The pulse was now 170, and the patient was in a precarious condition. A sterilized saline intravenous solution of one and one-half pints was given in the right median vein. The pulse, which was almost imperceptible previous to this, became fuller, and nine hours after the operation it had dropped to 110, and the boy was resting comfortably. By 11 P. M., or twelve hours after the operation, the pulse was 190, and almost imperceptible. Another intravenous infusion of nearly two pints brought the pulse to 120 in eight hours. While administering the infusion the pulse gradually became fuller and harder. I asked the boy how he felt. He replied that he had pain in his head. Upon inquiring how his head. felt, he said it felt full, whereupon I discontinued the infusion. While I feared hemorrhage from a possible giving away of the femoral artery, I concluded to give him all I possibly dared, as the case seemed utterly hopeless. By noon of the following day gangrene of the inner portion of the anterior flap had set in. The following morning the line of demarkation had formed, and I excised as near as possible all of the gangrenous portions. The day following the operation the boy took two and one-half quarts of milk during twenty-four hours and stimulants were administered freely. Nothing of event occured until the 27th. In the meantime the boy was rapidly gaining both in flesh and spirits, the temperature remaining about 99°. The wound required daily dressing. On the day above mentioned the temperature rose to 102°, and the patient complained of chilly sensations with pain in the left leg. Upon examination, tenderness was found along the shafts of upper one-third of both humeri and lower third of left femur. The tongue was dry. On the following day tenderness was marked along the whole shaft of the right humerus, twothirds of the left humerus and the entire femur. These symptoms, together with a dry condition of the tongue, free perspiration, rapid emaciation and a cough, continued until October 2, or about six days, when they subsided, and rapid improvement began. On October 8, after the dressing of the wound was all but completed, a secondary hemorrhage of the femoral artery took place. This was the result of extensive suppuration of the flaps, the artery not having been disturbed in any of the dressings, as I feared such a catastrophe and had continually warned the nurse of its possible occurrence. After considerable difficulty the artery was secured and ligated. There was profuse bleeding and the boy was in a condition of collapse, but under a saline infusion and stimulants he again rallied. Nothing further remains to be recorded in the history of the case, except that the boy made a perfect recovery and has attended school daily since January 1. Quinine and strychnine were employed throughout the illness. Calcium sulphide was also freely administered from the time the symptoms in the other bones manifested themselves, and to what extent that may have aided in preventing pus formation in them is difficult to determine. That these were centers of infection and subsided without pus formation is scarcely to be questioned. Finally, the following lessons are to be learned from the recital of this case: (1) That early diagnosis is imperative. (2) That early operative measures should be undertaken to remove the foci of disease before the periosteum becomes separated and destruction of the corresponding bone ensues. (3) From its tendency to develop at the epiphyseal junction, the open EXAMINATION OF THORAX IN STOMACH DISEASES. 375 ing should be made as near that junction as possible and sufficiently large to enable one to remove all the diseased focus, including the diseased marrow, and provide for ample drainage. Had an early operation been permitted the probabilities are that the bone and limb could have been saved; as it was, over half of the bone was totally destroyed before operation was allowed. (4) That intravenous saline infusions are of great value. I believe the boy would have succumbed without them. One year later a small sinus with discharge was formed in the left femur, but no operative procedure was instituted, and later the wound. healed. The boy is now wearing an artificial leg. In conclusion, I wish to tender my thanks to DOCTORS HANLON, WALLACE, LOWRY, YOUNG, and COMFORT for assistance rendered during the management of this case. IMPORTANCE OF MAKING A THOROUGH EXAMINATION OF PUBLISHED IN The Physician and Surgeon EXCLUSIVELY] THE importance of making a careful examination of the thorax in all supposed stomach diseases, is a subject which I have selected for the purpose of showing how easily physicians may be led astray in diagnosis. by neglecting to examine the heart of patients who come to them complaining of some disturbance of the stomach. In the process of digestion there are three factors: (1) Secretion of the gastric juice. (2) Movements of the stomach to break up the food and mix it thoroughly with the solvent juice. (3) Absorption of the products of digestion. Since secretion depends upon the activity of the