Current Surgical and Medical Selections.

ACTION OF ARSENIC.-Gautier has an interesting paper (Bull. Acad. de med., Paris, August 7, 1900) on the rôle of arsenic in the bodily metabolism. Like iodine, arsenic is chiefly contained in the thyroid gland. It is also found in the brain and the appendages of the skin. The amount in the average thyroid is 0.15 mgrm. It occurs along with iodine in the form of a nucleo-proteid, which is excreted, and stimulates the epidermic tissues chiefly. Normal blood contains only a very faint trace of arsenic, less than 0.05 mgrm. per kilo., whereas menstrual blood contains as much as 0.28 mgrm. In the male, the arsenic is being constantly eliminated by the hairs of the head and beard and epidermic scales. In the female there is much less removed in this way, as the epidermic wear and tear is much less, so that periodically the surplus arsenic gravitates to the genital organs, where, if the woman is not pregnant, it is discharged; but if she be pregnant it is utilized by the fetus. Gautier suggests that up to the onset of menstruation the growth of the hair uses up the arsenic, whereas in the adult female there is little growth and falling out of the hair. In males at puberty there is the great development of facial hair, which corresponds to the loss by menstruation. He considers that in the lower animals the growth of the fur or feathers up to the time of rutting, followed by the casting of the coat, represents the male analogy of menstruation. He thinks that this relationship between the epidermic appendages and genital activity holds good also for human beings. Thus pregnant women may suffer from loss of hair and pigmentation and disturbances of the skin, which may be due to the arsenical nucleo-proteid being so much utilized by the fetus that there is not enough available to regulate the nourishment of the skin. In tuberculosis, arsenic may almost entirely disappear from the thyroid gland, and the attendant skin alteration and amenorrhea yield very rapidly to arsenical treatment, especially if it be combined with small doses of iodine.-The Edinburgh Medical Journal.

TREATMENT OF SIMPLE FRACTURES.-Bennett (British Medical Journal) concludes a discussion of this question as follows:

1. The treatment of simple fractures at present, although less stereotyped than hitherto, is still conducted generally too much upon lines which are traditional rather than rational.

2. The use of splints for long periods is disadvantageous, especially in the form of irremovable appliances, such as plaster of Paris and the like.

3. Speaking generally, the earlier movements of the joints above and below the fracture in a long bone are used the shorter is the time occupied in recovery.

4. The legitimate scope of the operative treatment of simple fracture is limited, and should be confined to (a) cases which are otherwise unman

ageable; (b) special cases, such, for example, as certain spiral and oblique fractures, mainly of the tibia; and (c) certain fractures near joints in adults, notably of the humerus at the elbow.

5. The operative treatment of recent fracture of the patella is by no means so generally satisfactory or so free from risk as published cases would tend to show; and further, in cases in which the separation of the fragments does not exceed half or even three quarters of an inch, as good results for practical purposes are usually obtainable without operation, although less rapidly.

6. The use of massage and passive movements immediately in simple. fracture when the circumstances of the patient and of the practitioner admit of it, either in its entirety or with modifications, is, in the majority of cases, the best means of effecting a rapid and useful recovery.

7. The tendency of late has been to exaggerate the degree of disability and diminution in wage-earning capacity following upon simple fractures.

8. Although no pains should be spared in obtaining perfect position of the fractured ends, moderate displacement, provided it is not rotary, is not necessarily followed by any disability if care be taken by the use of early movements to prevent any matting of the parts around the fracture; in other words, the disability which follows in certain cases in which the position of the united fragments is not ideal is due, not to the bony deformity, but to the adhesion of the soft parts around, which is easily preventable.

9. Having regard to the unavoidable modifications which must be dictated by the circumstances, social and otherwise, of the patient, and by the facilities possessed by the practitioner, no one method of treatment for simple fractures can be insisted upon for routine use, even in cases in which the local conditions are precisely alike.-Medical Standard.

