when he says that there is too great a tendency to depend on the microscope in the diagnosis of malarial fever or typhoid fever. I say the tendency is not sufficient. I know that in my own practice and in the practice of some of my fellows, we have had cases where we didn't know whether we had typhoid or malarial fever. I wish the tendency greater in Wilson to use the microscope. I want to make a statement from a letter which I received from Dr. Pate. Dr. Pate writes: "I have been using Wyatt Johnson's modification of Widal's serum test for typhoid fever for the past seven months-have examined 22 cases diagnosed clinically to be typhoid fever with the following results, viz: Agglutination occurred in sixteen of these cases within the first week.

Agglutination failed in one case within the first ten days, whose subsequent clinical history indicated typhoid fever-was not tested later. Serum test negative in 4 cases. In all of these the malarial parasite was present and yielded to quinine in 10 to 14 days. The remaining one case was that of a young man sent from town to his country home by an able physician with a clinical diagnosis of typhoid fever. The serum test was negative. An examination for the plasmodium of malaria was also negative. Made a culture from a moderately inflamed pharynx, from which he had suffered since his illness, and found streptococci. His temperature was normal after 48 hours-antiseptic local treatment-ten days from the time he was taken. His continual rise of temperature and nervous symptoms were all due to the streptococcal sore throat." There would have been a serious mistake if he had relied on clinical diagnosis alone.

Dr. Hines.-Typho-malarial fever was a name invented and given by Dr. Woodward. He thought that there was such a fever, but before he died he admitted that he had made a mistake, and said that he was confident that there were only two distinct types-typhoid and malaria. He invented the name,

but demonstrated the truth that there was no such fever. In a microscopic test in New York the doctor proved that a man could have typhoid fever and after the recovery from the symptoms, have regular malarial fever. The reason that it is thought to be a separate fever is because a man can have the two fevers entirely distinct. The doctor seems to have misunderstood me. I said that the great majority of the physicians must not de

pend on the microscope. You must, it seems to me, examine a man thoroughly, examine him so thoroughly at first that you would not have to examine the blood to find out what he had. Dr. Whitehead: I want to say this in defense of my paper. I think we all want to do what is best for our patient, consequently we use every means to make a diagnosis. If we rely on clinical symptoms alone, we are bound to make a mistake. My paper was not written from any knowledge of books; it was written out of my own experience. I know that it is not a hard thing to do, and that it does not require any great knowledge of the microscope to do it.

T"

AN INTERESTING CASE OF APPENDICITIS.*

BY A. J. CROWELL, M. D., China Grove, N. C.

HIS report is not submitted on account of the recent discovery of this disease or in support of some new line of treatment, but to impress the paramount importance of an early diagnosis, and the good that may result therefrom, even under the most adverse and hopeless circumstances. The case which I refer to is as follows:-John L. Oct. 24th, white, occupation, farmer. Father died from fracture of skull. Mother living and in good health. Three sisters and one brother living, all of whom are in good health. No hereditary history. On the evening of Feb. 11th patient complained of uneasiness in bowels and took pills which operated the next morning. In the afternoon of the 12th, he was seized with pains in the right iliac region which radiated over the entire abdomen, and began to vomit which continued more or less until after the operation. Dr. McW. was called about 9 p. m. and found him in the following condition:expression anxious, suffering excruciating pain in the right iliac region which radiated to all parts of the abdomen. Legs flexed and abdominal muscles in tonic condition with exceeding tenderness, throughout abdomen. Tongue furred, temperature 101° pulse 120. Satisfactory examination could not be made on account of extreme abdominal tenderness, but deeming it a case of

hæpatic colic, Dr. McW. administered 1⁄2 gr. of morphine, hypodermically, with directions to give oil, followed by enemas if necessary, and to use turpentine stupes over right iliac region. The oil was not retained.

Early the next morning the Dr. returned and ascertained that the patient had rested but little during the night.

Temperature was 120° pulse 130, muscles in tonic contraction, and pain still severe. Tenderness marked in right iliac region. One half gr. of morphine was again given. Enemas of oil and glycerine were administered with a long tube a number of times without any result. At 3 p. m. another 1⁄2 gr. of morphine was given. At 6 p. m. the patient felt his bowels give way, as he expressed it, and thought he would have an action. Temperature declined rapidly to 97%. Pulse became weak and thready and patient was soon bathed with perspiration, which indicated collapse from perforation.

On morning of the 14th the writer was called in consultation and found patient somewhat recovered from shock, but had every symptom of an acute attack of peritonitis.

