through long continued obstruction in order to keep the mortality low.

The suitability of individual cases for prostatectomy is based on the pre-operative cystoscopic examination, the determination of the elimination time and intensity of colorimetric tests, and of the urea output and blood nitrogen retention.

In many cases, pre-operative urinary drainage is an essential factor in reducing prostatic mortality. This is accomplished by continuous catheterization or preliminary cystotomy. The object of this treatment is to raise the index of renal efficiency and this is manifest by an increase in the urine's specific gravity and urea output. When these figures reach a stationary point the gland should be removed and not before. During this time the patient should drink large quantities of water and the bladder should be daily irrigated with some antiseptic fluid, preferably silver nitrate. The urine should be rendered acid and hexamethylenamine given in 20 grain doses every 4 hours for 24 to 48 hours. After this time the hexamethylenamine can be given in 10 grain doses. If the renal function has shown pronounced improvement, ether is quite safe and should be the anesthetic chosen.

Martin claims that it is only by a rigid adherence to these factors of safety that success in prostatic surgery is attained, and unless the operator is painstaking in his application of every pre and post-operative detail, and has an intelligent appreciation of its rationale, his prostatic surgery will not measure up to modern requirements.

E. M. JONES.

POSTURE IN CASES OF ABDOMINAL DRAINAGE: Roland Hill (Annals of Surgery, Vol. LXVI., No. 4), maintains that in the case requiring drainage, there has been delay. In abdominal cases where drainage is established it is not effectual for a much larger period than 24 hours.

The three important factors in abdominal drainage are gravity, intra-abdominal pressure and capillary attraction.

To secure the influence of gravity the patient is placed in one of the following positions:

1. Fowler position: this position has been generally in use. Hill points out that in order to establish drainage of spaces in front of kidneys the patient leans forward; this he regards as a great strain upon a patient with an already weakened heart and low blood pressure. The pelvis is lower than the pelvic arch and there is tendency for pus to accumulate in dependent pouches.

2. Prone position: patient is placed on the abdomen from 24 to 48 hours, the head of the bed elevated 10 to 12 inches, with a pillow under lower chest region. The position though uncomfortable is perhaps the most efficient. Purulent material is unable to become lodged in the spaces along the spine and pelvis. 3. Lateral position: patient on right side with pillow below liver region and turned so that pus will drain from in front of left kidney.

A series of 104 drained cases is reviewed. In the 47 cases in which the Fowler position was used, there were 5 deaths. In 57 cases (in 15 of which the lateral position was used), where the patient was prone there were 2 deaths. Hill in treating these cases gives them glucose 3 per cent and soda 2 per cent in solution per rectum by the drop method. Peristalsis is controlled by opiates and no food is given by mouth. GEORGE GEIST.

TREATMENT OF PERNICIOUS ANEMIA-ESPECIALLY BY TRANSFUSION AND SPLENECTOMY: Geo. R. Minot and Roger I. Lee (The Boston Medical and Surgical Journal, Vol. CLXXVII, No. 22, Nov. 29, 1917), considers the treatment of pernicious anemia, especially by transfusion and splenectomy, from a study of 96 cases and the literature.

The first essential for treatment is a correct diagnosis. The diagnosis is not to be made on the blood smear alone and, unfortunately, is seldom made early. A careful, detailed study of the activity of the bone marrow and red cell destruction is important for prognosis and therapy. Not only one but all of the three chief elements of the marrow must be studied: the polymorphonuclear neutrophiles, red cells, especially young red cells, and platelets. Observations on the latter are important. Certain elements, often taken to indicate stimulation of the marrow, do not always indicate this, or at least are not always associated with a favorable prognosis. Such elements at times are of bad omen.

The authors point out that certain types of pernicious anemia are to be recognized. Those types of cases that do the best spontaneously usually, but not always, receive the most benefit from treatment. Older patients are more apt to have a less relapsing and less hemolytic type of the disease than younger individuals. Cases with enlarged spleens, together with somewhat enlarged livers, when these enlargements are associated with and probably due to hemolytic activity, are apt either to have, or to have had, a more favorable course of the disease than those cases without such enlargements.

It is important that all cases should have proper general treatment.

Transfusion and splenectomy offer the best means for inducing remissions, though a remission can occur spontaneously as marked as those inaugurated by these procedures.

Transfusion It may also,

No case is too sick for transfusion. can give rapidly symptomatic benefit. either directly or indirectly, rapidly or slowly, cause stimulation of the marrow or allow increased activity of the marrow, so that a remission is inaugurated.

