rhage occurs by diapedesis and is not by a solution of continuity in the vessel walls."

On this experimental work and corroborative clinical experience Schnitzler explained his theory of the occurrence of enterorrhagia in taxis or incarcerated hernias reduced by operation. Clinically it is observed that strangulated hernias of largest size, i.e., those containing the greatest lengths of intestine, furnish the largest number of cases of early enterorrhagia; a fact easily understood according to the theory of Schnitzler. When the sac is opened there is generally an abundance of bloody liquid, and the color of the intestine corresponds with the color of the fluid in the sac. Hemorrhages occurring in these cases are usually benign, as in my case, but may be fatal. Ullmann's theory of the occurrence of late hemorrhages is based upon Litten's experiments in that as a result of a constriction or trauma to a mesenteric artery a thrombosis occurs, then an infarction forms in the intestine, and in from four to seventeen days a necrosis of the mucosa follows and a sharp or fatal hemorrhage results.

If the thrombosis does not occur in the terminal artery, infarction will not take place, according to the experiments of Litten, but a retrograde thrombosis may follow until a terminal branch is reached. In the same way hemorrhages from the stomach may follow manipulations or operations upon the omentum or peritoneum. The shorter the distance of the trauma from the omental base, the quicker the formation of the clot and the earlier the hemorrhage-the clot passing into the gastro-epiploica early.

At the Congress of German Surgeons, 1899, Eiselsberg presented the report of seven cases of gastric or duodenal hemorrhage consecutive to abdominal operation where there has simply been a resection of the cmentum without bloody interference on the intestine itself. None of these cases had at any time presented before operation symptoms of ulcer of the stomach. Afterwards they presented all the symptoms composed in the term hematemesis, in three of the cases ulcer was found on post-mortem. Eiselsberg thought that they were the result of retrograde thrombosis.

Professor Frederick having seen in his practice temporary icterus consecutive to resections of the omentum and noting researches of Eiselsberg, conceived the idea that this icterus was the result of retrograde thrombosis in the hepatic system, and he instituted an order to clear up this point of general pathology, which was undertaken by Dr. Hoffman, his student. These are the results: Guinea-pig resections of the omentum or ligature of the vessels of the omentum which included from onethird to two-thirds of the great omentum, determine the production of areas of hepatic necrosis, sometimes anemias, sometimes hemorrhages. In an undetermined number of cases when the zone of the ligature approaches the neighborhood of the gastric epiploic artery, stomachic ulcers develop with hemorrhages. The length of time between the operative thrombosis and the production of these lesions is variable.

Conclusion. The resection of the omentum in animals is susceptible of provoking a retrograde thrombosis followed by gastric hemorrhages. It is interesting and perhaps will serve to clear the question by following still further the experiences of Frederick in other animals.

Rabbits in contradiction to guinea-pigs, very rarely present similar alteratious, and among dogs and cats the thrombosis is still more rare. The

explanation of this experimental phenomena is probably chargeable to the increase in size of the animal, that is, the omentum and vessels become larger-the greater the distance of the point thrombosed, to the large blood vessels, the less the danger of the retrograde thrombosis in the formation cf necrosis and hemorrhage. In other words, obstruction of the large vessels is not likely to be produced. However, that may be, these experimental facts are precise; they accord with the clinical facts and pathological anatomy, and justify us in the belief that these types of hemorrhage are the result of arterial obliterations which produce this retrograde thrombosis.

It is interesting to know that Eiselsberg considered the ulcers in the stomach and intestine as embolic, but on post mortem examination no emboli were found in the liver, kidneys or lungs The other explanation was that emboli had passed through these organs without producing symptoms. This did not seem reasonable, so Eiselsberg fell back upon the opinion of Reklinghausen, which naturally could be explained only by a centripetal movement in the venous circulation, as example, by insufficiency of the tricuspid valves, by tracheal stenosis, and by strong efforts at coughing.