secreting cells and supply of new material to them from which they may manufacture the secretion, we find that abundant secretion is usually, though not invariably, associated with an abundant blood supply. All the processes which go on in the stomach, namely, secretion, peristaltic action, and absorption, are much influenced by the condition of the circulation. This being true, it is not difficult to understand why a patient suffering from organic heart lesion should complain of stomatic disturbances. During the past year a number of patients of this class have come to me complaining of impaired gastric digestion, and in a large percentage of these cases I have found the true trouble to be an organic heart lesion, the stomach trouble being merely secondary. I consider it imperative for physicians to thoroughly acquaint themselves with the normal and abnormal heart sounds. Until recent years I believe the methods employed in making a thorough, scientific examination of patients were greatly neglected. I am pleased to note the interest taken and the thorough course given in physical diagnosis in many of our medical colleges. It is due to this thorough training that many of our recent graduates are able to detect, quickly and accurately, abnormal heart sounds, splenic tumors, cancer of the stomach, and many other abnormal conditions. * Read before the MICHIGAN STATE MEDICAL SOCIETY at its Battle Creek meeting. Perhaps the citing of two cases may be of interest to you. A lady, about forty-five years of age, gave the following history: For four weeks she had been unable to attend to her duties on account of general weakness, pain in the epigastric region, eructations of gas, constipation, loss of appetite, cold extremities, and gradual loss of weight. Patient showed no signs of heart lesion except shortness of breath on exertion. On examination there was found over the apex a whistling murmur during systole, which was transmitted into the axilla. There was also increased area of heart dullness. This murmur was difficult to detect except on very careful auscultation. On February 15, 1901, a gentlemen told me that he had suffered for a long time with stomach trouble, and asked if I could do something for him. He gave the following history: For several weeks there had been a loss of appetite, strength, and weight. At times patient experienced pain in the epigastric region, cold extremities, slight blueness of lips, and shortness of breath on exertion. This patient said he had not been bothered with cardiac or precordial distress, and apparently did not dream that there was anything the matter with his heart. On examination there was found a distinct murmur over the second intercostal space on the right side, and also a whistling murmur over the apex, showing that the patient was suffering from two distinct heart lesions. I shall not take time to cite other cases, as there is such a similarity in their history. In conclusion, I will say that I have made it a rule to examine the heart in all cases of supposed stomach diseases of obscure origin, and have found heart lesions to be the true causes in about fifteen per cent. TRANSACTIONS. DETROIT ACADEMY OF MEDICINE. STATED MEETING, APRIL 9, 1901. THE PRESIDENT, ARTHUR D. HOLMES, M. D., IN THe Chair. DISCUSSION OF PAPERS. DOCTOR HEDLEY WILLIAMSON, of Detroit, read "Fever-A Symptom." (See page 363.) a paper entitled DOCTOR FLINTERMANN: The views of fever have changed a good deal in late years. Formerly it was considered a disease; now it is supposed to be a process. There is often a rise of temperature in those who are perfectly well. In such cases a rise of temperature is not dangerous. No one knows what fever is. It is a symptom in certain diseases, that is. typhoid fever, scarlet fever, et cetera. Yet the duration is not the same, I would rather see a patient with high temperature and good pulse, than one with low temperature and poor pulse. We cannot say whether fever is caused by the exudates in the body. The fever of pneumonia is very strange. It comes on suddenly and almost as suddenly disappears. The reduction must be due to the formation of an antitoxin. As for the treatment of fever, I believe the essayist is on the right track. Many observers have shown that the danger is not in high temperature. DOCTOR AARON: I believe we know little of the cause of fever. The theory is that just as there is a center of respiration, so there is one of heat production, dissemination, and regulation in the corpus striatum. In typhoid fever, for instance, the absorption of toxic materials acts on the heat centers of the brain. We should regulate the amount of food by the amount of heat it will produce. DOCTOR CONNOR: I was hoping that it might be brought out whether mental and moral disturbances might increase the local temperature, or whether temperature is due to bacteria and to the decomposition of tisHeat in physics is a form of motion. It must be the same in the body. There must be a mechanism in the body whereby the transformaSome day it may be found that the nervous system can cause it