Isohemolytic reactions will not occur with properly selected donors. Other reactions of unknown nature, usually much less severe, cannot at present be avoided. It is suggested that some reactions following transfusion may be dependent upon the fact that the patient has previously received transfusions of blood. Such reactions are, perhaps, associated with

a rapid and excessive accumulation of blood pigment in the body.

Splenectomy for pernicious anemia is a palliative operation. It checks the red cell destruction and increases the activity of the marrow. Good remissions follow splenectomy more consistently and uniformly than after other forms of treatment. Splenectomy is reserved for only selected cases in certain stages of the disease. It is a serious procedure, is not to be urged, but at times may be advised, provided the patient understands that its effect is only temporary. The cases of pernicious anemia that approach the disease hemolytic jaundice are the most suitable ones for splenectomy.

By means of transfusion and splenectomy the writers believe that patients do better and can be made more comfortable while they live, and that in certain instances they may perhaps live longer than without such treatment. Probably when transfusions are begun relatively early, so that the patients never remain very anemic for long periods, the best ultimate results will be seen.

Roentgen ray exposures of the spleen have at present shown no definite beneficial effect.

ERNEST T. F. RICHARDS.

CONCERNING THE CAUSATION OF EDEMA IN CHRONIC PARENCHYMATOUS NEPHRITIS: Epstein (Am. Jour. Med. Sc., Vol. 154, No. 5), from a new standpoint explains theoretically the cause of edema and suggests a revolutionary method of attack.

The author first shows that Widal's theory of salt retention in the tissues due to defective elimination of salt by the kidney is best substantiated by clinical experience.

He goes on to show in two tables which he published a few years ago giving the results of some of his own investigations, that in chronic parenchymatous nephritis the blood serum contains about half the percentage protein that it does normally and that about 90 per cent of this protein is globulin compared with 37 per cent in normal individuals. The albumen content of the blood serum is correspondingly reduced from about four and one-half per cent to one-half per cent in the parenchymatous type. This condition of affairs is explained by the author as being due to the very considerable loss of protein in the urine in these cases.

The author has previously shown that the subcutaneous fluids in this kind of nephritis contain a negligible amount of protein.

The author cites Starling's explanation of the mechanism which regulates the interchange of fluid between capillaries and tissue spaces. He believes there are two factors, (1) pressure and (2) osmosis which tend to produce an equilibrium. If the pressure is greater in the capillaries, fluid is forced into the tissues, and vice versa. Thus in case of hemorrhage, fluid is forced into the circulation because the pressure in the capillaries is diminished. Osmosis on the other hand is produced by the proteins which are colloids, and the osmotic pressure is greatest in the

circulation because of the greater amount of protein in the blood serum than in the lymph. That is, osmosis tends to force fluids from the tissues into the circulation.

Applying this theory to chronic parenchymatous nephritis he has shown that the continual loss of albumen through the kidneys causes an actual reduction in the percentage of protein in the serum. The work of Dieballa and von Ketly has proven this is not due to an hydremia. This lowered protein content of the blood lowers the osmotic pressure of the blood, and fluid passes from the blood stream into the tissues.

The treatment indicated to reduce the edema in these cases is therefore to increase the protein element of the blood. Blood transfusion should help but being impractical in many cases protein feeding remains to be considered.

The author advises this along with restriction of fluid intake to 1200 to 1500 c. c., only enough salt to make the food palatable, low carbohydrate diet and no fat.

Carbohydrates should be cut down as low as possible because water is the end product in their metabolism to a very considerable degree. The fats are excluded because a marked increase of fatty substances in the blood has been demonstrated in this type of nephritis. The author has instituted this line of treatment in a few extreme types of the disease and the results obtained have been very encouraging. C. B. DRAKE.

SYPHILIS OF THE STOMACH: Paul Rockey (Northwest Medicine, April, 1917), states that in syphilitics with gastric complaints, where the cause is not in the stomach, it may be due to syphilis of organs in relation, as liver, pancreas, lymph nodes; to perigastric adhesions of syphilitic origin; to reflexes from syphilitic lesions at more distant points in abdomen; to the toxemia and cachexia of the disease elsewhere than in the stomach; and to specific lesions in the brain or to the gastric crises and gastric symptoms of tabes. Apparently syphilis of the stomach occurs in the tertiary stage or occasionally late secondary.

