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THE TREATMENT OF ACUTE PURULENT EPIPHYSIAL OSTEOMYELITIS.
826
and to recommend its use in similar cases. He believes that the ice cream in those cases is beneficial because of the local ansesthetic action of the cold permitting digestion to go on without pain, while at the same time sufficient material for digestion and nourishment is supplied in the cream. But he insists that every care must be taken to ensure the absolute purity and freshness of the ice cream, and for this purpose he recommends that only that which is made at home should be used in such cases.
CONCENTRATED PREPARATIONS. MANY years ago concentrated preparations were introduced by some of the largest and most reliable wholesale
druggists, and they found very ready acceptance with all who were called upon to dispense drugs. It was claimed for them that by dilution with spirit, water, or syrup, preparations could be obtained which in no important respect differed from the tinctures, decoctions, infusions, or syrups of the British Pharmacopoeia. Their convenience, when space in the dispensary is limited, is of course obvious, and this alone would readily explain the favour with which they have been received. A correspondent from South Africa indicates another great advantage to medical men resident abroad-viz , the immense saving in package, freight, duty, &c., which results from being able to order drugs in a concentrated form and dilute them on delivery. On the other hand, he confesses that he has not been free from an uneasy feeling that the preparations might not be reliable in strength or quality, and he instances two which throw down a heavy and insoluble precipitate when diluted with rectified spirit, as directed, to form the respective B. P. tinctures; while a third when diluted gives a preparation which, though clear in appear. ance, is very unlike the corresponding Pharmacopoeia tincture. His experience is, we believe, rather exceptional. Most of such preparations which we have examined have been made apparently with a due regard to the interests both of buyer and seller, and really contain the amount of active ingredients represented. Whether they travel well is another matter, upon which we should be glad to receive information from medical men resident abroad.
24 ; while in 1890, when the deaths from diphtheria 141, the deaths referred to laryngitis &c. also rose to 38, thus seeming to negative the supposed transfer under
were rose
’,
to
the influence of notification of cases of laryngitis &c. to diphtheria. That fatal cases of diphtheria are not unfre. quently certified as laryngitis, croup, &c., is beyond doubt; but the figures for St. Pancras do not support the theory that the amount of this error is affected by notification. Iu is, moreover, admitted by Dr. Sykes that "notification does not appear to have had a corresponding effect upon the number of deaths from any other notifiable diseases." The recent increase of mortality from diphtheria in London and in other large towns is so marked, and is a fact of so much importance, that its attribution in St. Pancras to notification is to be regretted, as not being conducive to the solution of this serious sanitary problem.
THE POLICE AND MEDICAL AID. IT is very necessary that every facility should be afforded for securing medical assistance in cases of street accident or illness, and this desirable result can only be attained by cordial cooperation of practitioners with municipal autho. rities. A recent decision by the Edinburgh Town Council is in this connexion of some practical importance. In reply to a complaint that medical men had repeatedly been reo fused remuneration for services rendered on such occasions on the ground that they had not been summoned by the police, it was resolved that every such attendance in future should be recognised by a printed form of application. A similar method is in use in London, where the form is usually presented soon after the attendance. This obviates the possibility of delay in an emergency, and assures official recognition of the service rendered. There are, however, certain cases in which a practitioner may have to act professionally without waiting for an official request. It is more especially at such times that his fee is apt to be for. gotten. It is of course only right in the circumstances that the police should proceed in such cases with due deliberation ; but it is no less clear that in order to ensure prompt aid in emergencies the service willingly rendered in any obvious case of illness or injury should be duly reported and remunerated. ___
DIPHTHERIA AND NOTIFICATION IN ST. PANCRAS. THE recent marked increase in the mortality from diphtheria in the metropolis has been specially noticeable in St. Pancras. The report for 1890, recently issued by Dr. Sykes, the medical officer of health for this metropolitan district, points out that in 1888 the deaths from diphtheria in St. Pancras were72, and that in 1889 they fell to 62, whereas in 1890 they rose to 141. These deaths from diphtheria were equal to an annual rate of 0-60 per 1000, which was very nearly double the mean rate from this disease in the whole of London. Dr. Sykes expresses the opinion, to which, however, we find it difficult to subscribe, that there was an evident connexion between the notification of infectious diseases and this increased mortality from diphtheria, because the increase was coincident with the commencement of the operation of the Infectious Diseases (Notification) Act at the end of October, 1889. Dr. Sykes suggests in support of this opinion that possibly "a proportion of deaths formerly certified as due to tonsillitis, sore-throat, or quinsy, possibly also to croup and laryngitis, may now be certified as due to diphtheria," because doubtful cases having been notified as diphtheria, the cause of death would probably be certified in the san e manner. This opinion is not borne out by the figures in Dr. Sykes’s report, from which it appears that in 1889, when only 62 deaths from diphtheria were recorded, the deaths attributed to laryngitis, croup, sore-throat, and quinsy
THE
TREATMENT OF ACUTE PURULENT EPIPHYSIAL OSTEOMYELITIS.
