1903 Journal of the American Medical Association  
medical men in this matter is beyond comprehension. With a 95 per cent, mortality rate staring them in the face they very often neglect to call in the surgeon until it is too late. Our homeopathic brethren are the worst offenders in this grave matter, for they usually give the patient a dose of medicine every fifteen minutes until he dies. The excuse usually given by the medical man for his neglect in these cases is that he was not sure of his diagnosis, and that he does not approve of the
more » ... as a diagnostic agent. Exploration has enabled us to reduce the medical mortality of 95 per cent, in these cases to 45 per cent., and when we secure the co-operation of all practitioners it will fall much lower. At this point I can not refrain from calling attention again to the restrictions that should be thrown around exploratory abdominal operations, for it is worse than useless for an inexperienced operator to open the ab¬ domen in suspected perforation, or in cases of obstruc¬ tion of the bowels, except when the obstruction is caused by strangulated hernia. Chronic peritonitis is a condition very frequently de¬ manding exploration. When the condition is tubercular the operation per se will often prove curative. We have learned with the development of abdominal surgery that the old idea that all cases of chronic peritonitis are tubercular was a mistaken one. The majority of cases of chronic peritonitis are the sequels of acute appen¬ dicitis, salpingitis or cholecystitis, but a great many cases develop independent of an acute inflammation. There are many chronic invalids in every community suffering from peritoneal adhesions caused by chronic non-tubercular peritonitis who could be restored to health and comfort through an exploratory opening. It is very important to remember that a patient may be a great sufferer from peritoneal adhesions who has never had an acute abdominal inflammation. When making an exploratory operation in a case of suspected peritoneal adhesions it is very important to so locate the incision that all parts of the abdomen may be reached. My per¬ sonal preference is for an incision through the right rectus muscle, large enough to admit a hand, thus en¬ abling the surgeon to explore the pelvis, the appendix and the gall bladder. In conclusion, allow me to express the hope that this brief paper will be understood as denouncing the abuse of exploratory incisions as emphatically as it advocates their use. An earnest endeavor has been made to make such clear statements that no honest man can offer them as an excuse for the unwarranted substitution of the knife for surgical knowledge or diagnostic ability, and to convince the doubting ones that their refusal to use the knife as a means of diagnosis where other means have failed is to sacrifice human life on the altar of prejudice. Fatal Emotions.-Keraval is director of an insane asylum in France, and he reports three deaths occurring there recently which demonstrate anew that a vivid emotion is capable of affecting the cerebral circulation to such an extent as to entail lesions immediately or rapidly fatal. One patient was a man of 44, with atheromatous degeneration, but apparently robust. He succumbed to a cerebral congestion induced by intense delight at the news that he was to be released from the asylum. The other cases were those of a man of 65, with ideas of perse¬ cution, and a man of 57, a general paralytic. Both died from cerebral congestion following a comparatively slight annoy¬ ance. The autopsy revealed in the last case the fresh hemor¬ rhage among the lesions of old meningo-periencephalitis.-'"Nord Mëd.," vi, 30. The important significance of mixed germs and certain d\l=e'\brisof the respiratory organs in phthisis is evidenced by the confusing variety of grave symptoms and lesions that accompany them and their too frequent fatal sequence. Yet the problems of mixed infections in this ruthless malady are still considered very largely with the same old indifference and skepticism that bred empirical treatments one hundred years ago. Impractical theories continue to sway a vast army of medical and laymen. The practitioners who seriously undertake to differentiate and individualize among their tubercular patients, with a view to ascertain the true conditions existing, and select appropriate remedies and proper nutrition are still in the minority; and the patients who look upon consumption with discriminating common sense are few. For many of the profession and laity consumption is consumption and usually fatal anyway; for a large number of others, in all walks of life, they will procrastinate till broken down, and then expect relief or cure in a few weeks or months-a thing impossible without a miracle. This is very unfor¬ tunate, because many consumptives are curable if they have the courage to begin to arrest the development early enough, the patience to persist, and if they are not too dissipated. No case is cured quickly. On the other hand, too many rash promises are made by too many doctors in desperate cases. In order to present the significant differences in the microbiology and pathology of the various classes of consumptives, and suggest the errors of stereotyped treat¬ ments and the reasonableness of discriminate therapeu¬ tics, I beg leave to present a résumé of clinical and labor¬ atory observations dating back a few years. For the purpose I have reviewed carefully a number of micro¬ scopic slides and macroscopic specimens and sections prepared for diagnosis and medical advancement in the course of practice. In fact, I have ransacked clinical his¬ tories related thereto and many works bearing on the subject. I shall here attempt to place briefly the most important data and findings before the profession. 'Each of the microscopic pictures represents the important things found in a given specimen of sputum. In some of them, however, I have grouped the findings of two or more differently stained slides of one expectoration in order to render more appreciable and clearer the various germs and débris present in the case. The macroscopic cut needs no attention at this point. Fig. 1 shows the usual appearance of sputum in pure, so-called subacute pulmonary phthisis. Pus cells, bronchial epithelial cells, bacilli of tuberculosis and some mucus are present. There were none of the com¬ plication germs in this case of the kind and quality that do harm. The patient presented an area of dulness about three inches in diameter below the right apex, some fine moist murmurs and considerable expectora¬ tion, which was occasionally grayish and occasionally yellowish, or a mixture of both colors. Few bacilli of tuberculosis were present. The patient had come from
doi:10.1001/jama.1903.92490200001002 fatcat:gsridhmyzbgknamugn2ulcl7fq