Syphilis affecting the stomach directly might do so by its toxins affecting the stomach wall and the gross and minute pathology of this change might be recognizable. Syphilis might affect the stomach by the presence of the spirochete pallida in its layers. The therapeutic test when used should be adequate. Response to it will probably be definite, but there are cases of syphilis usually resistant to anti-luetic treatment. There are now syphilitic dyspepsias that may be benefitted for a time by anti-specific treatment. Simple gastric ulcer is subject to spontaneous cure, also to periodicity, of course. Presumably syphilitic gastric ulcer is subject to similar phenomena. The prognosis of luetic gastric ulcer untreated would presumably be worse than that of simple ulcer, but if treated probably as good or better.

C. D. FREEMAN.

BOOK REVIEWS

GENERAL SURGERY. The Practical Medicine Series. 1917, Vol. II. (Edited by ALBERT J. OCHSNER, M. D., F. R. M. S., LL. D., F. A. C. S. Surgeonin-Chief Augustana and St. Mary's of Nazareth Hospitals; Professor of Surgery in the Medical Department in the State University of Illinois. Published by the Year Book Publishers, Chicago. Price $2.00.)

This volume is a review of the surgical literature of the past year. It is very complete, and while of necessity its references are brief, it is of value as a reference book.

There has been a notable increase in surgery pertaining to war and a decrease in foreign surgical reference-probably due to a lack of foreign journals. L. E. DAUGHERTY.

MILITARY SURGERY. (BY DUNLAP PEARCE PENHALLOW, S. B., M. D. (Harv.), Chief Surgeon American Women's War Hospital, Paignton, England; Captain Medical Corps, Massachusetts National Guard; First Lieutenant Medical Reserve Corps, U. S. Army (Inactive List); Director of Unit, American Red Cross European Relief Expedition. With Introduction by SIR ALFRED KEOGH, K. C. B., Director-General Army Medical Service. Published by The Oxford University Press, American Branch, New York. Price $5.00.)

This book deals with modern warfare and the many complex problems which involve the treatment of wounds by various projectiles. The author is Chief Surgeon of the American Women's War Hospital, Paignton, England, and has had ample opportunity to study wounds and their method of treatment. Many individual cases are cited and the illustrations are new and excellent. Shell Shock, Gas Poisoning, and Trench Foot, are amongst the conditions dealt with. One of the most interesting and pathetic chapters deals with gas poisoning before the troops were protected by gas masks.

L. E. DAUGHERTY.

PEDIATRICS. The Practical Medicine Series. 1917, Vol. V. (Edited by ISAAC A. ABT, M. D., Professor of Pediatrics, Northwestern University Medical School, Attending Physician Michael Reese Hospital, and A. LEVINSON, M. D., Associate Pediatrician Michael Reese Hospital. Published by The Year Book Publishers, Chicago. Price $1.35.)

This short symposium on pediatrics covers 148 pages with short references to the advances and dis

THE CAUSE of TUBERCULOSIS, Together With Some Account of the Prevalence and Distribution of the Disease. Cambridge Public Health Series. (By LOUIS COBBETT, M. D., F. R. C. S., University Lecturer in Pathology, Cambridge. Published by the Cambridge University Press, 1917. Price $6.50.)

The title of this book is unfortunately chosen (according to the opinion of the abstractor) as being uncomprehensive and misleading. Outside of the treatment and clinical phases of tuberculosis, this book contains practically everything pertaining to all the various ramifications occupied by the subject of tuberculosis in its relation to mankind and animal life. It covers in fine detail the mortality records of the disease in various countries and proves conclusively the actual decline of tuberculosis. It also deals thoroughly with the different types of tubercle bacilli and their effects on man and animals, together with the different modes of infection and contagion.

A wealth of statistical charts and pathological specimen photographs are shown to illustrate the diseased conditions in various organs of animals produced by the experimental injections of the three types of tubercle bacilli.

This book should find a place in the library of every public health officer, sanitation engineer, social welfare worker, phthisiographer, and all physicians or laymen who have at heart the stamping out of tuberculosis.

EUGENE F. WARNER.

Vol. I

No. 2

ORIGINAL ARTICLES

COLLES' FRACTURE.*

OWEN W. PARKER, M. D., Ely, Minn.

The treatment of fractures was, no doubt, one of the earliest surgical procedures, dating back to prehistoric medicine.

The studies of Egyptologists prove that many thousand of years ago bones were broken and tied up with splints much in the same way that we do today.