DR. 0. THELEN has observed that in all cases of acute osteomyelitis the region of the epiphysis was the original seat of the disease. The treatment has hitherto been until the formation of a periosteal essentially expectant, abscess, which it has been the practice to incise down to the bone and then to make an opening with a perforator, removing enough of the cortical substance to expose the Dr. Thelen, however, who, as reported in the marrow. Memorabilien, has had during the last four years and a half fourteen cases of osteomyelitis, has operated immediately even in recent cases, when there was violent pain and much fever, without waiting for the formation of an abscess. He perforates the bone and removes the whole of the infiltrated tissue, by which means he succeeds in cutting short the morbid process more or less completely. The disease is at its initial stage frequently mistaken for typhoid fever, especially when the history of the case is obscure, the patient comatose, and the symptoms indefinite. Still more frequently acute joint inflammation is erroneously diagnosed, especially when the attack is complicated with sudden and exten. sive effusion into a joint. With a history of previous injury and a subacute course of the disease, doubts may be entertained whether the case may not be one of traumatic injury of the bone difficult to trace. The greatest number of cases, however, present themselves
for treatment only when the periosteal abscess has been formed. Under these circumstances the abscess must be immediately incised, the bone perforated, and all diseased tissue removed. Even here the prognosis is generally favourable. Secondary abscesses, when developing with fever, must be treated exactly like primary abscesses. In osteomyelitis at the upper epiphysis of the femur or
We refer to the increase of
have to face ourselves.
which, as at home, is assuming somediphtheriawhat serious proportions. Quite apart from the dispropora
matter
tion in the number of children in the city and in the suburban district, there seems to be some special influence at work in the latter area which causes a great excess of suburban diphtheria. This is to some extent attributed to the influence of emanations from tips for garbage and other refuse ; but it was pointed out early this year by Dr. Thorne Thorne, in the Milroy Lectures on this subject, that ordinary sanitary circumstances can hardly be held to be accountable for the increase of this disease, since that increase has steadily and continuously gone hand in
humerus, the epiphysis is sometimes completely separated. This lesion may, however, heal if the parts are kept in the completely extended position. The author still treats osteomyelitis of the wrist and ankle with simple incisions. All treatment is, of course, hopeless in those rare and serious cases of osteomyelitis in which the infec. tion is so virulent as to carry off the patient in about two hand with progressive improvement in our national sanitary days, before any localisation of the disease has had time to state. The influence of aggregation of children for educational purposes was, on the other hand, shown to be intishow itself. mately related to the rapid spread of diphtheria in England, CORONERSHIP OF THE CITY OF BIRMINGHAM. and it may be that this same circumstance may be in AT a special meeting of the Birmingham City Council on operation in New South Wales, and that differences in the 2nd inst., on the proposal of the Mayor, Mr. Joseph aggregation, whether as regards the number of children or Ansell was appointed temporarily to the post of coroner for the conditions under which they are collected together, may, the city of Birmingham, a vacancy having been created by in some measure, explain the different incidence of the the death of Mr. Henry Hawkes. The permanent appoint- disease in city and in suburbs. The subject is one that seems ment will be made by the first week of D 3cember, an arrange- to call for further investigation, and our home experiences ment which will afford the committee time to sift more tho- may possibly be useful to that end. roughly the qualifications of the aspirants to the coroner’s THE LEPROSY COMMISSION. office. Mr. Oliver Pemberton has definitely resolved to contest the vacant coronership, and as Mr. Councillor DR.inJCKMASTER, ot St. Georges Hospital, one ot the Wilders has retired in his favour, he is at present the only of the Leprosy Commission