without pathogenic germs. sues. tion occurs. DOCTOR MANTON: I believe that the introduction of the clinical thermometer has been harmful as well as beneficial. There is a distinction between fever and temperature. There can be a high temperature without pathologic changes. DOCTOR METCALF: In pneumonia temperature is an index of the force of the body in overcoming resistance. It is a lack of balance. We are uneasy when we have a patient without temperature. The thermometer is invaluable as an index of the volume of the vital force to overcome irritation. DOCTOR TIBBALS: It occurs to me that we cannot discuss the subject intelligently because we know so little about fever. The use of the thermometer is invaluable, and except in a few nervous cases there is always a cause for the rise of temperature, even though we fail to find it. DOCTOR GIBBES: I am interested in the paper because it is on the right track. The variations in temperatures may be due to an alteration in the blood. All blood is not similarly affected. A slight alteration may allow the bacteria to grow, or it may destroy them. DOCTOR WILLIAMSON: There is a distinction between fever and temperature. Why should we wait before attempting to lower temperature in typhoid fever until it is about 102°? If rise of temperature is harmful, it should be treated with the same vigor when it is 100° or 101°. EDITORIAL ARTICLES. COWS' MILK FOR INFANT-FEEDING. INFANT-FEEDING is always a subject of great interest and importance, but with the advent of the summer season it assumes again renewed prominence. Were mother's milk never deficient nor pathologic we should likely never hear of artificial foods, but as the human race is constituted we are confused with the great variety of substitutes offered, which, by the way, may be taken as an indication of our ignorance of the whole subject. It is not more than about ten years' time since the correct solution of the problem was thought to be the sterilizing and mixing of cows' milk and water in various proportions to imitate the natural food of the infant. Other artificial foods have also been employed at different. periods of the child's life, but the profession have looked with most favor upon cows' milk as a substitute. Gradually, however, there has arisen a feeling of insecurity and finally a sense of disappointment even in sterilized milk. The closest study and finest shading of percentages. have often failed to produce normal stools and make the child grow. Sterilization has little by little given way to pasteurization, but even such treatment of the milk has been found to so change the casein and to so diminish the peculiar germicidal powers of fresh raw milk as to make it less effective. Indeed rickets and other scorbutic affections have been frequently demonstrated in infants nourished by those substitutes exclusively. Accordingly the processes of observation and experimentation. have been carried on until now it is insisted that if desirable results are to be obtained we must start with clean, raw milk. Asepsis is to be religiously applied to every detail of the milk producers' art. The pasture, stable, the cow's body and especially the udder and teats, the handsand clothes of the milker, and pail, must be given careful attention and scrutiny. The first few streams of milk should be discarded as they contain large numbers of bacteria. The collected milk should be mixed, aerated, and cooled and kept at a temperature not to exceed 60° Fahrenheit. With such milk at hand the difficulties in infant-feeding are well overcome. The varying richness of milk will necessitate more or less dilution, but superfine percentages are not essential. A correct understanding of the effects of an excess of either fat or casein upon the infant's stomach and bowels will dispose of the other bugbears so generally feared. ANNOTATIONS. SIGNIFICANT CIRCULATORY STRUCTURE OF THE OVARY. PUBERTY, the periodic appearance of menstruation, and the menopause, have all been the sources of numerous interesting hypotheses. Few, however, have rested upon scientific study. The latest notable explanation of these phenomena has come from the pen of JOHN G. CLARK, who submits a short statement in "Progressive Medicine" for June, 1901. The vascular system of the ovary is said to form a tree-like structure. The five largest branches of the ovarian artery enter the base and seek the center of the organ, and then branch out toward the surface. At birth the ovary is encapsuled by a dense fibrous membrane, and holds. within the meshes of its stroma myriads of follicles containing enough ova, it is said, to populate a city of many thousand people. Already periodic changes begin, or have begun, in the Graafian follicles. rally those nearest the center of the ovary, under the influence of greater vascularization, are the first to undergo cyclic development, but from their position do not escape on the surface. At puberty, however, the follicles near the surface begin to undergo these changes, and their rupture upon the surface constitutes ovulation. If an ovum remains unim Natu |