Strange as it may seem, the so-called Colles' fracture was not recognized until comparatively recently. Formerly all wrist injuries were considered as dislocations. Now we know that dislocation of the wrist is a surgical rarity. In 1783, Pouteau, a Frenchman, first described a fracture of the lower end of the radius. His view of the subject did not seem to have attracted much attention, for during the thirty years following its publication only an occasional mention is made of even the possibility of such a lesion and this common injury was still called a dislocation. His description and arguments did not avail against the authority of the eminent French surgeons of that time.

In 1814, Colles, a distinguished Dublin surgeon, published his masterly paper, describing the fracture, in the Edinburgh Medical Journal. This was a clear and brief description of the

lesion.

*Read before the Annual Meeting of the Minnesota State Medical Association, St. Paul, October 11, 12, 1917.

In 1820, Dupuytren established among the French the frequency of fracture of the carpal end of the radius and also proved the rarity of dislocation of the wrist. Sir Astley Cooper, in 1823, described in his book fracture of the lower end of the radius.

Velpeau, in 1842, called attention to the characteristic S-shaped deformity, which he likened to a dinner fork, or the so-called silver-fork deformity.

Thus we find a period of forty years from Pouteau's and Colles' descriptions before the true lesion was generally recognized. It was difficult to dislodge the old idea that the lesion was a dislocation.

In more recent years, Pilcher, Roberts, Cotton, Codman, and others have made careful studies of the fracture and contributed valuable

scientific knowledge on the subject. Dr. Murphy often talked on Colles' fracture in his clinics and emphatically impressed on his listeners the important facts in the treatment.

Colles' original description was of a fracture of the base of the radius, occurring as high as 11⁄2 inches above the carpal articular surface. On an average, however, it lies about 1/2 to 3/4 inches above the articular surface.

The anatomical parts entering into the formation of the wrist joint are the lower end of the radius and the under surface of the interarticular fibrocartilage, which form together the receiving cavity, a transversely elliptical concave surface. The articular surfaces of the

scaphoid, semi-lunar, and cuneiform bones form together a smooth, convex surface, making the

condyle which is received into the concavity

above mentioned. The ulna does not form a part of the wrist joint, but connects with the radius by a separate articulation formed by the

Radiograph of normal wrist anterio-posterior. Note the two rows of bone of the carpus, and the scaphoid and simi-lunar articulating directly with the base of the radius.

Note also that the ulna does not articulate with the wrist bones, but does articulate with the radius.

head of the ulna received into the sigmoid cavity at the inner side of the lower end of the radius.

The surfaces of the bones entering into the formation of the wrist joint are covered with cartilage and firmly held in apposition by four ligaments, the external lateral, internal lateral, anterior and posterior, together forming a capsule. At the lower extremity of the radius a prominent lip projects anteriorly into which is inserted the anterior radiocarpal ligament, whose fibers are continued for one-fourth inch or more above the articular margin. This ligament, though dense and strong, is sufficiently loose to permit considerable latitude of motion backwards of the carpus from the radius. The posterior radiocarpal ligament unites the bones. together behind.

The anterior radiocarpal ligament is a very important anatomical structure in the production of Colles' fracture. It consists of three distinct sets of fibers or bands, the anterior surface of the scaphoid, semi-lunar, and cuneiform bones being the common point of origin. One set passes obliquely outward to be inserted into

Figure 2.

Radiograph lateral of wrist showing Colles' fracture with marked upward and backward displacement of lower fragment. Note the sharp jagged appearance anteriorly of the lower end of the upper fragment of the radius. Marked injury and irritation of the flexor tendons would be produced by it, especially if there were not complete reduction.

the styloid process and the adjoining anterior margin of the lower end of the radius. A second set passes obliquely in the opposite direction, and is inserted into the styloid process and anterior margin of the lower end of the ulna. The third set passes directly upward and is inserted into the greater part of the anterior margin of the lower end of the radius.

Colles' fracture is one of the most frequent fractures and also one of the most frequent surgical conditions that the practitioner is called upon to treat. One can appreciate its frequent occurrence when the manner in which it happens is considered. A fall and the force of the fall broken by an outstretched hand in hyperextension, never in flexion, are the usual conditions from which it results.

Out of the 2,521 fractures treated at Roosevelt Hospital in five years, 444 were Colles', it being the most frequent. In the great majority of cases the injury was caused by slipping, or tripping and falling on the floor or sidewalk. Other causes were falling from a ladder, falling downstairs, falling while skating, direct violence, being knocked down, warding off pres