which has been medical candidate for the appointment. He comes forward to inquiring into the subject of leprosy in India during the vindicate the claims of the medical profession to such a post past ten months, has returned to London. The remaining with an extensive medico-legal knowledge, and the possession members are also on their way home, and it is believed that of qualities which eminently fit him for properly discharging the report of the Commission will be ready before the end the duties of the coroner’s court without fear or favour. of the year. It will of course largely deal with the questions of heredity and contagion, and the practical conclusions to PUBLIC HEALTH IN NEW SOUTH WALES. which their investigations have led the commissioners. -
members
Two interesting documents have been issued by Mr. GOVERNMENT BY GUARDIANS OR BY Edmund Sager, the Secretary to the State Board of Health PARLIAMENT. of New South Wales. One relates to typhoid fever, which has been so grave a source of death in Sydney and its IT is high time that the British people knew whether suburbs. Indeed between 1876 and 1885 the mortality from they are to be governed by local authorities or the Imperial this one cause varied between 46-07 and no less than 102’17 Parliament. We are perfectly willing for our part to let per 100,000. Fortunately diminution set in after this date, everybody that pleases have the small-pox and other preand the rate, though not continuously diminishing, has on ventable diseases (in spite of the Prince’s wise words, " If the whole undergone substantial decrease, until in 1890 it disease is preventable, why is it not prevented ?"). Nobody To some extent this can gain by that arrangement but the medical profession. was reduced to 36-6 per 100,000. result is believed to have been brought about by a wet We say we are perfectly willing for everybody to have preseason, during which the street gutters, drains, and other ventable diseases if they please-on one condition, that, foul places were washed out; but the new sewerage scheme after due deliberation in Parliament, this conclusion is and the extension of the Prospect water-supply have reached but we protest against Bumbredom assuming also had a share in it. In one case an outbreakithat he has authority to override Acts of Parliainvolving fifty-nine cases was traced to neglect of ment, by neglecting to make appointments which the a local authority in administering the Dairies’ Super-law requires to be made in order to carry out these Acts. vision Act, and the second document referred to relatesThe high health of this nation and metropolis has not been to action under this statute. The actual administration of reached by the wisdom of guardians and vestries, but this Act is carried out by the local authorities, but central by the action on these bodies of Parliament, and it is inspectors supervise it. The need for it is convincingly set treason to the constitution to allow any guardian to forth in the official report in question, and its extension to induce his board to play with arrangements meant to districts immediately beyond the metropolitan area has protect the community from the most deadly diseases. The been decided on, both on account of the general sanitary Board of Guardians contains members who, state of these more distant dairies, and because the milk- judging by reports which appear from time to time in the think the board wiser than Parliament, and supply for the city comes more and more from beyond the local urban precincts. Somewhat recently 347 samples of water who wish to induce it, contrary to the plainest intimafound on dairies were submitted to analysis, and no less tion by the clerk of the illegality of such a course, to than 155 of these turned out to be polluted and unfit for forego the appointment of a vaccination officer. One human consumption. Where infectious disease is found member of the board speaks of the vaccination law as one to prevail in dairies stringent precautions are taken. imposed in the dark ages, and declares that medical science Thus, pending the removal of a patient to hospital the had said vaccination could not stand. Surely this gentleregistration of a dairy is suspended. In another matter man might wait till the Royal Commission reports. If the colony seems to be suffering from a difficulty which we he is so sure of the support of medical science, he can T""J.
1
Mile-end
press,
n
.