THE USE OF NORMAL SALT SOLUTION. -John G. Clark (Progressive Medicine) says the more extensive one's experience becomes in the use of normal salt solution as a stimulant in abdominal operations, the more convincing is the evidence of the benefits to be obtained by its use. During the past four years he has made it a practice to leave at least one liter in the peritoneal cavity, after even the simplest operations. It increases the volume of the blood, lessens its specific gravity, stimulates the cardiac ganglia, and accelerates the circulation. The skin, kidneys, and intestines are stimulated, and all the organs of the body functionate better under its influence. The number of red blood-corpuscles is distinctly increased. Its special use in abdominal cases is to prevent shock, to lessen the effects of hemorrhage, and decrease the virulence of infection. Next to the Trendelenburg posture, the author regards the introduction of the normal salt solution as one of the greatest benefits which have been conferred upon modern surgery in the last five years. Its most marked advantages are claimed to be a lessening of the thirst and an increase in the urinary excretion. Drainage from the peritoneal cavity the author regards as a prob

lematic benefit, because of the rapidity with which absorption takes place by the lymphatics and peritoneum. In these cases he employs an infusion of large quantities of normal salt solution combined with the elevated dorsal posture. In moribund patients he has seen a marvelous stimulation from this treatment, which safely tided them over the critical period. Submammary infusions are quite as beneficial; they act almost as rapidly as intravenous transfusions, and are devoid of some of the complications which attend the latter. The writer's plan is to leave at least one or two quarts of salt solution in the abdominal cavity after every abdominal operation, and in addition to this a quart may be given beneath the mammary glands, in case the patient shows immediate shock. As a routine practice in all operations, either minor or major, one or two liters of salt solution is given per rectum, for the purpose of alleviating thirst.Medicine.

THE AMOUNT OF DIPHTHERIA ANTITOXIN REQUIRED.--In summing up the study of ninety-three cases, Park says that the local condition in children in markedly severe cases did not clear up as rapidly with 1,000 as with 2,000 units, and in two or three cases he believes death would have been prevented by larger doses. In several other cases better results would have been obtained by 3,000 to 5,000 units. Very large and repeated doses of antitoxin somewhat increase the liability to serum complication, but he thinks it correct to say that the increase in serum effects from very large doses is much less than is generally believed. In his second paper he concludes that antitoxins are, in all probability, substances having the properties of globulin. They can not, with our present knowledge, be separated from that portion of the blood-serum which in susceptible persons produces disagreeable effects. The fact, however, that the antitoxin serum from some horses is scarcely at all deleterious, leads us not to give up the attempt of procuring the serum either by selection of animals or by the treatment of serum itself, which, while antitoxic, is not to any important degree deleterious. For routine practice at present we can scarcely do better than to follow the general plan of using the serum from all healthy animals, which have remained healthy during their period of immunization, and which have in their blood a sufficient concentration of antitoxin. This should not be less than 200 units in each c.c.—Journal American Medical Association.

PERFORATION IN TYPHOID Fever from AN OPERATIVE STANDPOINT. Davis (Amer. Jour. Surg. and Gynec.) says: The diagnosis of perforation is not always easy. A decided and sudden increase, especially of pain, in the abdominal symptoms, associated with an abrupt fall of temperature, is diagnostic of perforation. Leukocytosis is a confirmatory sign. Hemorrhage is accompanied with a sudden fall of temperature, but not by a sudden increase of abdominal symptoms. Dullness in the right iliac region is not to be expected in cases of perforation. Localized impairment of resonance may be due to free abdominal fluid; change of position causes

it to disappear. Localized pain and dullness may be due to a plastic peritonitis around the site of perforation. This may be observed perhaps in one case in ten, possibly one in five. It is impossible to recognize that a perforation is about to occur. It is not necessary to operate before a perforation occurs, but it is necessary to operate before collapse is marked. Typhoid fever patients when not in total collapse bear operation much better than was formerly expected. Patients operated on in marked collapse are liable to die on the table. I know of some such cases. Washing out the abdominal cavity with hot normal salt solution, even if no perforation is present, seems to improve the condition of the patient at the time of operation, and to favorably influence the subsequent course of the disease. Operate as soon as the diagnosis of perforation is made. It is less dangerous for the patient to run the risk of having an operation done during the first period of depression than to wait and run the risk of having collapse preclude all operative measures. In operating, incise as for appendicitis, and not in the median or semi-lunar line.-Memphis Medical Monthly.

