Tuberculous Disease of the Spine in Children. In a study based on 28 cases of Pott's disease, treated at the Victoria Hospital for Sick Children, Hull, OLIVE ELGOOD writes as follows with reference to vaccine treatment.

"Sir Alfred Wright's method of the determination of opsonic indices has safeguarded a treatment which proves itself of great value in carefully selected cases of this disease, although it should be understood that in nearly all cases its use should be an adjunct to one of the other forms of treatment described. In every case, rest is essential, and it is, in many cases, wise to combine mild surgical measures with the injections of tuberculin.

"Thus, where sinuses are present, it is reasonable to suppose that healing will be facilitated by the removal of the lining membrane by curetting, while, on the other hand, it is obviously unreasonable to expect that tuberculin can effect the absorption of a portion of necrosed bone, which in many cases is the cause of the persistence of a sinus. Again, it frequently happens that in a chronic tubercular sinus there is a mixed infection, so that the injection of tuberculin alone is insufficient. Therefore it is best, where a sinus fails to respond to tubercular treatment, and where irritation by dead bone is not suspected, to cultivate a growth from the pus and if possib.e to make a vaccine from the culture obtained and to inject it concomitantly with the tuberculin." "Out of seven cases treated by tuberculin inoculation, I have found complete satisfaction with the healing of long standing sinuses only in two, in a third the general condition showed a marked improvement, though the local condition remained unchanged, while in the other four cases no effect from the treatment was noticed."

"It is certain that there are few treatments in medical science that require so much individual selection of cases if satisfactory statistics are to be obtained, and it appears to me that the surgeon who relies solely on his opsonic chart for indications to inoculate will certainly meet with disappointment. Thus in cases where the cause of a persistent sinus is the presence of a sequestrum, it must be unreasonable to suppose that

tuberculin can effect its cure. On the other hand, if the sequestrum be surgically removed, the tuberculin will most probably be a most valuable adjunct towards the final healing of the sinus."

"Again, the system of dosage entirely from the opsonic curves, in any case, does not always seem justified by results. In illustration, I quote two charts, one of which showed a satisfactory curve under treatment, but the patient steadily declined in health; the other received doses according to her local condition, i .e., when the 'discharge from the sinus began to increase slightly, the dose of 1/1000 K. T. R. was repeated, irrespective of the opsonic index. This latter case was the one brilliant cure under tuberculin of my series, the child having had six months' treatment of mild surgical measures and immobilization without improvement while in two months of tuberculin treatment all the sinuses healed and the condition apparently cured."

"I have neither seen nor read of any case in which harm has been done by inoculations of the small doses, which produce immunizing responses without constitutional disturbance, and therefore, although it is admittedly of limited use in bone troubles, there is no reason why it should not have an extensive trial in all forms of this disease. It is questionable, however, whether the amount of labor consequent on a systematic examination of the opsonic index meets with sufficient reward.

"Besides the charts noted, I have seen a fairly large variety of charts of cases of various forms of tuberculosis, and have frequently been struck by the loss of conformity between satisfactory clinical and pathological results."

"In conclusion, Elgood quotes the words of Watson Cheyne, "In joint and bone diseases, where no operation would formerly or now have been considered necessary, by all means add the use of tuberculin to other methods employed. But blindly to convert the practitioner into an immunisator, as Professor Wright puts it, is, I believe, a totally retrograde step."-Brit. Jour. Children's Diseases, June, 1907, IV., 6, pp. 229

253.

I am decidedly of the opinion that the usual method of reporting instances of rare conditions is a prejudicial one, in no way tending to render the rank and file of physicians any better diagnosticians, at present the crying need of the profession. Too often the reverse obtains, because the reporters describe how rarely, in their vast experience, still more in that of the profession at large, are such cases. met with, ergo, the audience need not bother about such occurrences as they will probably never run across any such. On the other hand, certain common ailments are believed to be so well understood that, when these occur at an unusual age or under circumstances which appear to the superficial observer to preclude the possibility of the presence of such diseases, serious errors in diagnosis and treatment are made.

The first case I shall mention is one of fistula-in-ano in an infant, aged between seven and eight months. One portion of the profession still believes in the tuberculous origin of this disease, while the majority of the remainder have a hazy

Read at the Saginaw meeting of the Michigan State Medical Society, May, 1907, and approved for publication by the Publication Committee.

notion that in some way, trauma of the mucous membrane, followed by ulceration with resultant peri-rectal abscess, is the usual cause of this condition. These rotions comprise but a portion and probably the smaller portion of the truth, in many cases the process starting as a lymphatic infection, or possibly an infective thrombo-phlebitis of the ischiorectal fossa, a denudation of the rectal coats by the pus, and a progress of the infection and the pus in the direction of least resistance, i. e., inwards, between the internal and external sphincters of the anus, guided thither by the fascia of the levator ani muscle. When a complete anal fistula results, the skin opening may possibly form first, but there is often evidence, when incising an ischiorectal abscess, that a minute opening into the bowel (or at least a potential one) has preceded the advent of the pus beneath the thinned integument.

The impression that infants do not have tuberculosis of the anal region and being fed on liquids cannot have fishhones or fragments of other bones, etc., in the rectum to produce trauma and ulceration of the mucous membrane, does not preclude lymphatic infection through

temporary fissures of the anal mucocutaneous covering produced by costive movements, etc. (in my experience incontestibly the most common cause of the ischio rectal abscesses causative of anal fistulae), nor can these cases be treated otherwise than in the adult, i. e., detection of the opening into the bowel and slitting up the whole tract.