Eiselsberg also explained that another cause of mucous necrosis, stomach ulceration and hemorrhage might be found. If an artery of the great omentum were ligated, and as a result an extensive centripetal thrombosis develop, the thrombosis can extend up to and obstruct the stomach arterial supply so as to interfere with the nutrition of an area of the mucosa to the extent that the gastric juice acting upon it results in the formation of an ulcer. Numerous surgeons, among them Kehr, Mayo Robson and others of less experience, have seen severe and even fatal gastric hemorrhage follow operations upon the gall bladder and gall ducts, and in spite of any theories to the contrary, I am convinced that these hemorrhages are reproduced in exactly the same way as the others we have discussed. The manipulation by the examining fingers called for in determining the exact conditions present, and the operative technic following the diagnosis can be readily understood as the cause of gastric or duodenal hemorrhages; they are either directly traumatic or secondary to a thrombosis in the gastric artery. Kehr is of the opinion that in some cases these hemorrhages are the result of the use of the tampons which produce a damming back of the portal circulation. It is certainly true that in cases of incarcerated hernia, hemorrhages into the sac and into the intestines are in many cases produced by a venous stasis. The veins being more compressed than the arteries because of their weaker walls, so it would appear to me that in cases of very early copious and perhaps fatal gastric hemorrhage, the condition is brought about by a venous centripetal thrombosis and a rapid transudation of blood through the gastric mucosa. This is the only way in which I can exactly comprehend these early frightful hemorrhages, and is in line with the opinion of Kukula.

Cackovic has often observed gastrorrhagia in suppurative peritonitis and attributed it to the ligation of the omentum, general stasis and hyperemia.

Sanio states that many cases of gastric hemorrhage have been observed after operations for appendicitis. Macrae reports two cases of this kind, each of a different type: in the one, on the thirteenth day following

an interval operation for the removal of an enormous appendix, when the patient was about to leave the hospital, the wound having healed per primam, he was taken with a terrible gastric hemorrhage and nearly died. In the other, on the fourth day following a simple incision, and the establishment of drainage of an immense appendiceal abscess, eight or nine days old, the patient a strong man, 41 years of age, was seized with gastric hemorrhages and died.

From what I have written, all of these hemorrhages, mild or fatal in types, are the result of trauma, and I think they may be classed as preventable and non-preventable. The preventable are such as follow trauma in surgical manipulation, and are usually followed by early hemorrhage. It may, however, belong to the latter type. The non-preventable types are such as follow simple incision and drainage of appendiceal abscesses; dexterously performed operations for the radical cure of hernia; the interval operation for appendicitis and similar procedures. When gastric or intestinal hemorrhage follows such operations under the conditions given, the result is unavoidable. Even these unfortunate circumstances, however, and the knowledge that preventable cases are due to manipulation, should teach us all the necessity of extreme gentleness in the handling of the mesentery and omentum.

I believe the treatment of these hemorrhages is usually medical. Kehr recommends that in addition to the subcutaneous infusion of normal salt solution and rectal alimentation, that the stomach should be washed out with 1-100 per cent solution of nitrate of silver followed by further washing with plain cold water. In addition ergot is administered suboutane

ously. Dahler reported one fortunate recovery after this line of treatment, and Macrae had a fortunate recovery in a desperate case after using a somewhat similar practice.

As far as the surgical treatment of hemorrhages is concerned I am somewhat in doubt. In very early hemorrhages, if my premises are correct, that they follow a venous thrombosis, then surgery would be unavailing, as per ex. in cases II and IV of my series, the blood oozed from numerous punctate points. Many years ago I adopted a surgical procedure in a case of hemorrhage of this type, but from an unknown cause. There had been a history of "gastralgia;" the patient a man 35 years of age, just before the beginning of the hemorrhage, took several drinks of whisky to allay the pain. The technic consisted, after the failure of medical measures, in opening the abdomen, incising the stomach freely in its long axis, and irrigating the interior with hot water. This controlled the bleeding for some time, but recurrences followed, and the man died. (Patient operated in Clarkson Hospital.) Continuous irrigations through a stomach tube or through a surgical fistula into the stomach directly, might be tried; if the patient were weak from the loss of blood and the recently carried out surgical operation, then the stomach tube, and the hot or iced water medicated or not, would be indicated in conjunction with intravenous or subcuticular saline infusions.

In late cases when the hemorrhage is from a recently formed ulcer, medical means failing, the stomach may be opened and the bleeding area obliterated by a purse string suture applied from within, and this further protected by sutures introduced from without after closing the exploratory incision into the stomach.

