that such a tubercle is thrombotic in origin.

A Practical Point in Intestinal Suture.-FRAZER (Lancet, May 13, 1899) suggests a simple method to insure accurate union along the mesenteric line, in suture of the small intestine. His plan is to rotate the two ends of bowel for a slight distance in opposite directions, so that there may be room for two or three stitches between the cut ends of the mesentery. This insures that there shall be no place in the suture line where there shall not be at least one serous surface involved in the suture. The procedure can be carried out with any end-to-end anastomosis.

THERAPEUTIC NOTES.

The Treatment of Carbuncles.-CREEL (Cincinnati Lancet-Clinic, April 29, 1899) strongly recommends the use of ecthol, both for internal medication, and as an external application. He employs the drug internally in doses of a teaspoonful every two hours, continuing the remedy until the healing has been completed, gradually prolonging the interval between the doses. He claims that ecthol is a corrector of blood dyscrasia, and in the best sense an antipurulent. The local treatment consists in free incision and thorough evacuation of the pus-cavity by scraping, thus removing all the dead. and inflamed tissue. The wound is then carefully cleaned with peroxid of hydrogen and dressed with absorbent cotton saturated with ecthol. This dressing should be changed every four to eight hours. Creel has treated fifteen cases of carbuncle in the manner here outlined, and claims that the duration in each case has been gratefully shortened and the convalescence of the patient improved.

Cure of a Bad Paraphimosis by a Simple Method.. LEWIS (North American Med. Rev., April, 1899) was called upon to relieve a patient with a bad paraphimosis of many hours' duration. A bandage was wound as tightly around the penis as the feelings of the patient would permit. This was saturated with lead and opium solution, and a rubber bandage applied outside of it. The following day the swelling had diminished somewhat, but reduction of the prepuce was still impossible, and the treatment was continued for another day. By that time the edema was so far pressed out that reduction in the usual manner was easily accomplished.

Treatment of Certain Summer Diarrheas of Infancy.STENGEL (North Car. Med. Jour., April 20, 1899) says that a certain class of summer diarrheas of infants are amenable to prompt and vigorous treatment. The cases are usually sudden in onset, and marked by some regurgitation of food, high temperature, copious brownish, then greenish and finally often watery stools and rapidly developing signs of collapse. The external temperature is low, while that in the rectum is high. The child moans, lies with upturned eyes, and occasionally gives a sharp cry like that heard in meningitis. Such cases are classified by him as entero-colitis. The gravity depends not on the extent of the intestinal lesion, but on the amount of the intoxication. The most important part of treatment is the flushing of the colon, and

the use of tepid baths. These measures will cause the temperature to fall, and the symptoms to abate. A long catheter is passed into the bowel, and one or two quarts of water at a temperature of 85 or 90 degrees allowed to flow into the bowel. Two or three douches may be required daily, though in other cases one may suffice. Small doses of opium, not to check the diarrhea, but to allay nevous symptoms, are serviceable in the early stages of the disease. Following are two useful prescriptions: Bismuth subgallat.

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gr. xxix-xxxvi gr. ss gr. vi-xii.

Treatment of Diarrheal Diseases in Children.-UPSHER ("Keating's Cyclopedia," Vol. V.) advises in acute milk infection, the entire withdrawal of milk from the diet and thorough lavage of the bowel with warm water, to which borax is added if there is much mucus present. When the patient is in a state of toxemia, large quantities of a saturated solution of boric acid are to be used once or twice a day for washing out the bowel. When an astringent is indicated, the best agent to employ is a one or two-per-cent. solution of tannic acid, and from to 1⁄2 a grain of calomel may be given every two hours for three or four doses. When stimulants are required, either brandy or whisky may be given according to the indications. Nervous symptoms are to be met by morphin hypodermatically in doses of of a grain for a child of one year, to be repeated cautiously if necessary, and an ice-cap applied to the head. No food is to be allowed other than small quantities of Valentine's beefjuice in ice-water. In some cases, if food be entirely withdrawn for some hours, and small, frequently administered quantities of some feebly alkaline, sparkling water be given, the results are excellent. The return to a milk diet must be slow and cautious. In subacute milk infection, the child should have cracked ice to relieve its thirst and be given plenty of fresh air. Castor oil is to be given if there is evidence of intestinal irritation. Broths or albumin water may be substituted for milk, or all food be withdrawn. Calomel in doses of 4 to 1⁄2 a grain, combined with precipitated chalk should be administered when the stools are sour, and continued until the consistence of the stools is better. Then astringents-kino, catechu, or logwood-are to be given in combination with chalk-mixture. Free lavage of the bowel with a weak salt solution should be employed every day. If much soreness or tenderness of the abdomen is present, hot spice fomentations are to be applied, or enemata of thin starch water and laudanum are to be administered. If stimulants become necessary, iced mint julep is the best form for use. If the disease remains obstinate, the child should be removed to the air of the mountains, if possible.