-
1
n
.
n
T
7 1
0
.
and to recommend its use in similar cases. He believes that the ice cream in those cases is beneficial because of the local ansesthetic action of the cold permitting digestion to go on without pain, while at the same time sufficient material for digestion and nourishment is supplied in the cream. But he insists that every care must be taken to ensure the absolute purity and freshness of the ice cream, and for this purpose he recommends that only that which is made at home should be used in such cases.
CONCENTRATED PREPARATIONS. MANY years ago concentrated preparations were introduced by some of the largest and most reliable wholesale
druggists, and they found very ready acceptance with all who were called upon to dispense drugs. It was claimed for them that by dilution with spirit, water, or syrup, preparations could be obtained which in no important respect differed from the tinctures, decoctions, infusions, or syrups of the British Pharmacopoeia. Their convenience, when space in the dispensary is limited, is of course obvious, and this alone would readily explain the favour with which they have been received. A correspondent from South Africa indicates another great advantage to medical men resident abroad-viz , the immense saving in package, freight, duty, &c., which results from being able to order drugs in a concentrated form and dilute them on delivery. On the other hand, he confesses that he has not been free from an uneasy feeling that the preparations might not be reliable in strength or quality, and he instances two which throw down a heavy and insoluble precipitate when diluted with rectified spirit, as directed, to form the respective B. P. tinctures; while a third when diluted gives a preparation which, though clear in appear. ance, is very unlike the corresponding Pharmacopoeia tincture. His experience is, we believe, rather exceptional. Most of such preparations which we have examined have been made apparently with a due regard to the interests both of buyer and seller, and really contain the amount of active ingredients represented. Whether they travel well is another matter, upon which we should be glad to receive information from medical men resident abroad.
24 ; while in 1890, when the deaths from diphtheria 141, the deaths referred to laryngitis &c. also rose to 38, thus seeming to negative the supposed transfer under
were rose
’,
to
the influence of notification of cases of laryngitis &c. to diphtheria. That fatal cases of diphtheria are not unfre. quently certified as laryngitis, croup, &c., is beyond doubt; but the figures for St. Pancras do not support the theory that the amount of this error is affected by notification. Iu is, moreover, admitted by Dr. Sykes that "notification does not appear to have had a corresponding effect upon the number of deaths from any other notifiable diseases." The recent increase of mortality from diphtheria in London and in other large towns is so marked, and is a fact of so much importance, that its attribution in St. Pancras to notification is to be regretted, as not being conducive to the solution of this serious sanitary problem.
THE POLICE AND MEDICAL AID. IT is very necessary that every facility should be afforded for securing medical assistance in cases of street accident or illness, and this desirable result can only be attained by cordial cooperation of practitioners with municipal autho. rities. A recent decision by the Edinburgh Town Council is in this connexion of some practical importance. In reply to a complaint that medical men had repeatedly been reo fused remuneration for services rendered on such occasions on the ground that they had not been summoned by the police, it was resolved that every such attendance in future should be recognised by a printed form of application. A similar method is in use in London, where the form is usually presented soon after the attendance. This obviates the possibility of delay in an emergency, and assures official recognition of the service rendered. There are, however, certain cases in which a practitioner may have to act professionally without waiting for an official request. It is more especially at such times that his fee is apt to be for. gotten. It is of course only right in the circumstances that the police should proceed in such cases with due deliberation ; but it is no less clear that in order to ensure prompt aid in emergencies the service willingly rendered in any obvious case of illness or injury should be duly reported and remunerated. ___
DIPHTHERIA AND NOTIFICATION IN ST. PANCRAS. THE recent marked increase in the mortality from diphtheria in the metropolis has been specially noticeable in St. Pancras. The report for 1890, recently issued by Dr. Sykes, the medical officer of health for this metropolitan district, points out that in 1888 the deaths from diphtheria in St. Pancras were72, and that in 1889 they fell to 62, whereas in 1890 they rose to 141. These deaths from diphtheria were equal to an annual rate of 0-60 per 1000, which was very nearly double the mean rate from this disease in the whole of London. Dr. Sykes expresses the opinion, to which, however, we find it difficult to subscribe, that there was an evident connexion between the notification of infectious diseases and this increased mortality from diphtheria, because the increase was coincident with the commencement of the operation of the Infectious Diseases (Notification) Act at the end of October, 1889. Dr. Sykes suggests in support of this opinion that possibly "a proportion of deaths formerly certified as due to tonsillitis, sore-throat, or quinsy, possibly also to croup and laryngitis, may now be certified as due to diphtheria," because doubtful cases having been notified as diphtheria, the cause of death would probably be certified in the san e manner. This opinion is not borne out by the figures in Dr. Sykes’s report, from which it appears that in 1889, when only 62 deaths from diphtheria were recorded, the deaths attributed to laryngitis, croup, sore-throat, and quinsy
THE
TREATMENT OF ACUTE PURULENT EPIPHYSIAL OSTEOMYELITIS.