Pulse 130. Temperature 1011⁄2° with a great deal oftympanitis, and abdominal tenderness was so marked that it was impossible to make a satisfactory examination without the use of an anæsthetic. Under an anesthetic a small tumor was found in the region of Mc Burney's point, and diagnosis of appendicitis with. peritnoitis was made. Immediate operation was advised. Having no instruments or sterilized dressing with me, I returned home for instruments and dressings while patient was being prepared for operation. On my return at 4 p. m. I found they had been unable to get any assistance on account of neighboring physi cians being absent from home. Deeming immediate operation very important, instruments and towels were boiled, patient, anæsthetized and operation begun. An incision about four inches. long was made, commencing about one inch above a line drawn from the anterior superior spinous process of ilium to the umbilicus parallel to and just to the right of the rectus muscle avoiding the sheath of the rectus as hemorrage is usually qreater when incision is made through the sheath. On reaching the peritoneum it was seen to be highly inflamed, and when incised a large amount of seropurulent fluid, which was very of

fensive escaped from abdominal cavity. Further examination showed that the intestine, omentum and peritonum were all in a state of high inflammation and adhered together. It was then seen beyond a doubt that there was a general septic peritonitis. Hence the rush with the operation and the crudness with which it was done. The adhesions were broken up and the appendix reached. It was about 5 inches long, very much enlarged, perforated and gangrenous. A ligature was carried around the base of the appendix about 4 inch from cæcum and appendix servered as close to the ligature as possible. On examining the appendix a cholesterine about the size of a pea was found near the place where the appendix was perforated. In order to cut

short the operation the stump was returned without further treatment. The abdominal cavity was thoroughly flushed with steriled hot water, drainage tube inserted and wound closed with great difficulty by interrupted sutures through skin, muscle and peritoneum and dressed with steril dressing. One fourth gr. of morphine was administered and patient had a good night's rest. There being no nausea the following morning the patient was put on a small amount of milk and lime water every two hours. On the afternoon of the same day the temperature reached 99% and, the attending physician being a great advocate of nuclein, one nuclein tablet every two hours was added to the treatment which was continued till patient recovered. The following day, Feb. 15th the temperature was 99°. The 17th the temperature rose to 99 when the abdominal cavity was washed out with a normal sterilized salt solution, woun ddressed and the temperature again came to normal, pulse being 80, and remained so until the 21st when it ran up to 101, after taking a large dose of salts. After the discharge of a large amount of hard fecal matter, the temperature returned to normal. The wound was also dressed at this time and tube removed.

From this date the patient's recovery was uneventful and complete.

The points of interest in this case are first, etiology; 2nd recovery after perforation and general peritonitis.

AMONG THE NEGRO POPULATION OF

THE SOUTH SINCE THE WAR.*

BY THOMAS J. MAYS, A. M., M.D., Professor of Diseases of the Chest in the Philadelphia Polyclinic, and Visiting Physician to the Rush Hospital for Consumption in Phila

delphia.

(Read before the Section of Neurology and Medical Jurisprudence of the American Medical Association, June 3, 1897.)

ST

TATISTICS gathered from the superintendents of Southern hospitals for the insane show that both insanity and pulmonary consumption increased disproportionately among the negroes of that section of the country since the close of the civil war. Thus according to the United States census there were in 1860 only 44 insane negroes in the State of Georgia; in 1870, there were 129; in 1880, 411; and in 1890, 910. In North Carolina there were in 1880, 91 colored insane; in 1885, 144; in 1890, 244; in 1895, 307; and in 1896, 370. In Virginia before 1865 there were about 60 insane negroes in the asylums of that State and now there are over 1000. In the Eastern Hospital for the colored insane in North Carolina, consumption caused 14 per cent. of the total number of deaths, in 1884, while in 1895 it produced 27 per cent, of all the deaths, and this in spite of a reduced general mortality rate. In the Mississippi Lunatic Asylum from 1892 to 1896, consumption caused 42 per cent. of the total number of deaths among the negroes, or an increase of 22 per cent. over the death rate from this disease among the white population outside of hospitals for the insane (it being of course well known that insanity predisposes the phthisis) if the latter is estimated at 20 per cent. In the Alabama Insane Hospital during three years and nine months beginning October 1, 1890, there occurred 295 deaths. among 1700 white and negro patients. Of the 179 deaths among the white patients, 28 per cent. were due to tuberculosis, and of the 116 deaths among the negroes 42 per cent. were due to the same disease.

From this and other evidence which is presented, it is con

*Authors Abstract.