THE COUNTY SANATORIUM FOR THE TREATMENT OF PULMONARY TUBERCULOSIS.*

Richard C. Moore, M. D., Omaha.

HE indications for the successful management of pulmonary tuberculosis are three in number: surveillance, disinfection and by appropriate means increase the natural power of resistance, these indications can be followed out most satisfactorily by establishing and maintaining sanitoria. Several of the states have established such institutions, and the subject is now under consideration by several other states with the probability that within the next few years the maintaining by the state of sanitoria for the treatment of consumption will be considered as necessary for the safety of the people as is the building and maintaining of hospitals for the insane and asylums for the feeble minded.

We will consider the question of practical importance to us as citizens of the Missouri Valley, namely: Is there an urgent demand in this district for the establishment of a sanatorium for the treatment of pulmonary tuberculosis? But before answering this question, I will call your attention to statistics of the deaths from consumption in several states taken from the report of the census of 1900. The statistics from several of the states are not accurate, there being no laws relating to registration of deaths, the figures there published being derived from the report of the census enumerators, and as consequence are incomplete. But as they are I will give them to you. The population of the United States in 1900 was 76, 303,387. Deaths from consumption 109,750, being 143 for every 100,000 inhabitants.

The population of the four states of Missouri, Kansas, Iowa and Nebraska 7,875,313; deaths from consumption 7,910, being 100 in every 100,000.

This table shows a range of 55 per 100,000 in Nebraska to 186 per 100,000 in Massachusetts, and 166 in Connecticut. There must be a cause for this great difference, which I think can be explained, when we consider that Nebraska is an agricultural state, which requires constant outdoor life in rigorous, active employment, while Masschusetts and Connecticut are manufacturing states, which compels its workers to live their entire lives within doors and subject to the constant breathing of vitiated air.

1906.

*Oration on Medicine, Medical Society of the Missouri Valley, Council Bluffs, September 6,

California with 301 per 100,000 population, tells the disastrous story of unreasonable flocking of the unfortunate victims of consumption to this much vaunted climatic resort. Many are no doubt benefited by the change to this beautiful climate, but only when the change is made in the early stage of the disease.

The following table of deaths from consumption in the census year, with per cent of deaths from all causes in the following registered cities, is probably accurate:

Omaha in 1901: Deaths from all causes, 993; from consumption, 81, per cent 8.1. Omaha 1902: Deaths from all causes, 1050; from consumption 92, per cent 8.7. Omaha in 1903: Deaths from all causes, 966; froin consumption 108, per cent 11.2. Omaha in 1904: Deaths from all causes 1108; from consumption 114, per cent 10.3.

From this table we learn that Omaha has comparatively a low death rate from consumption, and could reliable statistics be obtained of the State of Nebraska, the showing would be still better than would be inferred from computing from the Omaha reports. According to the statistics of 1900, Nebraska had 592 deaths from consumption, which was proportionally far less than that of any other state to which I have referred. And Omaha has, as reported by the board of health, an average death rate of 94 from this cause. From this showing I cannot state that there is an immediate and urgent demand for a sanatorium in that state, but on the other hand, we must be impressed with the fact that Nebraska has never been considered a desirable resort for "lungers," therefore probably only few of the consumptives who have died in that state were imported. A sanatorium in Nebraska would be the means of saving many lives, and also would be a center from which information would be promulgated for the early management of such cases, and would thus, in time, by instructing the people in prophylaxis and in the home treatment of consumption, greatly reduce the mortality from this cause. The expense of building such a hospital and maintaining it will be very great, and should not be undertaken until first fully investigating the subject. Patients who are continually in the open air have most voracious appetites, and to keep them satisfied they are fed in the sanatoria six square meals per day, which makes their keeping expensive, between $9 and $10 per week per capita, and the buildings of sufficient capacity for one hundred patients will cost over $100,000.

Theoretically the modern treatment of pulmonary tuberculosis can be carried out in the home of the patient, but practically it has been my experience that it is impossible to convince the laity, and in fact many of the profession, that night air is not injurious, and that wind, rain or snow