DR. 0. THELEN has observed that in all cases of acute osteomyelitis the region of the epiphysis was the original seat of the disease. The treatment has hitherto been until the formation of a periosteal essentially expectant, abscess, which it has been the practice to incise down to the bone and then to make an opening with a perforator, removing enough of the cortical substance to expose the Dr. Thelen, however, who, as reported in the marrow. Memorabilien, has had during the last four years and a half fourteen cases of osteomyelitis, has operated immediately even in recent cases, when there was violent pain and much fever, without waiting for the formation of an abscess. He perforates the bone and removes the whole of the infiltrated tissue, by which means he succeeds in cutting short the morbid process more or less completely. The disease is at its initial stage frequently mistaken for typhoid fever, especially when the history of the case is obscure, the patient comatose, and the symptoms indefinite. Still more frequently acute joint inflammation is erroneously diagnosed, especially when the attack is complicated with sudden and exten. sive effusion into a joint. With a history of previous injury and a subacute course of the disease, doubts may be entertained whether the case may not be one of traumatic injury of the bone difficult to trace. The greatest number of cases, however, present themselves
for treatment only when the periosteal abscess has been formed. Under these circumstances the abscess must be immediately incised, the bone perforated, and all diseased tissue removed. Even here the prognosis is generally favourable. Secondary abscesses, when developing with fever, must be treated exactly like primary abscesses. In osteomyelitis at the upper epiphysis of the femur or
We refer to the increase of
have to face ourselves.
which, as at home, is assuming somediphtheriawhat serious proportions. Quite apart from the dispropora
matter
tion in the number of children in the city and in the suburban district, there seems to be some special influence at work in the latter area which causes a great excess of suburban diphtheria. This is to some extent attributed to the influence of emanations from tips for garbage and other refuse ; but it was pointed out early this year by Dr. Thorne Thorne, in the Milroy Lectures on this subject, that ordinary sanitary circumstances can hardly be held to be accountable for the increase of this disease, since that increase has steadily and continuously gone hand in
humerus, the epiphysis is sometimes completely separated. This lesion may, however, heal if the parts are kept in the completely extended position. The author still treats osteomyelitis of the wrist and ankle with simple incisions. All treatment is, of course, hopeless in those rare and serious cases of osteomyelitis in which the infec. tion is so virulent as to carry off the patient in about two hand with progressive improvement in our national sanitary days, before any localisation of the disease has had time to state. The influence of aggregation of children for educational purposes was, on the other hand, shown to be intishow itself. mately related to the rapid spread of diphtheria in England, CORONERSHIP OF THE CITY OF BIRMINGHAM. and it may be that this same circumstance may be in AT a special meeting of the Birmingham City Council on operation in New South Wales, and that differences in the 2nd inst., on the proposal of the Mayor, Mr. Joseph aggregation, whether as regards the number of children or Ansell was appointed temporarily to the post of coroner for the conditions under which they are collected together, may, the city of Birmingham, a vacancy having been created by in some measure, explain the different incidence of the the death of Mr. Henry Hawkes. The permanent appoint- disease in city and in suburbs. The subject is one that seems ment will be made by the first week of D 3cember, an arrange- to call for further investigation, and our home experiences ment which will afford the committee time to sift more tho- may possibly be useful to that end. roughly the qualifications of the aspirants to the coroner’s THE LEPROSY COMMISSION. office. Mr. Oliver Pemberton has definitely resolved to contest the vacant coronership, and as Mr. Councillor DR.inJCKMASTER, ot St. Georges Hospital, one ot the Wilders has retired in his favour, he is at present the only of the Leprosy Commission which