TRAUMATIC NEUROSES FROM THE STANDPOINT OF A SURGEON.Bevan (Jour. Amer. Med. Asso.) says:

1. Real injuries of the nervous system present positive and immediate symptoms.

2. Those alleged injuries of the nervous system, without positive and immediate symptoms of gross lesions, are either cases of malingering or abnormal cerebral states, traumatic neuroses, or a mixture of the two.

3. Traumatic neuroses are the result of two factors: First, a brain readily affected by suggestions; second, suggestions furnished by an accident with or without injury to the individual, suggestions furnished by sympathetic care or a craving for sympathy, and lastly and of greatest importance, suggestions furnished by medical attendants.

4. To establish a diagnosis requires the immediate and sometimes protracted observation of the patient, as in the study of any psychosis. The supposed refined means of diagnosis, as the dynamometer, esthesiometer, and electricity, are seldom of value and are often of positive harm as suggestions to the patient.

5. These cases recover rapidly under proper surroundings and advice when the continuing causes are removed. Recovery may be indefinitely postponed under improper surroundings and advice.

6. No secondary degenerations of the nervous system follow traumatic neuroses. The pathologic conditions due to an old standing traumatic neurosis are the degenerations of disuse and the general deterioration of the individual from confinement, lack of exercise, dejection, etc.

7. The subject of traumatic neuroses will not receive its proper place until the medical profession recognizes their responsibility in the development and continuance of these conditions, and until proper means are provided for the punishment of malingerers and their alleged medical experts.

EXCISION OF THE SHOULDER-JOINT.-(A. R. Shands, M. D., Medical Semi-Monthly.) Tuberculous disease of the shoulder-joint is rare. Dr. Young reports that in 2,292 cases of orthopedic affections treated in the Orthopedic Department of the Hospital of the University of Pennsylvania there were only two such cases.

Reviewing the literature upon the subject, these figures are practically confirmed. The text-books dispose of the subject in very few words, but all agree that excision for relief of extensive osteitis of the head of humerus is quite justified by the excellent results obtained, but excision of the shoulder-joint should never be made as a routine practice, for under conservative treatment cures are so frequently made, even though an absolutely ankylosed joint is the result, that the patient has an exceedingly useful arm because of the free motion of the scapula. Almost every motion can be affected except the overhead one. Excision of the shoulder in gun-shot injuries is an operation of great value, well demonstrated in our recent wars. The writer was unable to find the report of any case of excision of the shoulder in which more than the head and neck had been removed, but reports a case of his own in which seven and one half inches of the humerus with the head had to be excised to remove all of the diseased bone, leaving the patient a very useful arm.-St. Paul Medical Journal.

EXCLUSIVE SOUP DIET AND RECTAL IRRIGATIONS IN TYPHOID FEVER.-Seibert (Arch. of Ped.) has obtained the following result by pursuing the above regimen:

1. Delirium, headache, insomnia, nausea, vomiting, and tympanites usually disappeared within forty-eight hours of treatment.

2. Tympanites, nausea, and vomiting never developed in any patient, even when complicating pneumonia was present.

3. The fur on the tongue disappeared within a few days.

4. Appetite came frequently on the fourth day of treatment, even when the thermometer registered 102° to 103° F.

5. Even excessive diarrhea (fifteen to twenty-five daily stools) disappeared invariably within first week of treatment.

6. In all uncomplicated cases the temperature began to decline within twenty-four to forty-eight hours after the beginning of treatment, and invariably would reach the normal figure within ten to twelve days.

7. In cases complicated by pneumonia, nephritis or phlebitis, when treatment began the temperature usually remained in accord with the inflammatory conditions found until these also disappeared, while the cerebral, gastric, and intestinal disturbances usually subsided as rapidly as in the uncomplicated cases, excepting anorexia.

8. Complications, when not present at the start, were very rare, and then usually developed within the first two days.

9. Intestinal hemorrhage was noticed in three cases, none ending fatally. Perforation did not occur.