In the briefest form the history of the case mentioned is as follows: The patient is now thirteen months of age. About five months ago the patient had a severe attack of gastro-intestinal trouble with diarrhea which lasted four weeks.

A swelling then appeared to the left of the rectum which so compressed the anus that the bowels could not be evacuated for 24 hours. At the end of this time, during an effort to empty the bowels, the swelling ruptured, discharging much pus and blood. The skin opening closed on several occasions, but cpened again, giving vent to pus. Some form of operation was done in February, since which time the discharge has been much less. Examination under an anesthetic enabled the easy passage of the probe along the sinus into the rectum between the two sphincters. This tract was freely laid open and packing was introduced, healing promptly taking place.

The general belief that the symptoms, course, and diagnosis of deep-seated abscess, osteomyelitis and sarcoma are thoroughly understood, and that the differential diagnosis between these can be readily made, together with a misconception as to the prevalence, the symptoms, the course, the diagnosis and pathognomic symptoms of actinomycosis, frequently leads to both errors of diagnosis. and failure in treatment. This disease is far more prevalent than is usually believed. The reason for its infrequent

detection is due to the fact that the description in the books is such as to lead to the following misconceptions, viz.,

that it occurs chiefly, if not solely, among those engaged in agricultural pursuits and that it is quite usual to find that an animal suffering from "lumpy jaw" is, or has been, on the farm. Another error is that the discharge will invariably contain gritty, calcareous particles of sulphur yellow bodies, while as a matter of fact the so-called fishroe bodies (at least in this country) are far commoner than the other two forms of granules, and these are not easy of detection, while they are also absent for variable periods from the discharge. The description in the books still further leads astray by inducing the readers to believe that the ray-form of the fungus can be readily and easily detected in the discharges, whereas it may require prolonged and careful search, even after proper staining, to detect the filamentous form of the organism which branches at acute angles. Finally, recent investigations. seem to go to prove that the idea commonly prevalent that the organism is introduced into the tissues from without is probably incorrect. It is taught that the organisms enter through a carious tooth, or through damages of the buccal or intestinal mucous membrane induced by foreign bodies from without, such as beards of grain or pieces of straw contaminated with the organism. This is probably a misrepresentation of the facts. The organism in the filamentous form has been probably shown to have its normal habitat in the buccal cavity, and there is ground for belief that the role played by pieces of straw and other vegetable materials is that simply of vulnerating objects providing an infection atrium in tissues of lowered resistance. The histories of the succeeding cases speak for themselves.

A school girl aged 17 entered the hospital January pital January 12, 1907, stating that trouble had been noticed with an aching tooth in the left side of the lower

jaw in September, 1906. In Janu

below the lower jaw upwards to the zygoma, and posteriorly bulging about one centimeter behind the ramus. By palpation no sharply defined tumor could be made out, the whole mass moving with the inferior maxilla when the patient opened or closed the mouth. The trouble evidently involved the pterygoid and masseter muscles-possibly the temporal; (this suspicion proved later to be correct). Opposite the last upper molar tooth there was a small opening in the mucous membrane, giving vent to pus. No fluctuation could be detected anywhere. By enlargement of this opening about a dram of pus was evacuated, but in a few days softening with fluctuation developed near the angle of the jaw; this ruptured, giving vent to a a moderate amount of pus. Two months later a large fluctuating tumor appeared above the zygoma in the temporal fossa. Meanwhile the site of the softening areas near the angle of the jaw broke down extensively with undermined but elevated skin margins, now presenting the appearance of actinomycosis as pictured in most of the books, and shown in the illustration. On the first of April the extensive pus collection in the temporal fossa opened, giving vent to a large quantity of pus, when the cavity was found continuous (after a little manipulation through the granulation tissue) with the openings in the cheek before mentioned. Search was made for actinomyces when the first abscess was opened, but it was only some ten days after the spontaneous openings were formed in the cheek that the characteristic fishroe bodies were detected, and then only in small numbers. The question of treatment will not be touched upon here, as the case is chiefly of interest from the diagnostic point of view. Let me now read the notes of a second antecedent case.

was

A patient, a male, age 41 years, entered the University Hospital, stating that about six months previous to his admission to the hospital he began to

notice a slowly increasing swelling located in the right inguinal region, which extended finally from the pubes to the anterior superior iliac spine. The patient had had three years ago a swelling in the left groin, which later giving vent to pus, soundly healed. About one month after the appearance of this last swelling a physician believed he detected an abscess and opened it, evacuating a blood-stained fluid but no pus. This wound has never healed, a considerable area of skin becoming ulcerated with undermined margins, and at many points from the deeper parts a thick, dirty pus mixed with fresh blood has exuded. The scrotum was riddled with openings from which a similar discharge came. Free incision with curetting of the spongy granulation tissue was done on more than one occasion by Dr. Darling, the last one revealing the fact that the bowel was involved, a fecal fistula being present. After repeated examinations of the discharge fishroe bodies were detected and proven by the microscope to be actinomyces bovis. When the patient was discharged from the hospital six months later the fistula had closed, and the disease seemed to have been recovered from.

That the usual confidently expressed professional opinion that an interval operation for appendicitis presents no dangers, if infection can be avoided, and that nothing but the establishment of the diagnosis is necessary before proceeding to operate, is contradicted by the following case. For some reason the patient concealed the facts, justifying himself by saying that no one had asked him if he was a bleeder. If the typewritten directions for the examination of the patients in my service had been complied with, when securing the history of this patient, the question as to serious. bleeding after slight injuries would have demonstrated the exstence of hemophilia.

P. H. B. Male. Aged 39 years. Came to the University Hospital for an interval operation for appendicitis. The pa