has been medical candidate for the appointment. He comes forward to inquiring into the subject of leprosy in India during the vindicate the claims of the medical profession to such a post past ten months, has returned to London. The remaining with an extensive medico-legal knowledge, and the possession members are also on their way home, and it is believed that of qualities which eminently fit him for properly discharging the report of the Commission will be ready before the end the duties of the coroner’s court without fear or favour. of the year. It will of course largely deal with the questions of heredity and contagion, and the practical conclusions to PUBLIC HEALTH IN NEW SOUTH WALES. which their investigations have led the commissioners. -
members
Two interesting documents have been issued by Mr. GOVERNMENT BY GUARDIANS OR BY Edmund Sager, the Secretary to the State Board of Health PARLIAMENT. of New South Wales. One relates to typhoid fever, which has been so grave a source of death in Sydney and its IT is high time that the British people knew whether suburbs. Indeed between 1876 and 1885 the mortality from they are to be governed by local authorities or the Imperial this one cause varied between 46-07 and no less than 102’17 Parliament. We are perfectly willing for our part to let per 100,000. Fortunately diminution set in after this date, everybody that pleases have the small-pox and other preand the rate, though not continuously diminishing, has on ventable diseases (in spite of the Prince’s wise words, " If the whole undergone substantial decrease, until in 1890 it disease is preventable, why is it not prevented ?"). Nobody To some extent this can gain by that arrangement but the medical profession. was reduced to 36-6 per 100,000. result is believed to have been brought about by a wet We say we are perfectly willing for everybody to have preseason, during which the street gutters, drains, and other ventable diseases if they please-on one condition, that, foul places were washed out; but the new sewerage scheme after due deliberation in Parliament, this conclusion is and the extension of the Prospect water-supply have reached but we protest against Bumbredom assuming also had a share in it. In one case an outbreakithat he has authority to override Acts of Parliainvolving fifty-nine cases was traced to neglect of ment, by neglecting to make appointments which the a local authority in administering the Dairies’ Super-law requires to be made in order to carry out these Acts. vision Act, and the second document referred to relatesThe high health of this nation and metropolis has not been to action under this statute. The actual administration of reached by the wisdom of guardians and vestries, but this Act is carried out by the local authorities, but central by the action on these bodies of Parliament, and it is inspectors supervise it. The need for it is convincingly set treason to the constitution to allow any guardian to forth in the official report in question, and its extension to induce his board to play with arrangements meant to districts immediately beyond the metropolitan area has protect the community from the most deadly diseases. The been decided on, both on account of the general sanitary Board of Guardians contains members who, state of these more distant dairies, and because the milk- judging by reports which appear from time to time in the think the board wiser than Parliament, and supply for the city comes more and more from beyond the local urban precincts. Somewhat recently 347 samples of water who wish to induce it, contrary to the plainest intimafound on dairies were submitted to analysis, and no less tion by the clerk of the illegality of such a course, to than 155 of these turned out to be polluted and unfit for forego the appointment of a vaccination officer. One human consumption. Where infectious disease is found member of the board speaks of the vaccination law as one to prevail in dairies stringent precautions are taken. imposed in the dark ages, and declares that medical science Thus, pending the removal of a patient to hospital the had said vaccination could not stand. Surely this gentleregistration of a dairy is suspended. In another matter man might wait till the Royal Commission reports. If the colony seems to be suffering from a difficulty which we he is so sure of the support of medical science, he can T""J.
1
Mile-end
press,
n
.
-
1
n
.
n
T
7 1
0
.